Rural Health
Research Gateway

2016 Research Publications

Browse the full list of research publications from the Rural Health Research Centers.

Products – Freely accessible products include policy briefs, fact sheets, full reports, chartbooks, and interactive data websites.

Journal Articles – Articles in peer-reviewed journals may require a subscription or affiliation with a subscribing library. For these publications, Gateway lists the article citation, a brief summary, a link to additional information and access to the full-text of the article, if available.

  • How Would Rural Hospitals Be Affected by Loss of the Affordable Care Act's Medicare Low-Volume Hospital Adjustment?
    Journal Article
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2016
    Using data from the Hospital Market Service Area File, the Hospital Cost Report Information System, and Nielsen-Claritas Pop-Facts, this study examined the effect the low-volume hospital payment adjustment has on a hospital's finances. It also looked at the effects of losing the payment adjustment.
  • To What Extent Do Community Characteristics Explain Differences in Closure Among Financially Distressed Rural Hospitals?
    Journal Article
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2016
    This study examined the differences between rural hospitals at high risk of financial distress that stayed open and those that closed.
  • Relationship Between Hospital Policies for Labor Induction and Cesarean Delivery and Perinatal Care Quality Among Rural U.S. Hospitals
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 11/2016
    This study focused on maternity care quality by taking a look at hospitals' policies regarding induced labor and Cesarean deliveries.
  • What Is the Potential of Community Paramedicine to Fill Rural Healthcare Gaps?
    Journal Article
    WWAMI Rural Health Research Center
    Date: 11/2016
    This study collected information on rural community paramedicine in the U.S. programs to describe their goals, target populations, services offered, connections with local community providers and resources, outcomes measured, and results, where available.
  • Medicare Accountable Care Organizations: Quality Performance by Geographic Categories
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2016
    Provides an analysis of the differences in Accountable Care Organization (ACO) performance on the quality measures among the Medicare Shared Saving Program ACOs with varying levels of rural presence. Findings suggest that ACOs with significant rural presence have performed as well as, if not better than, urban ACOs in delivering quality care.
  • The Financial Importance of the Sole Community Hospital Payment Designation
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 11/2016
    Assesses the financial importance of the Sole Community Hospital (SCH) program by: the proportion of SCHs that was reimbursed at the hospital specific rate between 2006 and 2015; the profitability of providing services to Medicare patients in SCHs between 2006 and 2015, and; the financial consequences if the SCH program had not existed in 2015.
  • Health-Related Quality of Life Among Adults 65 Years and Older in the United States, 2011-2012: A Multilevel Small Area Estimation Approach
    Journal Article
    Rural and Minority Health Research Center
    Date: 10/2016
    This study compiled estimates, at the county level, of poor health-related quality of life among those ages 65 and older. The study examined physical and mental health and found significant differences in health across the United States.
  • Community Factors and Outcomes of Home Health Care for High-Risk Rural Medicare Beneficiaries
    Policy Brief
    WWAMI Rural Health Research Center
    Date: 10/2016
    Outcomes of care vary by region of the country for rural Medicare beneficiaries receiving home health services for high-risk conditions such as heart failure. Those in the East South Central and West South Central Census Divisions had lower rates of community discharge and higher rates of hospital readmission and emergency department use.
  • The Impact of the Low Volume Hospital (LVH) Program on the Viability of Small, Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2016
    This brief compares rural Low Volume Hospital (LVH) to non-LVH characteristics and estimates the financial impact of eliminating the LVH program and reverting to the original (2005) LVH classification and payment adjustment.
  • Spread of Accountable Care Organizations in Rural America
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 10/2016
    This brief updates a RUPRI Center analysis of the presence of Medicare Accountable Care Organizations (ACOs) in rural areas of the US in 2013. Using participation data through 2015, the current brief finds that there has been broad growth in the number of places where ACO participating providers can be found, including rural locations.
  • Health Insurance CO-OPs: Product Availability and Premiums in Rural Counties
    Policy Brief
    Maine Rural Health Research Center
    Date: 10/2016
    We describe regional distribution and market prevalence of Consumer Operated and Oriented Plan (CO-OP) products in rural and urban counties, and compare the number of products available in counties with and without CO-OP plans in 2014 and 2015.
  • Trends in Risk of Financial Distress Among Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2016
    From January 2005 to July 2016, 118 rural hospitals have closed permanently, and the rate of rural hospital closures is increasing. Hospital closures impact millions of rural residents. Identifying hospitals at high risk of closure and assessing the trends over time may inform strategies to prevent or mitigate the effects of closures.
  • Do Residencies That Aim to Produce Rural Family Physicians Offer Relevant Training?
    Journal Article
    WWAMI Rural Health Research Center
    Date: 09/2016
    Examines the rural-centric family medicine residencies, their training locations, and rurally relevant skills training provided. Rural training can promote rural practice, but the number of family medicine residencies with a rural focus, geographic distribution of training, and training content are poorly understood.
  • Current State of Child Health in Rural America: How Context Shapes Children's Health
    Journal Article
    Rural and Minority Health Research Center
    Date: 09/2016
    Provides an essay on the status of children in rural America that focuses on the rural environment that may affect health.
  • Medicare Advantage Enrollment Update 2016
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2016
    This annual brief examines Medicare Advantage (MA) enrollment data from March 2015 and March 2016. It shows that enrollment in MA and other prepaid plans increased, both nationally and in non-metropolitan areas, but the rate of growth has slowed compared to previous years.
  • Supply and Distribution of the Behavioral Health Workforce in Rural America
    Policy Brief
    WWAMI Rural Health Research Center
    Date: 09/2016
    This brief uses National Provider Identifier (NPI) data to report on the variability of the supply and provider to population ratios of five types of behavioral health workforce providers (psychiatrists, psychologists, social workers, psychiatric nurse practitioners, counselors) in Metropolitan, Micropolitan and Non-core rural areas across the U.S.
  • Telemedicine Penetration and Consultation Among Rural Trauma Patients in Critical Access Hospital Emergency Departments in North Dakota
    Policy Brief
    Rural Telehealth Research Center
    Date: 09/2016
    This study describes the penetration of ED-based telemedicine in North Dakota critical access hospitals and its use for rural trauma patients. Investigators showed that telemedicine subscription increased to 81 percent of rural North Dakota hospitals, and 11 percent of patients in a telemedicine-capable ED used telemedicine as part of their care.
  • Financial Performance of Rural Medicare ACOs
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2016
    Assesses the financial performances of rural accountable care organizations (ACOs) based on different levels of rural presence.
  • Why Are Obstetric Units in Rural Hospitals Closing Their Doors?
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 08/2016
    Analyzes the reasons behind hospital- and county-level factors for rural obstetric unit closures.
  • Rural-Urban Differences in Insurer Participation for Marketplace-Based Coverage
    Policy Brief
    University of Minnesota Rural Health Research Center
    Date: 08/2016
    This policy brief examines the differences between rural and urban counties in terms of the number and composition of insurers in Federally-Facilitated Marketplaces.
  • The Practice of Midwifery in Rural U.S. Hospitals
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 07/2016
    Analyzes the role of certified nurse-midwives (CNMs) in providing maternity care in rural US hospitals and to examine state-level variations on rural CNM practice. CNMs play an important role in the maternity care workforce in rural US hospitals.
  • Factors Associated With High-Risk Rural Women Giving Birth in Non-NICU Hospital Settings
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 07/2016
    Identifies rick factors for childbirth in facilities without neonatal intensive care unit (NICU) capacities among high-risk rural women. The study found that rural women with preterm birthday and multiple gestation pregnancies were less likely to give birth in a hospital with NICU capacity if no local hospital had this capacity.
  • Understanding the Business Case for Telemental Health in Rural Communities
    Journal Article
    Maine Rural Health Research Center
    Date: 07/2016
    This article describes the current landscape and characteristics of rural telemental health programs and then examines their business case.
  • Rural Medicare Advantage Market Dynamics and Quality: Historical Context and Current Implications
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2016
    There is significant variation in the quality ratings of MA plans that are available to rural beneficiaries. This brief suggests that policy interventions may be necessary to improve the quality of MA plans in rural areas.
  • Graduates of Rural-centric Family Medicine Residencies: Determinants of Rural and Urban Practice
    Policy Brief
    WWAMI Rural Health Research Center
    Date: 07/2016
    This study of graduates of family medicine residencies seeking to produce rural physicians identified influences on rural practice choice, including significant others, residency, and practice communities. Findings point to the need to sustain the preferences of physicians interested in rural practice and encourage this interest in others.
  • Vulnerable Rural Counties: The Changing Landscape, 2000-2010
    Policy Brief
    Rural and Minority Health Research Center
    Date: 07/2016
    This brief illustrates the distribution of rural vulnerable populations and the challenges they face. Understanding the demography of rural America is vital to understanding what programs, interventions and policy initiatives are needed to improve healthcare access, delivery and outcomes.
  • Colonoscopy Access and Utilization – Rural Disparities in the Carolinas, 2001-2010
    Policy Brief
    Rural and Minority Health Research Center
    Date: 07/2016
    This study aims to use data on where patients travel for their colonoscopies to determine the extent to which access is changing over space and time, and to better understand utilization patterns among rural residents of North and South Carolina between 2001 and 2010.
  • Looking Ahead: Rural-Urban Differences in Anticipated Need for Aging-Related Assistance
    Policy Brief
    Rural and Minority Health Research Center
    Date: 07/2016
    Rural older adults with a disability can anticipate a longer lifespan than urban adults. Rural areas tend to be served by fewer providers of home health services. This brief describes the degree to which rural and urban pre-retirement age adults, persons ages 40-64, anticipate the need for assistance later in life and where they obtain such help.
  • Ambulatory Care-Sensitive Condition Hospitalizations Among Medicare Beneficiaries
    Journal Article
    Rural and Minority Health Research Center
    Date: 06/2016
    Examines the relationship between the distribution of primary care physicians and Medicare beneficiaries' ambulatory care-sensitive condition hospitalizations using statistical and spatial analyses.
  • Geographic Disparities in Mortality Among the End Stage Renal Disease Patients: An Analysis of the United States Renal Data System, 2007-08.
    Journal Article
    Rural and Minority Health Research Center
    Date: 06/2016
    Explores the association between morality, rurality, and distance from the treatment facility of patients with end-stage renal disease (ESRD). Rural patients were found to have a mortality advantage.
  • Rural Enrollment in the Federally Facilitated Marketplace
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 06/2016
    Analyzes the differences in rural and urban enrollment rates in counties across 32 states by using data from the Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services.
  • Medicare Accountable Care Organizations: Beneficiary Assignment Update
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2016
    This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services Accountable Care Organization regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Understanding ACO beneficiary assignment policies is dire in managing ACO providers and beneficiaries.
  • Health Insurance Marketplaces: Premium Trends in Rural Areas
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2016
    Total Health Insurance Marketplace premiums have grown disproportionately in rural places in 2016. Urban counties have an average of 4.2 firms, while rural counties average 3.2 firms offering coverage through the HIMs. This causes concern since, at the county level, we find that as the number of firms increases, premiums increase at a slower rate.
  • Are Rural Older Adults Benefiting From Increased State Spending on Medicaid Home and Community-Based Services?
    Policy Brief
    Maine Rural Health Research Center
    Date: 06/2016
    Little is known about variations in the availability or use of Medicaid Home and Community-Based Services (HCBS) within states, across rural and urban areas. This study used national claims data to examine differences in HCBS use and expenditures among rural and urban older adult Medicaid beneficiaries receiving LTSS.
  • Ensuring Access to High-Quality Maternity Care in Rural America
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 05/2016
    Examines the access to high-quality for rural women care during pregnancy and childbirth. Policy interventions at the local, state, and federal levels could help to address maternity care workforce shortages and improve quality of care available to the one-half million rural U.S. women who give birth each year.
  • Location of Childbirth for Rural Women: Implications for Maternal Levels of Care
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 05/2016
    This study looks into the rate at which rural women give birth at nonlocal hospitals. Approximately 75% of rural women gave birth at local hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at nonlocal hospitals, implying a potential access challenge for this population.
  • Quality Measures and Sociodemographic Risk Factors: The Rural Context
    Policy Brief
    University of Minnesota Rural Health Research Center
    Date: 05/2016
    This policy brief aims to inform discussions concerning whether or not to adjust provider quality measures for differences in patient characteristics by examining how rurality and key sociodemographic variables might affect quality-of-care outcomes.
  • State Variations in the Rural Obstetric Workforce
    Policy Brief
    University of Minnesota Rural Health Research Center
    Date: 05/2016
    Many types of staff are necessary to successfully run an obstetrics unit. Rural hospitals face unique staffing challenges. This policy brief describes the obstetric workforce in rural hospitals by state for nine states: Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin.
  • Health Information Exchange: A Strategy for Improving Access for Rural Veterans in the Maine Flex Rural Veterans Health Access Program
    Maine Rural Health Research Center
    Date: 05/2016
    This paper reports on the design and implementation of a first-in-the-nation project to expand rural veterans' access to healthcare by establishing a bi-directional connection between Maine's statewide health information exchange (HIE) and Veterans Administration facilities and centers.
  • Characteristics of Medicaid Beneficiaries Who Use Rural Health Clinics
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2016
    The RHC role varies by state. While we don't have an understanding of what this looks like for each state, we can see that RHCs are an important provider for Medicaid beneficiaries. One of the most important differences is by age groups. All states tend to cater RHC services toward children, with a minimum of 39% of the RHC population < 18.
  • Identifying Rural Health Clinics in Medicaid Data
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 05/2016
    Identifying Rural Health Clinics (RHCs) in Medicaid claims across states is challenging, but this brief recommends methods for identifying the majority of these claims in four states.
  • Rural Implications of Expanded Birth Volume Threshold for Reporting Perinatal Care Measures
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 04/2016
    In 2016 the minimum annual birth volume threshold for required reporting of the Joint Commission Perinatal Care measures by accredited hospitals decreased from 1,100 to 300 births. This study used the publicly available Join Commission Quality Check data from April 2014 to March 2015.
  • Adverse Childhood Experiences in Rural and Urban Contexts
    Policy Brief
    Maine Rural Health Research Center
    Date: 04/2016
    This study was designed to address the gap in the literature examining rural-urban differences in adults' exposure to adverse childhood experiences (ACEs) and to inform health system initiatives geared toward mitigating the impacts of ACEs on rural populations.
  • Does ACA Insurance Coverage Expansion Improve the Financial Performance of Rural Hospitals?
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 04/2016
    Views on how the implementation of the Affordable Care Act's (ACA) expanded insurance coverage is affecting the financial performance of rural hospitals. The study found that while respondents believe the expanded insurance coverage was the right thing to do for patients, they worried coverage may not be adequate to ensure access to care.
  • Variation in Primary Care Service Patterns by Rural-Urban Location
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2016
    Examines primary care physician service patterns by rural-urban location and discusses effect on recruitment strategies for primary care providers in rural communities.
  • Medicare Costs and Utilization Among Beneficiaries in Rural Areas
    Policy Brief
    University of Minnesota Rural Health Research Center
    Date: 03/2016
    This study assesses the relationship between service utilization patterns and costs for rural Medicare beneficiaries across the rural continuum. It also examines the relationships between rural beneficiaries' service utilization and healthcare delivery market structure and evaluates strategies and policies to address high costs in rural areas.
  • How Could Nurse Practitioners and Physician Assistants Be Deployed to Provide Rural Primary Care?
    Policy Brief
    WWAMI Rural Health Research Center
    Date: 03/2016
    New (2014) rural enrollees in the insurance plans on federal and state exchanges are expected to generate about 1.39 million primary care visits per year. At a national level, it would require 345 full-time equivalent physicians to provide those visits. This study examines how different mixes of physicians, PAs, and NPs might meet the increase.
  • Conrad 30 Waivers for Physicians on J-1 Visas: State Policies, Practices, and Perspectives
    Report
    WWAMI Rural Health Research Center
    Date: 03/2016
    States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban underserved areas. This study collected quantitative and qualitative information from states to assess how state policies and practices shape IMG recruitment and practice in underserved areas.
  • Outcomes of Rural-Centric Residency Training to Prepare Family Medicine Physicians for Rural Practice
    Policy Brief
    WWAMI Rural Health Research Center
    Date: 03/2016
    Among those with eight or more weeks of rural training, no single program characteristic or model offered sustained advantages over any other type in producing high yields to rural practice.
  • Geographic Variation in the Profitability of Urban and Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2016
    Historic and recent evidence suggest that unprofitability can reduce hospital services and quality, or worse, lead to closure. This study describes the current geographic variability of hospital profitability by comparing the 2014 profitability of CAHs, other rural hospitals, and urban hospitals by census region, census division, and state.
  • 2012-14 Profitability of Urban and Rural Hospitals by Medicare Payment Classification
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2016
    The profitability of urban hospitals to that of rural hospitals are compared for fiscal years 2012-2014 based on size and rural Medicare payment classifications.
  • Exploring Rural and Urban Mortality Differences
    North Dakota and NORC Rural Health Reform Policy Research Center
    Date: 03/2016
    Contains visual aids which display indicators of mortality rates by cause of death, age group, rural-urban status, region, and sex for populations 15 years of age and older cross-referenced to tables and statistical results.
  • Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?
    Journal Article
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2016
    Examines how Critical Access Hospitals perform compared to Prospective Payment System hospitals on measures of quality.
  • Does the Medicare Part D Decision-Making Experience Differ by Rural/Urban Location?
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 02/2016
    Evaluates the personal experiences with choosing a Part D plan among rural residents. This study examines the geographic differences in Part D enrollees' opinion of the plans decision-making process.
  • Family Medicine Rural Training Track Residencies: 2008-2015 Graduate Outcomes
    Policy Brief
    WWAMI Rural Health Research Center
    Date: 02/2016
    This policy brief is the latest in a series tracking the rural practice outcomes of family physicians who have completed graduate medical education in Rural Training Track (RTT) residency programs.
  • Access to Rural Home Health Services: Views From the Field
    Report
    WWAMI Rural Health Research Center
    Date: 02/2016
    Access to home health care can be challenging for rural Medicare clients. Key informants for this study detailed obstacles, including financial, regulatory, workforce, and geographic issues. Rural communities will likely benefit from payment reforms that reward quality services while providing incentives to use best practices in home health care.
  • Rural Opioid Abuse: Prevalence and User Characteristics
    Policy Brief
    Maine Rural Health Research Center
    Date: 02/2016
    Opioid abuse is the fastest growing substance abuse problem in the nation and the primary cause of unintentional drug overdose deaths. This study examined the rural-urban prevalence of non-medical use of pain relievers and heroin in the past year and the socioeconomic characteristics associated with their use and other risky behavior.
  • Pilot Testing a Rural Health Clinic Quality Measurement Reporting System
    Policy Brief
    Maine Rural Health Research Center
    Date: 02/2016
    More than 4,000 Rural Health Clinics (RHCs) serve the primary care needs of rural communities. Unfortunately, the Rural Health Clinic Program is plagued by a lack of data participating clinics. This reports on the results with a focus on assessing the feasibility and utility of the reporting system and quality measures for the participating RHCs.
  • Which Physician Assistant Training Programs Produce Rural PAs? A National Study
    Policy Brief
    WWAMI Rural Health Research Center
    Date: 02/2016
    The proportion of physician assistant (PA) graduates who enter practice in rural settings has dropped over the last two decades, though PAs still continue to enter rural practice at a higher rate than primary care physicians. This identifies the PA training programs that produced high numbers of rural PAs and the programs associated.
  • Mental Health First Aid in Rural Communities: Appropriateness and Outcomes
    Journal Article
    Maine Rural Health Research Center
    Date: 01/2016
    Mental Health First Aid (MHFA), an early intervention training program for general audiences, has been promoted as a means for improving population-level behavioral health in rural communities by encouraging treatment-seeking. This study examined MHFA's appropriateness and impacts in rural contexts.
  • Nurse Practitioner Autonomy and Satisfaction in Rural Settings
    Journal Article
    WWAMI Rural Health Research Center
    Date: 01/2016
    Compares urban and rural primary care nurse practitioners (NPs) by practice location in urban, large rural, small rural, or isolated small rural areas by using analysis of the 2012 National Sample Survey of NPs.
  • Disparities in Home Health Service Providers Among Medicare Beneficiaries with Stroke
    Journal Article
    Rural and Minority Health Research Center
    Date: 01/2016
    Examines the intensity of home health services, by the number of visits and service delivery by rehabilitation specialists, among Medicare beneficiates with stroke. There were no significant rural-urban differences in the number of home health visits, but rural residents were less likely to receive services from rehabilitation specialists.
  • Rural-Urban Differences in Satisfaction With Medicare Part D: Implications for Policy
    Journal Article
    University of Minnesota Rural Health Research Center
    Date: 01/2016
    Examines the difference in rural and urban satisfaction with Medicare Part D coverage by using data from the 2012 Medicare Current Beneficiary Survey. The research found that rural residents have lower satisfaction with their coverage.
  • Geographic Variation in Risk of Financial Distress Among Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2016
    From 2005 to 2015, 112 rural hospital closures have been identified. The closures impact millions of rural residents. This brief describes the geographic variation in the proportion of rural hospitals forecasted to be at high risk of distress in 2015.
  • Prediction of Financial Distress Among Rural Hospitals
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2016
    From 2005 to 2015, more than 100 rural hospitals have closed their doors to patients in need of inpatient services. To understand factors affecting rural hospital financial distress and to develop an early warning system to identify hospitals at risk, the North Carolina Rural Health Research Program developed the Financial Distress Index.
  • Rural Medicare Advantage Plan Payment in 2015
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2016
    Payment to Medicare Advantage (MA) plans was fundamentally altered by the Patient Protection and Affordable Care Act of 2010 (ACA). This brief finds that while plans operating in both rural and urban areas have experienced a reduction in MA payment, the reduction in rural payment overall has been less significant.