U. S. Department of Health and Human Services

Agency for Healthcare Research and Qualitywww.ahrq.govAdvancing Excellence in Health Care

MEPS Chartbook No. 13Medical Expenditure Panel Survey

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Health Care in Urban aAreas, Combined Years 

Demographic Access characteristics 
Suggested citation:

Larson SL, Machlin SR, Nixon A, et al. Health care in urban and rural areas, combined years 1998-2000. Rockville Research and Quality; 2004. MEPS Chartbook No.13. AHRQ Pub. No. 04-0050.

The estimates in this report are based on the most recent data available from MEPS at the time the report was writteelements of MEPS data may be revised on the basis of additional analyses, which could result in slightly different estimahere. Please check the MEPS Web site for the most current file releases—

www.meps.ahrq.gov

The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans by:

• Using evidence to improve health care.• Improving health care outcomes through research.• Transforming research into practice.

MEPS Chartbook No. 13 by:1

Sharon L. Larson, Ph.D.Steven R. Machlin, M.S.Alice Nixon, M.A.Marc Zodet, M.S.1In alphabetical order.
Medical Expenditure Panel Survey Agency for Healthcare Research and Quality

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i

The percent of people under 65 who were uninsured was not significantly

different in rural counties than in the

others. People living in near-rural

counties were more likely to be

uninsured for an entire year than people

living in metro or near-metro counties.

Among both non-elderly and elderly

people with ambulatory expenses,

residents of rural counties had the

fewest visits per year.This difference was

especially prominent for the elderly,

among whom rural residents had only

half as many visits each year as metro

residents (5.5 visits versus 10.9).

The percent of the population under 65

years in rural counties who had

expenses for prescription medicines was

not significantly different from the

percent in other counties.

Uninsured residents of rural counties were more likely than their metro

counterparts to have a usual source of

care.

The likelihood of having dental expenses generally declined with increasing

rurality. For non-elderly people with

dental expenses, the average annual number of visits did not vary

significantly among the urban-rural

categories. However, elderly rural residents with dental expenses had an average of one fewer dental visit per

year than their counterparts in

metroplitan areas.

executive summary

Among elderly people with ambulatory expenses, residents of rural counties had

the lowest average annual expenses:

$662, compared with $1,432 or higher in

the other areas.

This chartbook examines the

differences in health care access, use,

and expenses between urban and rural

areas. Counties are classified along the

urban-rural continuum according to

whether they are metropolitan

statistical areas (MSAs) and, if not,

their proximity to an MSA. An MSA is

a large population nucleus with a high

degree of economic and social

interaction. The categories along the

continuum are metro (counties in an

MSA), near-metro, near-rural, and

rural. The last category includes only

the most rural areas in the Nation,

home to about 3.2 million Americans.

For more information on the

classification, see the Definitions of

Terms section at the end of this

chartbook.

Some highlights of information in

this chartbook follow.

1 Introduction

3 Data in This Report5 Section 1

Demographic Characteristics

13 Section 2

Access to Care

19 Section 3

Use and Expenses

35 References37 Definitions of Terms

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contents

In 2000, approximately 49

million people lived innonmetropolitan counties in theUnited States, about 3 million ofwhom lived in rural counties(nonmetropolitan counties with notown or city with a population of2,500 or more). Researchers andpolicymakers have found that thedemographics, culture, andstructural conditions of ruralsettings are associated with theinsurance status and health care useand expenditure patterns of ruralresidents. Because of the scarcity ofproviders and facilities in rural placesand the resulting potential for lackof access to health care, ruralpopulations have been designated asa priority group in the health policyarena. 

This chartbook presents data

from the Medical Expenditure PanelSurvey (MEPS), which is sponsoredby the Agency for HealthcareResearch and Quality (AHRQ). Thecharts illustrate similarities and

differences betweplaces on measuraccess, use, and eshown are for the noninstitutionalizthe period 1998-

The chartbo

into three sectioncompares people along the urban-(metro, near-metrural) by selected including age, racincome, health stlimitations. The sprovides informastatus and access section focuses oand expenses for prescription medcare. Comparisorural categories aeither the populaof age (also referelderly), the popuage and over (alselderly), or both. 

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introduction
The four urba

used in this report number of factorsis in a metropolitaproximity to a mearea, and populatilargest city in the Definitions of Termore details.

This chartboo

publications are avelectronically on tat: http://www.m

Agency for Healthcare Research and Quality

2

Medical Expenditure Panel Survey
The comparisons in this

chartbook are based on estimatedannual averages for the period1998-2000 using data from MEPS.Data for these three years werecombined to provide larger samplesizes that would improve theprecision of rural county estimatesand the ability to detect significantdifferences with other county types.Expense data for 1998 and 1999were adjusted to 2000 dollars basedon the Consumer Price Index for allgoods and services.

MEPS surveys a nationally

representative sample of householdsfor information on the health status,health care use and expenses, andhealth insurance coverage ofindividuals and families in the U.S.civilian noninstitutionalizedpopulation. Data for this reportcome from MEPS public use filesHC-028 (1998 Full YearConsolidated File), HC-038 (1999Full Year Consolidated File), andHC-050 (2000 Full YearConsolidated File). The utilizationinformation is based on medicalevents reported by households, and

the payment infoon data collected households and m

Expenses in 

payments to hospand other health services reported respondents. Thedefined as direct individuals, privaMedicaid, Medicsources for care pyear. 

MEPS is bas

sample design, so are subject to staerror. Unless othdifferences betwestatistically signifilevel (not likely tsampling error) atext.

In a few inst

that appear large statistically signifiestimates for ruraon much smaller can have relativelerrors. 

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data in this report

Demographic

Characteristics

Variations in 

sex, socioeconomphysical health acareas can provide differences in heaexpenses. For exliving in rural areto be elderly and activity limitationmetro areas. Demcharacteristics as location are relathealth care access section examines which demograpstatus differ acrosrural categories.

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section 1
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Agency for Healthcare Research and Quality

6

Medical Expenditure Panel Survey

Proportionately more elderly 

than metro 

• There were proportionately more

elderly people in rural counties(18.8%) than in metro counties(11.9%). However, differencesbetween rural counties and othercounty types were not statisticallysignificant.

• The percent of residents ages 18-

44 was lowest in rural counties(31.4%, compared to 36.0%-40.2% for the other threegroups).

• Approximately one-quarter of the

population were children under18 in all four categories.

• The proportio

45-64 did not by type of cou

0

20406080

100

11.9%

Metro

40.2%

26.4%21.5%

25.2%

Near-metro Near-rural Rur

15.1%36.8%24.4%23.7%

15.0%

36.0%27.0%22.0%

18.8

31.426.23.6
• While there are more elderly

women than men in all countytypes, the proportion of elderlypeople who were women wassignificantly higher in ruralcounties (63.0%) than in nearrural counties (54.1%).

• Among the population under 65

years of age, there wereapproximately equal numbers ofmales and females regardless ofurban-rural location.

Higher proportion of elderly in ruralcounties are women

0%

15%

30%

45%60%75%

50.4% 49.6%

Percent of females in population

57.9%

49.8%

58.5%

63.0%

Under age 65 Age 65 and over

49.4%

54.1%
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. • Among non-elderly adults, less

than one-third of rural residentshad post-high-school education(31.4%), compared to 53.6% inmetro counties and 42.5% innear-rural counties. Theproportion of non-elderly adultswith post-high-school education

was higher in near-metro co

• About half of 

counties had lschool educationly about a tin metro coun

Agency for Healthcare Research and Quality

8

Medical Expenditure Panel Survey

Educational attainment g

lower for rural r

Metro Near-metro Near-rural Rural

0%

20%40%60%80%

100%

31.8%

14.6%

53.6%

20.8%

40.7%20.4%38.9%

36.8%

19.9%

42.5%

48.8%

26.1%

31.4%

High schoolLess than high schoolMore than high school

Age 21-64

Metro Near-metro Near-rural 

0%

20%40%60%80%

100%

34.9%32.5%32.6%

43.6%

32.1%47.3%20.7%

36.4%20.0%

Age 65 and over
• Approximately one-quarter of 

non-elderly people in near-ruraland rural areas were in thepoor/near poor income category,having income less than 125% ofthe poverty line. In comparison,only about 16% of non-elderlypeople in the two more urbanareas (metro and near-metro) werepoor or near poor.

• Among people under 65, only

58.0% of residents in near-ruralcounties and 53.2% in ruralcounties were in the high/middleincome category (income over200% of the poverty line),compared to 72.4% of the nonelderly residents in metro areas and69.5% of those in near-metroareas.

• Among the el

counties in neareas were moincomes in thcategory (22.compared to metro areas.

• Metro areas h

proportion of the high/mid65.0%, compain the other a

Higher proportion of poor/near poor inless urban counties 

Metro Near-metro Near-rural Rural

0%

20%40%60%80%

100%

11.9%

72.4%

15.6%

58.0%

14.4%69.5%16.1%

17.7%

53.2%

24.2%

20.7%

26.1%

26.1%

Low incomeHigh/middle incomePoor/near poor

Under age 65

Metro Near-metro Near-ru

0%

20%

40%

60%80%

100%

19.8%65.0%15.2%

55.6%

20.3%59.0%20.7%

22.3%

22.0%

Age 65 and over
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• There were proportionately more

racial and ethnic minorities inmetro areas (31.5%) than in ruralcounties (9.1%) or near-metrocounties (12.0%).

• Minorities in t

all people not non-Hispanic. racial/ethnic gshown becausthese smaller sstatistically relfour urban-rur

Agency for Healthcare Research and Quality

10

Medical Expenditure Panel Survey

Metro counties hav

proportion of m

0%

20%40%60%80%

100%

31.5%

Metro

68.6%

25.2%

7.9%

OtherWhite non-Hispanic

Near-metro Near-rural Rural

12.0%88.0%

22.6%77.4%

9.1%

91.0%
• Among the non-elderly, metro

residents were less likely to havefair or poor health (7.4%) thannear-metro residents (9.7%).

• Although the proportion of nonelderly people in fair or poor

health appears to be highest inrural counties (11.4%), it is notsignificantly higher than for othergroups.

• Elderly residents in near-metro

and near-rural counties weresomewhat more likely thanmetro residents to have fair orpoor health (28.9% and 30.3%,compared to 24.2%).

• While the percent of elderly

people in fair or poor healthappears to be lower in ruralcounties than in near-metro ornear-rural counties, thesedifferences are not statisticallysignificant.

Metro residents less likely to be in fair or poor health 

0%5%

10%15%20%25%30%35%

9.7%

7.4%

Percent in fair or poor health

24.2%

9.0%

28.9%

24.7%

Under age 65 Age 65 and over

11.4%

30.3%
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• About one in five non-elderly

residents of rural counties(21.5%) had one or more activitylimitations, a notably higherproportion than for metroresidents (12.3%). The percentof non-elderly people withlimitations was also higher fornear-metro (17.2%) and nearrural counties (16.4%) than formetro residents.

• Among the eld

rural counties likely to have a(72.9%) than rmetro countiemetro countie

Agency for Healthcare Research and Quality

12

Medical Expenditure Panel Survey

Rural residents more likely 

activity lim

0%

10%20%30%40%50%60%70%80%

17.2%

12.3%

Percent with activity limitation

53.9%

16.4%

61.8%

72.9%

Under age 65 Age 65 and over

Near-metroMetroNear-ruralRural

21.5%

63.0%
Access to Care Adequate a

services can signhealth care use There has been rural residents hhealth care servimore densely posection examinelikelihood of hacoverage and tha usual source ocan affect access across the urban• Health insur

role in ensuobtain timelhave protecthealth care c

• Another me

access to carhave a usual person or plif they are siabout their usual source have importthe quality areceived.

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section 2
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• Among the population under 65

years of age, residents of nearrural counties were more likely tobe uninsured for an entire year(18.5%) than those living inmetro counties (12.7%) or nearmetro counties (12.0%). 

• The percent u

counties (15.2significantly frgroups.

Agency for Healthcare Research and Quality

14

Medical Expenditure Panel Survey

Percent uninsured h

near-rural 

0%4%8%

12%16%20%

Metro

12.7%

7.9%

Near-metro Near-rural Rural

12.0%

18.5%

15.2%

Percent uninsured, under age 65
• The likelihood of not having

Medicare supplemental coveragewas similar for metro, nearmetro, and near-rural counties,ranging from 29.4% to 32.8%. 

• Although the proportion of

elderly people without Medicaresupplemental coverage apppearshighest in rural counties (38.6%),the difference from other countytypes is not significant.

About one-third of the elderly in all countytypes lack Medicare supplemental insurance

0%

10%20%30%40%

Metro

31.7%

25.2%

7.9%

Near-metro Near-rural Rural

32.8%

29.4%

38.6%

Percent without supplemental coverage,

age 65 and over
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• For each of the four urban-rural

categories, only about 7 percentof adults 65 and over lacked ausual source of care.

• Regardless of type of county,

about 1 of every 10 childrenunder 18 lacked a usual source ofcare.

• Among adults 18-44 years,

lacking a usual source of care wasmore common for residents ofmetro counties (30.1%) and nearrural counties (27.2%) than forthose living in near-metrocounties (20.1%). 

• For adults ages 45-64, lacking a

usual source of care was more 

common for m(15.8%) than fnear-metro co

• For all age gro

people withoucare was not sidifferent for rufor other areas

• Regardless of 

ages 18-44 weto have a usua

Agency for Healthcare Research and Quality

16

Medical Expenditure Panel Survey

Elderly and children show little v

across areas in having a usual sourc

0%5%

10%15%20%25%30%35%

8.9% 9.5%

Percent without a usual source of care

12.1%

Under age 18 Age 18-44

Near-metroMetroNear-ruralRural

9.8%

Age 45-64 Age 65 and over

20.1%

30.1%

27.2%

22.7%

11.7%

15.8% 15.6%

13.3%

7.2% 7.1% 7.0% 7.1%
• Uninsured people under 65 were

more likely to lack a usual sourceof care if they lived in moreurban areas, with the proportionranging from 48.3% in metroareas to 28.7% in rural counties. 

• There was less variation across

urban-rural categories for theinsured than for the uninsured.Among insured people under 65,residents of metro and near-ruralcounties were more likely to lacka usual source of care (about16%) than near-metro residents(11.4%). 

Uninsured metro residents most likely tolack a usual source of care

0%

10%20%30%40%50%60%

11.4%

16.4%

Percent without a usual source of care,

under age 65

48.3%

15.7%

38.5%

28.7%

Insured Uninsured

13.5%

35.9%

Use and

Expenses 

While the lik

health care, as wehealth care expenwith many individemographic chapopulation densitproximity to healare also factors. Ssuggest that ruraaccess to primary care, and other hresidents of counpopulation or neareas. This sectiovariations in healexpenses across thtypes for three tyambulatory care hospital outpatienprescription medservices. 

For each typ

average expenses people having anthe year. Charts ipercent of the poexpenses are also charts can generaas the proportion had at least one vsince only a neglithe population viprovider without expenses.

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section 3
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Agency for Healthcare Research and Quality

20

Medical Expenditure Panel Survey

Ambulatory Care

Ambulatory care includes the

treatment of acute conditions andchronic diseases, both preventive anddiagnostic services. It generallyserves as the entry point for mosthealth care in the United States. Themajority of Americans have at leastone visit each year to a health careprofessional in an ambulatory

setting. The outcocannot obtain thepoorer general helife. While most Aambulatory care eyear, this section inoteworthy variatand expenses acrocategories.
• Among the non-elderly

population, near-metro residentswere slightly more likely to haveambulatory expenses (71.0%)than those living in metrocounties (67.2%) or near-ruralcounties (65.5%). However, theproportion of the rural groupwith expenses (65.1%) was notsignificantly different from theother groups.

• Regardless of urban-rural

category, approximately 9 ofevery 10 elderly people hadambulatory expenses. 

Percent of people with ambulatory careexpenses fairly similar across areas

0%

20%40%60%80%

100%

71.0%

67.2%

Percent with ambulatory care expenses

89.0%

65.5%

89.8% 89.2%

Under age 65 Age 65 and over

65.1%

88.0%
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• Among people with an

ambulatory expense, residents ofrural counties had the lowestaverage number of ambulatoryvisits per year. This was true inboth the elderly and non-elderlygroups, but the difference wasespecially prominent for theelderly. 

• Among the el

ambulatory exresidents had ambulatory vimetro residenvisits).

• Among the no

ambulatory exresidents had one fewer ambyear than thos(5.1 vs. 6.0-6.

Agency for Healthcare Research and Quality

22

Medical Expenditure Panel Survey

Rural residents ha

ambulato

02468

1012

6.3 6.3

Average number of ambulatory care visits

10.9

6.0

10.3

5.5

Under age 65 Age 65 and over

Near-metroMetroNear-ruralRural

5.1

9.9

1

For people with ambulatory expenses. 1
• Among non-elderly people with

ambulatory expenses, those inrural counties had a loweraverage number of ambulatorycare visits than residents of moreurban places. This difference wasespecially pronounced for peoplewith at least one activitylimitation. 

• For the non-elderly with at least

one limitation and some expensesfor ambulatory care, theestimated average number ofvisits was significantly lower inrural counties (8.1) than in metro(12.7) or near-metro counties(11.3). 

• For the non-elderly with no

limitations and some expenses forambulatory care, the averagenumber of ambulatory visits waslower in rural counties (4.3) thanin metro counties (5.2).

• Similar comparis

elderly are not slimited sample sgroup.

Area differences in ambulatory visitsgreater for people with activity limitation

02468

101214

5.2 5.1

Average number of ambulatory care visits,

under age 65

12.7

5.1

11.3

8.1

No limitation Some limitation(s)

4.3

9.7

1

For people with ambulatory expenses. 1
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• Among both non-elderly and

elderly people with ambulatoryexpenses, residents of ruralcounties had the lowest averageannual expenses. Differencesfrom other county types wereespecially large for the elderly. 

• Among the elderly with

ambulatory expenses, the averageexpense was less than half as largefor people in rural counties($662) as for people in the otherurban-rural categories ($1,432-$1,687). 

• Among the no

ambulatory exrural counties ambulatory exthose in the otcategories ($8

Agency for Healthcare Research and Quality

24

Medical Expenditure Panel Survey

People in rural counties ha

ambulatory e

$0

$300$600$900

1,200

$1,500$1,800

$848 $807

Average annual ambulatory expense

$1,596

$946

$1,687

$

Under age 65 Age 65 and over

$609

$1,432

1

For people with ambulatory expenses. 1
• Average ambulatory expenses for

children under 18 with expenseswere similar across the urbanrural categories (approximately$400). 

• Among people ages 18-44 with

ambulatory expenses, those inrural counties had lower averageambulatory expenses ($544) thanthose in the other categories($833-$895). 

• Among people a

ambulatory expein near-rural couaverage ambulat($1,568) than thrural counties ($

Ambulatory expenses for children similaracross areas

$0

$200$400$600$800

$1,000$1,200$1,400$1,600

$397 $394 $407

Under age 18 Age 18-44

$377

Age 45-64

$852 $833 $895

$544

$1,246 $1,224

$1,568

$91

Average annual ambulatory expense,

under age 65

1

For people with ambulatory expenses. 1
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• Non-elderly males with

ambulatory expenses who lived inrural counties had substantiallylower average expenses ($412)than their counterparts in theother urban-rural categories(ranging from $755 to $919). 

• Non-elderly females with

ambulatory expenses showed lessvariation than males in averageexpenses across urban-ruralcategories. However, non-elderlyfemales living in rural countieshad lower ambulatory expensesthan those in near-rural counties($765 vs. $968).

• Average ambulatory expenses in

rural counties were nearly twiceas large for females as for males.There was a smaller genderdifference in metro counties andno significant difference bygender in the other twocategories. 

• Similar compa

elderly are not limited sample group.

Agency for Healthcare Research and Quality

26

Medical Expenditure Panel Survey

Ambulatory expenses for males u

lowest in rural 

$0

$200$400$600$800

$1,000

$773 $755

Average annual ambulatory expense,

under age 65

$849

$919 $912

Males Females

$412

$968

1

For people with ambulatory expenses. 1
Prescription Medicines

Outpatient prescription

medicines play an ever-increasingrole in the health care system of theUnited States. The share of overallhealth spending in the U.S.community population that goes forprescription medicines has risenrapidly in recent years, from about12 percent in 1996 to about 18percent in 2001. Prescriptionmedicines are a key health policyissue, as evidenced by concernsabout the rising costs ofprescriptions and the recent

enactment of a Medicare drugbenefit. Along with other healthcare provider shortages in ruralplaces, there are fewer pharmacistsper capita in rural places than inmore populated settings.Additionally, there may bedifferences in prescribing patterns inthe most rural places because thereare fewer health care providers. Thissection provides data comparingprescription medicine use andexpenses across urban-ruralcategories.
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• In all of the urban-rural

categories, approximately 9 in 10elderly residents had expenses forprescribed medicines. Elderlyresidents of rural counties wereslightly more likely to haveprescription medicine expenses(91.2%) than the elderly in metrocounties (87.6%). 

• Non-elderly re

metro countiemore likely to prescribed methan those livicounties (57.7counties (59.2for rural counsignificantly frgroups.

Agency for Healthcare Research and Quality

28

Medical Expenditure Panel Survey

Percent of elderly with pres

medicine expenses similar acro

0%

20%40%60%80%

100%

64.4%

57.7%

Percent with prescription medicine expense

87.6%

59.2%

89.9% 91.2%

Under age 65 Age 65 and over

Near-metroMetroNear-ruralRural

60.4%

87.2%
• Among the non-elderly with

expenses for prescribedmedicines, annual per-personexpenses were slightly higher fornear-metro residents ($487) thanfor metro residents ($421) ornear-rural residents ($417). Theaverage for rural residents ($495)

was not significantly differentfrom the average for the othertypes of counties.

• Among elderly people with

prescription expenses, the averageannual expense per person didnot vary significantly across theurban-rural categories. 

• For each urban-r

the average annumedicine expenswith such expentwice as high for elderly people.

Average prescription medicine expensesvary little across urban-rural continuum

$0

$200$400$600$800

$1,000$1,200

$487

$421

Average annual prescription medicine expense

$1,017

$417

$1,074 $1,0

Under age 65 Age 65 and over

$495

$1,038

1

For people with prescription medicine expenses. 1
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Agency for Healthcare Research and Quality

30

Medical Expenditure Panel Survey

Dental Care

Access to and use of dental care

has been consistently identified as animportant factor in a person’s overallhealth. For example, periodontaldisease has been identified as apotential risk factor associated with anumber of health conditions,including cardiovascular disease,cerebrovascular disease, diabetes, andosteoporosis. Factors such as

socioeconomic stacoverage, transpornumber of dentistpresence of commprograms have beeassociated with discare use and oral hsection of the chardental care use anthe four urban-rur
• Among the non-elderly, 31.4% of

those in rural counties had dentalexpenses, a significantly lowerproportion than for residents ofmetro or near-metro counties(approximately 41% each). 

• Among individuals 65 and over,

the likelihood of having dentalexpenses generally declined withincreasing rurality, ranging from42.1% in metro counties to20.4% in rural counties.

Residents of rural counties less likely tohave dental expenses

0%

10%20%30%40%50%

41.8% 41.1%

Percent with dental expense

42.1%

36.4%

33.2%

20.4%

Under age 65 Age 65 and over

31.4% 31.2%
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. • Among the elderly with dental

expenses, residents of ruralcounties had an average of onefewer dental visit per year thanmetro residents (1.9 vs. 2.9).

• The average a

dental visits fopeople with excare did not vamong the urbcategories. 

Agency for Healthcare Research and Quality

32

Medical Expenditure Panel Survey

Frequency of dental visi

for rura

0.00.51.01.52.02.53.03.5

2.4 2.5

Average number of dental visits

2.9

2.4 2.5

1.9

Under age 65 Age 65 and over

Near-metroMetroNear-ruralRural

2.4

2.6

1

For people with dental expenses. 1
• Among the non-elderly with

dental expenses, average annualexpenses per person were higherfor metro residents ($482) thanfor residents of near-metro areas($391) or rural counties ($308). 

• Average annual dental expenses

for elderly metro residents withsuch expenses ($543) weresubstantially higher thanexpenses for elderly residents ofnear-rural counties ($381). 

Average expenses for dental care higher inmetro counties

$0

$100$200$300$400$500$600

$391

$482

Average annual dental expense

$543

$438

$496

*

Under age 65 Age 65 and over

$308

$381

1

For people with dental expenses.Estimate for rural counties not shown because thesample size was too small for reliable estimation.

1*

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references

Eberhardt MS, Ingram DD, Makuc DM,

et al. Urban and rural health chartbook:Health, United States, 2001.Hyattsville, MD: National Center forHealth Statistics, 2001. 

Ezzati-Rice TM, Kashihara D, Machlin

SR. Health care expenses in the UnitedStates, 2000. Rockville (MD): Agencyfor Healthcare Research and Quality;2004. MEPS Research Findings No. 21.AHRQ Pub. No. 04-0022.

Gamm LD, Hutchison LL, Dabney BJ, et

al., eds. Rural Healthy People 2010: Acompanion document to Healthy People2010. Vol. 2. College Station, TX: TexasA&M University System Health ScienceCenter, School of Rural Public Health,Southwest Rural Health ResearchCenter, 2003.

Larson SL, Fleishman JA. Rural-urban

differences in usual source of care andambulatory service use: Analyses ofnational data using Urban InfluenceCodes. Medical Care 2003; 41(7Suppl):III65-III74.

Machlin SR, Cohen 

Health care expenpopulation, 1996Agency for HealthQuality; 2001. MAHRQ Pub. No. 

National Rural Heal

different about rusite: http://wwwpagefile/differentApr 28, 2004.

Reid RA, Smith HL

Checkerboard Areplanning for rural Health Reports 197(2):156-64.

Ricketts TC, ed. Ru

United States. NeUniversity Press, 1

Please consult the MEPS Web site at http://www.m

an updated publications list and other information from Madditional information, contact the MEPS Project Directomepspd@ahrq.gov. 

Urban-Rural Categories

There is a lack of consensus in health

services research about what constitutes arural area. This chartbook examines urbanrural variations by four levels ofurbanization: one for counties comprisingmetropolitan statistical areas (MSAs) andthree for counties that are not classified aspart of an MSA. An MSA is generallycomprised of counties with a large urbancenter(s) along with other counties that areconsidered to have a high degree of

geographic, economintegration with the The categories are 

The four categ

were derived from Codes established bof Agriculture. The creating these categnumber of categorirelative continuum most rural. 

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definitions of terms 

Metro 1 MSA Large (central and 

fringe counties) 2 MSA Small 

Near-metro 3 Non-MSA Adjacent to large MSA 

4 Non-MSA Adjacent to large MSA 5 Non-MSA Adjacent to small MSA 6 Non-MSA Adjacent to small MSA 

Near-rural 7 Non-MSA Not adjacent to MSA 

8 Non-MSA Not adjacent to MSA 

Rural 9 Non-MSA Not adjacent to MSA 

Urban

Chartbook Influence MSA Characteristics/category Code status proximity 

Note: MSA is metropolitan statistical area. Urban Influence Codes are established by the U.S. DepaTable A. Urban-rural categories used in this report
Figure A shows the distribution of the

U.S. population in 2000 along this urbanrural continum.

It is important to note that urban-rural

classification schemes cannot fully describethe characteristics of individual counties.Locations within a county may varysignificantly. For example, somemetropolitan counties may be large andhave residents who live far from healthservices. Type-of-Service Categories

Health care services are categorized

according to reports by survey respondents.

Ambulatory service expenses cover visits

to medical providers seen in office-basedsettings or clinics, hospital outpatientdepartments, and clinics owned andoperated by hospitals.

Prescription medicine expenses cover all

prescribed medications that were initiallypurchased or refilled during 1998, 1999, or2000, as well as diabetic supplies (some ofwhich may have been purchased without aprescription).

Dental service expenses cover any type

of dental care, including services providedby general dentists, dental hygienists, dentaltechnicians, dental surgeons, orthodontists,endodontists, and periodontists. Population Characteristics

In general, population characteristics

were measured as of December 31st of theyear of study (1998, 1999, or 2000), orthe last date that the sample person was partof the civilian noninstitutionized populationliving in the United States prior toDecember 31st of that year.Race/Ethnicity

Comparisons by race/ethnicity in this

chartbook are based on the following tworace/ethnicity groups: non-Hispanic whiteand all others. Sample size limitationsprevented analysis using specific racial andethnic groups.

Classification by 

based on information each family member. asked if the race of thbest described as AmeNative, Asian or Pacifwhite, or other. They sample person’s main ancestry was Puerto RMexican, Mexican Amother Latin Americanpersons whose main nancestry was reported Hispanic groups, regabackground, are classHealth Insurance Status

The health insur

chartbook are based ocoverage during the y1999, or 2000). Indivclassified as follows:

Any private heal

individuals with coverphysician care (other Medicaid, or other pucoverage) at any time Persons with Armed Fcoverage–TRICARE–because the coverage insurance. Individuals service coverage for sand vision care are nocategory.

Agency for Healthcare Research and Quality

38

Medical Expenditure Panel Survey

Figure A. Populaton by urban-rural categories:

United States, 2000

Near-metro

11.3%

(31.9 million)

Metro

82.6%

(232.6 million)

Near-rural

4.9%

(13.9 million)

Rural

1.2%

(3.2 million)

Note: Based on 2000 census. Includes institutionalized

persons.
Public coverage only includes

individuals who met both of the followingcriteria:• They were not covered by private

insurance at any time during the year.

• They were covered by one of the

following public programs at somepoint during the year: Medicare,Medicaid, or other public hospital/physician coverage.

Uninsured includes individuals who

were not covered by Medicare, TRICARE,Medicaid, other public hospital/physiciancoverage, or private hospital/physiciancoverage during the year of study.Individuals covered by onlynoncomprehensive State-specific programs(e.g., Maryland Kidney Disease Program,Colorado Child Health Plan) or privatesingle-service plans (e.g., coverage fordental or vision care only, coverage foraccidents or specific diseases) are consideredto be uninsured.

Individuals age 65 and older were

classified as follows:

Medicare only includes individuals who

were covered by Medicare at any pointduring the year but did not have privateinsurance or any other public insurance. 

Medicare and private insurance

includes individuals who had supplementalprivate insurance in addition to Medicare atsome time during the year.

Medicare and other public insurance

includes individuals who had Medicaid orother public insurance in addition toMedicare but no private supplementalinsurance at any time during the year.Income Category

Each person was classified according to

the total income of his or her family in thegiven year. Within a household, allindividuals related by blood, marriage, oradoption were considered to be a family.Personal income from all family memberswas summed to create family income.Possible sources of income included annualearnings from wages, salaries, bonuses, tips,and commissions; business and farm gainsand losses; unemployment and Workers’Compensation; interest and dividends;alimony, child support, and other privatecash transfers; private pension, IRAwithdrawal, Social Security and veterans’payments; Supplemental Security Incomeand cash welfare payments from publicassistance, Aid to Families with DependentChildren, and Aid to Dependent Children;gains or losses from estates, trusts,partnerships, S corporations, rent, androyalties; and a small amount of otherincome. 

Income category was determined by

the ratio of family income to the Federalpoverty threshold for the year of study,which varies by family size and age of headof family. The three income categories inthe chartbook are defined as follows:

Poor and near poor 

families with incomes le125% of the poverty lin

Low income includ

with incomes greater ththan or equal to 200% o

Middle and high in

persons in families with of the poverty line.Perceived Health Status

The MEPS respon

rate the health of each paccording to the followexcellent, very good, goFor this report, the five categories were collapsetwo categories: excellenfair or poor health. Activity Limitation Status

A series of questio

limitations was asked abmember. Any family mlimitation that falls into groups was classified as an ADL (activity of dailsuch as needing help widressing; an IADL (instdaily living) limitation swith shopping or laundsuch as problems climbior lifting objects; vision impairment. 


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