“Left Behind Again:” Rural Children Enrolled in Medicaid Use Home Health Services Far Less Than Urban Children

“Left Behind Again:” Rural Children Enrolled in Medicaid Use Home Health Services Far Less Than Urban Children 1024 575 Jeb Phillips

Data from a pediatric accountable care organization is allowing physicians and researchers to explore the rural-urban health care gap.

While it’s long been clear that children in rural areas have reduced access to some kinds of health care services compared to their urban peers, understanding the specifics of the care gap has proven difficult, because population-level data on utilization is split among many insurers and providers.

But the accountable care organization (ACO) Partners For Kids has responsibility for the health of more than 400,000 children covered by the Medicaid Managed Care plans in Ohio, so it does have access to a geographically diverse data set. In fact, Partners For Kids, created in 1994 by Nationwide Children’s Hospital, is the largest and oldest pediatric ACO in the United States.

Physicians and researchers at Partners For Kids and the Center for Child Health Equity and Outcomes Research at Nationwide Children’s Abigail Wexner Research Institute have begun using that data to refine the understanding of the rural care gap, and a recent study shows just how stark the difference in pediatric home health service utilization is. It’s titled “Left Behind Again: Rural Home Health Services in a Medicaid Pediatric Accountable Care Organization” and is published in The Journal of Rural Health.

The authors found that among the children who are members of Partners For Kids, urban children used home health care 2x to 6x more than rural children. The difference is greatest in the Medicaid category known as ABD, composed of children who are disabled. The difference is significant but less pronounced among children who are part of the Covered Families and Children category (by far the largest cohort) and the Adoptive, Foster and Kinship category, comprising children who have been adopted or are under state custody.

The effects of such reduced access for rural children aren’t clear. The greater use of home health services among urban children was not always associated with less overall health care utilization, as the authors had originally assumed. Urban and rural children in the ABD category had statistically similar rates of emergency department care, for example, even though urban children have greater access to home health services.

There are a number of potential explanations for similar rates of other types of health care use even when homecare utilization is so different, says Kelly Kelleher, MD, MPH, vice president of Community Health at Nationwide Children’s and senior author of the study.

Perhaps most interestingly, there’s the chance that overall health care utilization isn’t the most important metric for discussing why home health services are necessary.

“It could be the biggest benefit is the way home health services reduce the burden for families,” says Dr. Kelleher. “Rural families may be spending a lot of time and resources on caregiving inside the home that urban families don’t have to, because urban families have better access to these services. We have to be open to the ways that these services matter to children and their caregivers, not just to the health care system.”

This is the second rural/urban study that Dr. Kelleher and his colleagues have published in 2021 using Partners For Kids data. The first examined differences in usage of children’s preventive health services, and found that rural communities show slightly less primary care usage, largely explained by the impact of social determinants of health, such as unemployment and education. The authors concluded that it was reasonable to think the disparity would increase over time as providers face increasing financial challenges, leading to closure.

“It can be hard to conduct this kind of research, both because of the challenges in access to data and because so many population health efforts are focused in cities,” says Dr. Kelleher. “But it’s important for all of us to know what challenges people in rural communities face so we can better address them.”


  1. Hardy RY, Liu GC, Conkol KJ, Gleeson SP, Kelleher KJ. Left behind again: rural home health services in a Medicaid pediatric accountable care organization. The Journal of Rural Health. 2021 May 12. [epub ahead of print]
  2. Hardy RY, Liu GC, Kelleher K. Contribution of social determinant of health factors to rural-urban preventive care differences among Medicaid enrollees. Academic Pediatrics. 2021 Jan-Feb; 21(1):93-100.

Image credit: Adobe Stock

About the author

Jeb is the Managing Editor, Executive Communications, in the Department of Marketing and Public Relations at Nationwide Children's Hospital. He contributes feature stories and research news to PediatricsOnline, the hospital’s electronic newsletter for physicians and other health care providers, and to Pediatrics Nationwide. He has served as a communications specialist at the Center for Injury Research and Policy at The Research Institute and came to Nationwide Children’s after 14-year career as daily newspaper reporter, most recently at The Columbus Dispatch.