Disparity grows in rural vs. urban health coverage

By Cindy Hadish

A new report from the University of Iowa documents a widening divide in health insurance coverage between rural and urban workers in Iowa.

Employees in Iowa's 79 rural counties pay significantly higher premiums, deductibles, co-pays and out-of-pocket maximums than workers in the 20 urban counties, according to the report.

Researchers with the UI College of Public Health's Healthier Workforce Center for Excellence collaborated on the project with David P. Lind & Associates of Clive.

“Real Iowans often don't have a voice in the dialogue,” said Dr. James Merchant, director of the center. “The goal of this report is to give employers and ordinary citizens a voice.”

To do that, researchers focused on surveys from 1,200 employed Iowans, comparing health outcomes, primary health care utilization, preventive services, insurance coverage and cost trends. Merchant and center coordinator Matt Lozier, co-authors of the report, spoke Friday to The Gazette editorial board about the study, called “Iowans Speak Out on Their Health: The Rural-Urban Divide.”

“The differences turned out to be surprisingly striking,” Merchant said.

Rural workers generally had less income than their urban counterparts and worked for smaller employers who often cannot provide company wellness programs and struggle to provide health insurance coverage. Forty percent of rural employees worked for companies with 1 to 19 workers, compared to about 28 percent of urban workers.

The rural respondents were more likely to be older women with a college degree, self-employed and to be obese, but were less likely to have a household income of more than $75,000.

Merchant said one surprise was that the mental health status of rural respondents was better than that of urban workers. That could be related to marital status, he said, as more rural residents were married - 77 percent - compared to 69 percent of urban dwellers, and married couples tend to report better mental health.

Rural workers, however, made more sacrifices to cut back on health care expenses. For example, 45 percent decided not to go to the doctor when needed because of the cost, compared to 35 percent of urban dwellers.

Nearly 23 percent of those rural respondents stopped taking medication to avoid the cost of prescription drugs versus 16 percent of urban workers. Moreover, more than 44 percent of rural workers switched to a health insurance plan with higher deductibles and co-payments to save money, compared to about 31 percent of urban employees.

“They're trying to cut corners in an unhealthy way,” Merchant noted.

Rural workers pay an average of $24 more per month in family coverage, or $362 compared to $338 for urban workers, according to Lind's Iowa Employer Benefits Study that was included in the report. The study showed single deductibles for rural workers averaged $1,464 in 2010, contrasted with $1,108 for urban employees; and $3,282 for rural family deductibles versus $2,255 for urban families.

Out-of-pocket maximums for rural family coverage averaged $5,953 compared to $4,846 for urban employees. Rural workers also pay an average of $2 more for office visit co-payments than their urban counterparts.

To cope with health insurance costs that have risen nearly 10 percent annually, the report notes that Iowa employers continue to shift costs to employees through plan design changes, such as higher deductibles.

If that trend continues, the annual deductible for rural employees would quadruple to a staggering 29 percent of household income in 2020, according to the report, with deductibles for urban workers projected to rise to 14 percent of income by 2020.

The full report is online at

www.realiowans.org