Rural vs. Urban Home Health Care: Critical Differences

As the baby boomer population gets older, demand for in-home health services is likely to increase. Many people in the 65 and older age range are finding home health more appealing, and overall, it's becoming exceedingly more popular. However, research shows that rural residents are getting the short end of the stick. Home health care is not created equal, and their urban peers seem to be getting better treatment.

According to the 2020 U.S. Census, the decade between 2010 and 2020 saw the largest growth in Americans over 65 years old from 1880 to 1890.

Despite rural communities being responsible for only 15% of the U.S. population, a 2019 study from the Census Bureau found that 22% of older Americans reside in these communities. As the U.S. population ages, demand for home health services will increase.

What are home health services?

Assistant Professor in the Department of Health Policy Management at Bloomberg’s School of Public Health at Johns Hopkins University, Katherine Miller, says the demand for home health services has increased in the last 20-plus years.

"There has been this really big shift from providing care in institutional settings to care in the home," she said. "There is a myriad of federal and state policies that have supported this shift, which is really in response to the 1999 Olmstead decision that said that people should be allowed to live as independently as possible."

Those who are older or living with an illness or disability may not only need medical care, but assistance with daily tasks and chores around the house. Miller explains home health services can be divided into two separate parts.

"Home health care really captures medical care, that is when a nurse, occupational, or physical therapist comes to provide care in the home. There is also another important aspect of helping people with bathing, toileting, eating, and chores around the house — we tend to think of that as home care," she said.

The U.S. Centers for Medicaid and Medicare Services says Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) cover eligible home health services for those unable to leave home without help, leaving home isn't recommended, or leaving home takes more effort.

Home health care services covered by Medicare:

• Part-time skilled nursing care
• Speech-language pathology services
• Medical social services
• Injectable osteoporosis drugs for women
• Part-time home aid
• Medical equipment
• Physical and occupational therapy

Medicare does not cover home care needs like 24-hour-a-day care, meals, grocery shopping, cleaning, and custodial or personal care such as bathing, dressing, or using the restroom. These tasks fall under home and community-based services which are funded by each state’s Medicaid program.

Rural vs. urban home health services

A 2022 review that evaluated the differences between rural and urban home health agencies found disparities in home health care quality. The results revealed rural home health care beneficiaries have lower utilization of home health care, fewer physical therapy or rehabilitation visits, and lower quality of home health care agencies.

Along with lesser quality of care, rural residents are also battling a shortage of home care workers.

Nursing home closures are a relatively rare event, but what we do see is when they occur, they are occurring disproportionality in rural areas. That is a potential concern because when you look at the workers who come into the home to provide care, we see there is some evidence that there are not enough workers to meet the needs of rural populations. There is this bigger concern of – if we don’t have an adequate workforce to provide care in the home, nursing homes are closing at a faster rate in rural areas, and we have an aging population, that collectively raises the concern of how these cares and meeds are going to be met.

- Miller

Some older Americans may not qualify for Medicaid’s home and community-based services, especially those who have not passed Medicaid Expansions. Research shows states that have passed these expansions are likely to have better rates of long-term care among older adults. Texas, the state with the largest rural population (over 4.7 million), is yet to pass these expansions. In some cases, individuals may be forced into tough financial decisions to receive much-needed assistance.

"Medicaid spend-down is where you have an individual, often an older adult who will spend down their assets if they are not healthy enough to pay out of pocket and don’t have insurance doesn’t cover it," Miller said. "This is often thinking about people who didn’t qualify for Medicaid originally, so they will spend down their assets so they qualify for Medicaid."

Miller was integral to the "Rural disparities in use of family and formal caregiving for older adults with disabilities" study released earlier this year. The study found older adults living in rural areas were more likely to receive home care from family members than urban adults. Between 2004 to 2016, Miller and her team found family members mostly served older adults compared to formal caregivers.

Being a caregiver to an ailing family member can be a stressful and difficult task. Rural areas are known for their tight-knit communities and sense of duty to family — could this be the reasoning behind high rates of family caregivers, or is it the lack of home health care agencies? Miller is hungry for answers in her future investigations.

"That is what my work is building towards, is trying to tease out how much of this disproportional reliance on family caregivers in rural areas reflects preferences versus lack of alternatives," Miller said. "We don’t have an answer yet, but that is a next-step project I’m working on."