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Millions of suburban residents in US lack health insurance

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Boston, MA – Nearly 40% of the uninsured population in America lives in the suburbs and nearly one in seven suburban residents lacks health insurance.

Despite the suburbs' general reputation of affluence, the U.S.'s growing poor population in suburban areas faces substantial barriers to accessing health care–similar to those faced by the urban and rural poor–according to the study.

It is the first national analysis comparing health care coverage and access between people living in the suburbs and people in urban and rural areas.

The study will appear in the October 2017 issue of Health Affairs.

"We rarely think about suburbs when we think about vulnerable populations. Increasing rates of suburban poverty haven't gotten much attention from the public health sector, and policymakers really haven't started to consider what these shifts in the geography of poverty mean for health care access and for health disparities," said lead author Alina Schnake-Mahl, a doctoral student at Harvard Chan School.

Poverty has been on the rise in suburbia for a number of reasons: job losses and loss of wealth during and after the 2008 recession; a "return to the city" trend among millennials and empty nesters and subsequent pricing out of lower-income families; more affordable suburban housing options; and international immigration to suburban communities.

To explore more about how these shifts are impacting health insurance rates and health care access, the researchers analyzed data from 2005-15 from roughly 2.7 million adults interviewed as part of the U.S. Centers for Disease Control and Prevention's Behavior Risk Factor Surveillance System, an annual national telephone survey.

The findings showed that:

  • The suburbs were home to 44% of the overall population and 38% of the uninsured population, and the uninsurance rate among suburbanites was 15%.
  • The probability of having no usual source of health care in the suburbs was 19%, and for having no routine annual checkup, 34%.
  • Among low-income suburbanites, 36% had an unmet health care need due to cost and 42% had not had a recent checkup.
  • All poor adults–whether they lived in cities, rural areas, or the suburbs–had 8 times higher odds of being uninsured and 1.7 times higher odds of no recent checkup compared to higher-income adults.

Uninsurance rates did decline in the suburbs after implementation of the Affordable Care Act (ACA) in 2014–as they did in all geographic regions–but suburban coverage gains appear to have been more limited than in urban and rural areas. While the uninsurance rate in the suburbs had been lower than in other regions from 2005-14, by 2015 it was essentially the same as in urban areas.

Speculating as to why poor suburbanites face barriers to health care coverage and access, the researchers pointed out challenges unique to the suburbs: the relative lack of community health centers and free clinics; safety net hospitals that are far from home with limited public transportation options; providers that may be reluctant to treat uninsured patients; and limited availability of services such as mental health and substance abuse treatment.

"In most studies, suburban areas are grouped with urban areas. But suburbs are unique geographies with specific challenges for health care access. Providing services and care to the suburban poor population may require different policies than those typically relied on in urban or rural areas," said Schnake-Mahl.

Senior author of the study was Benjamin Sommers, associate professor of health policy and economics at Harvard Chan School and associate professor of medicine at Brigham & Women's Hospital.

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"Health Care In The Suburbs: An Analysis Of Suburban Poverty and Health Care Access," Alina S. Schnake-Mahl and Benjamin D. Sommers, Health Affairs, October 2017, doi: 10.1377/hlthaff.2017.0545

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About Harvard T.H. Chan School of Public Health

Harvard T.H. Chan School of Public Health brings together dedicated experts from many disciplines to educate new generations of global health leaders and produce powerful ideas that improve the lives and health of people everywhere. As a community of leading scientists, educators, and students, we work together to take innovative ideas from the laboratory to people's lives–not only making scientific breakthroughs, but also working to change individual behaviors, public policies, and health care practices. Each year, more than 400 faculty members at Harvard Chan School teach 1,000-plus full-time students from around the world and train thousands more through online and executive education courses. Founded in 1913 as the Harvard-MIT School of Health Officers, the School is recognized as America's oldest professional training program in public health.

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Todd Datz
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http://dx.doi.org/10.1377/hlthaff.2017.0545

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