This project will assess changes in Medicare per-beneficiary spending across rural and urban counties from 2007 to 2020. It will examine differences in rural versus urban per-beneficiary spending on hospital inpatient, hospital outpatient, physician, and post-acute care after the Affordable Care Act (ACA).

The study will conduct a longitudinal quantitative analysis. There will be two set of outcomes:

1. County-level price-standardized per-beneficiary expenditures across all service settings and by setting
2. County-level proportions of total Medicare expenditures spent on each service setting

A trend analysis of both sets of the outcomes across counties by levels of rurality from 2007 to 2019 will be conducted. The ratio of total expenditures and specific expenditure categories between urban and rural in each year from 2007 to 2019 graphing the results to illustrate pre- and post-ACA differences will be calculated.

Z tests will be used to compare the following:

• Ratios of rural Medicare expenditures to the urban expenditures in 2007 to the ratios of rural Medicare expenditures to the urban expenditures in 2019 for total per-beneficiary expenditures
• Expenditures in each of the 4 subsets of services (except other services)
• Per-beneficiary expenditures for each of the 3 subcategories of post-acute care services