Cutler Institute

Projects (MRHRC)

The Center's current research agenda focuses on access to rural health services, behavioral health, and rural health clinics.

Projects funded by the federal Office of Rural Health Policy.

For projects of the Flex Monitoring Team, please visit their web site at

For more information about past projects and research findings including publications, policy briefs, working papers, and final reports, please visit the Maine Rural Health Research Center's page on the Rural Health Research Gateway

Access To and Use of Home and Community-Based Services in Rural Areas. This study will use data from the 2010 Medicaid Analytic eXtract (MAX) file, in-depth policy reviews to examine differences in the use of institutional and home and community-based service (HCBS) use by older adults across urban and rural areas, and the policy and community factors that contribute to differences or comparability in use. This study has been completed and a Research & Policy Brief is posted on our publications page.

Acuity Differences among Newly Admitted Rural and Urban Nursing Home Residents. Building on studies showing differences in how rural and urban older adults access and use long-term services and supports (LTSS), this study will use national, standardized Medicare and non-Medicare nursing home assessment data (MDS 3.0) to examine (1) differences in resident acuity (i.e., health and functional status) and other characteristics of rural and urban nursing home residents upon admission; (2) whether differences persist among newly admitted Medicare and non-Medicare residents; and (3) whether and how nursing home, local health system and market characteristics (e.g., nursing home bed supply) are associated with differences in resident acuity. Study findings will inform federal and state policy strategies to enable rural (and urban) older adults to access LTSS services most appropriate to their social, health, and functional needs.

Adverse Childhood Experiences (ACEs) and the Health Status of Rural Residents. Although adverse childhood experiences (ACEs) have been identified as important risk factors for the development of chronic illness and harmful health behaviors, researchers have not yet systematically examined ACEs and their linkages with health outcomes in the rural context. Using data from the data from the Behavioral Risk Factors Surveillance Survey, research staff assessed the prevalence of adverse childhood experiences (ACEs) in rural populations and examine associations of ACEs with health outcomes in rural versus urban settings. This study has been completed and a Research & Policy Brief is posted on our publications page.

Assessing Health Information Technology (HIT) Strategies to Improve Access for Rural Veterans. Rural veterans face unique barriers to care including insufficient communication and coordination of care provided across multiple settings—both within and outside of the Veteran’s Administration. To help reduce these barriers, multiple agencies within the federal government have promoted technology as an opportunity to improve access and care coordination to veterans living in remote areas. Most recently, programs in Maine, Montana and Alaska have received grants to use health information technology (HIT) to expand and integrate services—including mental health services—for rural Veterans.  However, little is known about the challenges these programs face on the ground, or what conditions and program strategies may facilitate success. This study focused on the implementation strategies and inter-organizational partnerships between the VA and HealthInfoNet in Maine regarding the development of bi-directional health record access. This study has been completed and the research report is posted on the publications page.

Assessing HIT Readiness of Rural Health Clinics: A National Survey. Research staff designed and conducted a national survey of rural health clinics, both independent and provider-based, to determine the current level of health information technology adoption and readiness in these clinics.This study has been completed. Working Paper #58 is posted on the publications page

Catastrophic Consequences: The Rise of Opioid Abuse in Rural Communities. Heroin use has grown significantly in recent years, particularly among those reporting nonmedical use of opioid pain relievers before initiating heroin. Past research has indicated that opioid pain reliever use is higher among specific rural populations than urban, including adolescentsand young adults. This study examined the rural-urban prevalence of non-medical use of pain relievers and heroin in the past year and the socio-economic characteristics associated with their use as well as treatment history and perceived need for treatment; perceived risk of using drugs; and other risky behavior, using data from the National Survey of Drug Use and Health (NSDUH). Key informant interviews with officials in four were conducted to understand the challenges and promising practices in monitoring opiate prescribing and diversion, prevention interventions, and opioid prevention and treatment infrastructure in rural communities.The project is complete, with a Research & Policy Brief focusing on prevalance statistics and a Working Paper and associated Research & Policy Brief highlighting  treatment strategies in four states. These are available for download from the publications page.

Expanded Look at Rural Access to Care. Recently, the access modules of the National Health Interview Survey (NHIS) have been modified to delve more deeply into individuals’ experiences of barriers to care. These new questions on access, use, and affordability, implemented in response to the Affordable Care Act (ACA), represent an important opportunity to better understand rural-urban differences in access to care and to monitor ACA implementation from a rural perspective. Using the 2011-2012 NHIS, this study provides detailed information about rural-urban differences among adults under age 65 in perceived affordability of health insurance coverage and services prior to implementation of the Affordable Care Act. This study has been completed, and results are posted in a Research & Policy Brief on the publications page.

Developing a Sentinel Cohort of Rural Health Clinics for Use in Developing Relevant Quality Measures and Monitoring Program Performance. This two year project will assemble a cohort of Rural Health Clinics (RHCs) thirteen states to participate in a sentinel quality measurement process. During the first year of the project, the project team worked with the cohort of RHCs along with an expert panel of RHC and quality measurement experts to identify, develop, and refine of a discrete set RHC quality measures. During the second year, the cohort will implement the reporting process, collect data from the RHCs on the quality measures, and evaluate the measures in terms of performance and quality improvement. This project has been completed and a Research & Policy Brief on the pilot testing of he RHC quality measurement reporting system is posted on the publications page.

Eligibility Transitions under the Affordable Care Act: Policy Considerations for Ensuring Coverage Continuity Among Rural Residents. This study will assess rural versus urban income volatility, the potential effects on states’ efforts to ensure continuous health insurance coverage to individuals enrolled in Medicaid expansions or Exchange plans under the Affordable Care Act, and develop policy recommendations to address any observed differences.

Health Care Access and Affordability Among Rural Children with Public Versus Private Health Insurance.To examine differences in health care access and affordability among rural children with public (i.e., Medicaid or CHIP) and private health insurance coverage, the study will address the following research questions, using data from the 2011-12 National Survey of Children’s Health:Do low-income rural families report differences in access to health care services for their publicly versus privately insured children? What are the differences in families' perceived affordability of premiums and cost sharing for low-income children with public versus private health insurance coverage? How do these patterns of access to care and affordability vary between rural and urban children with public and private coverage? This project is complete, and a Research & Policy Brief is available for download from the publications page.

Health Care Use and Access Among Rural & Urban Elderly Medicare Beneficiaries. Elderly individuals age 65 and over constitute the majority of the Medicare population, and among Medicare beneficiaries, health care access problems are greater among individuals with low incomes, in poor health, and with four or more chronic conditions. These and other barriers may lead to rural-urban differences in health care use among the elderly. This study uses the 2011-2013 Medicare Current Beneficiary Survey to compare health access and use of health services among fee-for-service Medicare beneficiaries age 65 and over in rural versus urban settings, and the factors associated with rural access problems. Findings from this study will help policymakers understand the needs of the growing elderly population and how best to adjust Medicare benefit design and service delivery to reduce barriers to care.

Health Care Use and Access Among Rural & Urban Non-elderly Disabled Medicare Beneficiaries. This project will explore health care use and barriers to health care access among disabled Medicare beneficiaries under 65 in rural and urban areas. The study will be based on quantitative analyses of the 2009-2013 Medicare Current Beneficiary Survey.

Impact of the Opioid Crisis on Rural Emergency Departments. This study will use data from the Nationwide Emergency Department Sample (NEDS) and information from a panel of rural emergency care experts to assess the impact of the opioid crisis on rural emergency departments (EDs). Findings will inform policies designed to help rural health care systems and communities address the growing problem of opioid abuse.

Issues Related to Rural Health Clinic (RHC) Participation in CMS’s Merit-Based Incentive Payment System (MIPS). This qualitative project will focus on understanding the reporting requirements for RHCs related to CMS’ Merit-Based Incentive Payment System as well as the challenges in doing so and options to support RHC reporting. 

Mental Health First Aid Evaluation. This project is a mixed-methods case study that focuses on the Mental Health First Aid training program, with a view toward clarifying the rural reach, feasibility, impact, and appropriateness of the program for rural communities.
This project is complete and a  journal article has been published in the Journal of Rural Health

Out-of-Pocket Costs Among Rural Medicare Beneficiaries. Research staff examined out-of-pocket spending among Medicare beneficiaries to identify whether there are rural-urban differences in out-of-pocket costs and to explore what factors account for these differences. Should Medicare redesign occur, this study will provide important information against which to assess the possible impact of different design options on rural Medicare beneficiaries.This project has been completed and a Working Paper and associated Research & Policy Brief have been posted to the publications page.

Preventive Health Service Use Among Rural Beneficiaries. Preventive health care use can significantly improve health outcomes and health status. Despite their poorer health status and higher rates of chronic conditions than urban residents, rural residents use fewer preventive services and screenings and are less likely to adopt healthy behaviors that could prevent high-cost chronic conditions. Examining differences in rural-urban preventive health service use is critical to assessing the impact of changes in health benefit design on access to preventive services and their use among rural and urban populations. This project will use nationally representative data from the NHIS to compare receipt of preventive health services among rural and urban adults.

Role and Early Impact of CO-OPs in the Rural Health Insurance Marketplace. The purpose of this study is to fill the knowledge gap about the extent to which CO-OP plans are participating in rural markets, their relative costs compared to other products, the challenges that CO-OPs have faced in reaching rural areas, and the strategies used to address these challenges. Using a mixed-method approach, we will combine quantitative analysis of administrative data with targeted case studies to examine the rural availability and pricing of CO-OP plans, and the early experiences of these plans. Findings will provide important information about the early availability, price-competitiveness, and implementation experience of these CO-OP plans as they have sought to serve rural markets and consumers under the ACA. This project is complete and aResearch & Policy Brief is posted on the publications page.

Rural Demography and Aging: The LTSS Imperative in Rural America. In the coming decades, the older adult population of the United States is projected to expand significantly. This demographic shift will pose challenges for the nation’s health care and LTSS systems. Rural areas are likely to experience a disproportionate share of this growth, due to existing rural infrastructure deficits and the relatively high needs of rural elders. In order to help rural communities meet the increased demand for health/LTSS services, rural stakeholders and policymakers will benefit from having a current, broad-ranging, detailed profile of health care/LTSS needs and use patterns among rural and urban older adults. The proposed project aims to create such a profile through a literature review and analysis of data sets including the American Community Survey, the Area Health Resource File, and the Medicare Current Beneficiary Survey.

Rural Health Clinics Chartbook. Rural Health Clinics (RHCs) address geographic access barriers for rural Medicare and Medicaid beneficiaries and, over time, have come to be recognized for their role in serving vulnerable rural populations. Over 4,000 RHCs serve rural communities in 44 states, and are considered part of the safety net by policymakers and rural advocates. Recommendations for updating and improving RHC policies and regulations have foundered on the lack of data on RHCs, which creates challenges in developing support for changes in the RHC program. Building on our extensive body of work on RHCs and our 2003 RHC Chartbook, this project will produce a comprehensive, descriptive chartbook detailing the characteristics and status of RHCs nationally.

Rural Health Clinic Financial Performace and Productivity. This study will use Medicare cost reports for independent and provider-based clinics to provide a detailed national picture of the financial and operational performance of RHCs and describe variations in performance related to revenue, costs, staffing, payer mix, productivity levels, and hours of operation across independent and provider-based clinics. The project will also develop measures that can be used to benchmark RHC performance over time.

Understanding Rural–Urban Mortality Differences. Growing evidence indicates that rural residents face a significant disparity in achieving longevity compared to their urban counterparts. While this rural mortality disparity has been well-documented, the reasons behind it are unclear. This study will address these gaps in our understanding of rural mortality disparities using the 1985-2009 National Health Interview Survey (NHIS), linked to national death certificate data, to explore the individual-level characteristics and health behaviors of rural and urban adults and their association with mortality. These analyses will provide greater understanding of the potential socioeconomic, health behavior and health resource reasons behind rural disparities in mortality, a critical step for identifying potential policy and practice interventions that may ameliorate the rural-urban mortality gap and lead to longer, healthier lives for rural populations.

Understanding Differences in Rural and Urban Adolescent and Young Adult Substance Use.  This study will use data from the 2010-2015 National Survey of Drug Use and Health to examine differences in rural and urban adolescent and young adult substance use. Recent national data indicate that substance use has declined among all adolescents over the past several years, but it is unclear whether these trends also apply to rural adolescents and young adults who have historically higher substance use rates than their urban counterparts. The purpose of this research is to establish current use rates of rural-urban adolescent and young adult substance use and identify some of the protective and risk factors that may influence these rates.