Opioid Prescriptions Are More Common in Rural Areas

Rural areas have been hit hard by the opioid epidemic. The injury is, in part, self-inflicted. Primary care physicians in rural areas are more likely than those in urban areas to prescribe opioids for their patients, reports the CDC in a study of opioid prescribing rates.

CDC researchers examined electronic prescriptions written by 31,422 primary health care providers during the January 2014 to March 2017 time period. Their findings document the big differences in opioid prescription rates by a county's urban-rural status...

Percent of patients receiving opioid prescriptions, January 2014—March 2017 average
9.6% in rural counties
9.4% in micropolitan counties
7.7% in small metro areas
6.7% in medium metro areas
5.6% in large fringe metros
5.2% in large central metros

The CDC undertook the study to determine whether the 2016 release of its Guideline for Prescribing Opioids for Chronic Pain had helped to reduce opioid prescriptions. It did. In every type of county, the opioid prescription rate declined over the time period. In rural counties, the percentage of patients who received opioid prescriptions fell from 10.3 percent in 2014 to 9.0 percent during the March 2016 to March 2017 time period. In large central metropolitan counties, the rate fell from 5.4 to 5.0 percent.

"As less densely populated areas appear to indicate both substantial progress in decreasing opioid prescribing and ongoing need for reduction," the researchers conclude, "community health care practices and intervention programs must continue to be tailored to community characteristics."

Source: CDC, Morbidity and Mortality Weekly Report, Opioid Prescribing Rates in Nonmetropolitan and Metropolitan Counties among Primary Care Providers Using an Electronic Health Record System—United States, 2014–2017

Suicide Rate Highest in Nonmetro/Rural Areas

Yet another study has found a widening health gap between rural and urban areas. In an analysis of suicide rates by urban status over the past decade, the CDC finds much higher suicide rates in nonmetropolitan and rural areas than in metropolitan areas. To make matters worse, suicide rates are rising faster in the hinterlands than in the rest of the U.S.

In 2013–15, the suicide rate in nonmetro/rural areas (19.74 suicides per 100,000 population aged 10 or older) was 18 percent higher than the rate in medium/small metro areas (16.77), 32 percent higher than the national average (14.98), and 55 percent higher than the rate in large metropolitan areas (12.72). Since 2001–03, the suicide rate has climbed across the nation, but nowhere more so than in nonmetropolitan/rural areas. Between 2001–03 and 2013–15, the suicide rate climbed 14 percent in the largest metros, 19 percent nationally, 25 percent in medium/small metro areas, and 27 percent in nonmetro/rural areas.

The pattern in the suicide rate is the same for both males and females, in every age group, and for every race and Hispanic origin group except Blacks—whose relatively low suicide rate has not increased much and is highest in medium/small metros.

Suicide rates are "consistently higher in rural communities," concludes the CDC. "Findings from this study underscore the need to identify protective factors as part of comprehensive suicide prevention efforts, particularly in rural areas."

Source: CDC, Suicide Trends among and within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death—United States, 2001–2015

Death Rates Higher in Nonmetro Areas

With the Affordable Care Act and expanded access to health care services under threat, the CDC has released a report suggesting any erosion of care will be a bigger problem for the residents of nonmetropolitan America than for those living in metro areas.

The CDC report compares age-adjusted death rates in metropolitan and nonmetropolitan areas for the five leading causes of death—heart disease, cancer, accidents (including drug poisonings), chronic lower respiratory disease, and stroke. Result: death rates in nonmetropolitan areas are higher for all five causes of death.

What accounts for the higher death rates? A cluster of characteristics, reports the CDC. The residents of nonmetropolitan areas "tend to have less access to health care services and to be less likely to receive preventive services," explains the report. "In addition, they are more likely to be uninsured or underinsured, delay seeking care, live in poverty, and have lower educational attainment."

Source: CDC, Mortality and Morbidity Weekly Report, Leading Causes of Death in Nonmetropolitan and Metropolitan Areas—United States, 1999–2014

Most Nonmetro Counties Are Losing Population

Two-thirds of the nation's nonmetropolitan counties lost population between 2010 and 2014, according to the USDA's Economic Research Service. The number of nonmetro counties with declining populations reached an historic high of 1,310 in the 2010-14 time period.

Population decline is caused by two factors: more people moving out than in, and more deaths than births. The number of nonmetro counties experiencing the "double jeopardy" of net-outmigration and natural decrease climbed from 387 in 2003-07 to 622 in 2010-14.

According to a Demo Memo analysis of population growth by metropolitan status, the nation's largest metropolitan areas, with a population of 1 million or more, grew 4.2 percent between 2010 and 2014. Smaller metropolitan areas grew 2.7 percent. Nonmetropolitan counties as a whole lost 0.2 percent of their population during those years.

Source: USDA Economic Research Service, Two-Thirds of U.S. Nonmetro Counties Lost Population over 2010-14

Explaining Nonmetro Population Decline

Between 2012 and 2013, the number of adults in nonmetropolitan areas declined, perhaps for the first time ever, according to the USDA's Economic Research Service.

Average annual percent change in nonmetro population aged 16+
2012-13: -0.07
2011-12:  0.07
2010-11:  0.19
2009-10:  0.37
2008-09:  0.36
2007-08:  0.49

This loss is the result of two trends: a decline in the rate of natural population increase in nonmetro areas (births minus deaths) and a decline in net migration (people moving in minus people moving out), which has been negative since 2010. Why are people moving out of nonmetro areas? Probably to find a job. According to the researchers, "nonmetro employment growth slowed in 2011 and fell to zero or slightly below thereafter."

Source: USDA, Economic Research Service, Rural Employment Trends in Recession and Recovery

Nonmetro Population Loss: The Hispanic Factor

Between 2010 and 2013, the nation's nonmetropolitan areas lost population. One factor behind the loss is slower growth of the Hispanic population...

Average annual percent change in the Hispanic population of nonmetropolitan counties
1990-2000: 4.9%
2000-2010: 3.6%
2010-2013: 2.1%

The one-two punch of slower Hispanic growth and an outright decline in the non-Hispanic population of nonmetropolitan areas (-0.2% between 2010 and 2013) led to the overall loss.

Source: USDA, Economic Research Service, Rural Hispanic Population Growth Mirrors National Trends

Job Growth along the Rural-Urban Continuum

The more urban the county, the greater the population growth during the 2010-to-2012 time period, according to my analysis of the Census Bureau's county population estimates by county rank on the Rural-Urban Continuum. But what about job growth along the Rural-Urban Continuum? Not surprisingly, the pattern is the same...

• The number of employed grew the fastest in the most urban counties between 2010 and 2012, up 2.9 percent. These are counties in metropolitan areas of 1 million or more people (a 1 on the Rural-Urban Continuum). 
• In smaller metros (2 or 3 on the continuum), the number of employed grew between 1.4 and 1.9 percent during those years. 
• In small-town America (nonmetropolitan counties ranking 4 to 7 on the continuum), the number of employed grew by only 0.8 percent. 
• In rural counties (8 or 9 on the continuum), employment climbed just 0.7 percent.  

Source: USDA, Economic Research Service, Rural-Urban Continuum Codes and Bureau of Labor Statistics, Local Area Employment Statistics, County Data

Population Change along the Rural-Urban Continuum

The nation's urban areas are growing, and rural areas are losing people. This is one of the distinguishing characteristics of the post-Great Recession era. An analysis of county population change along what is called the Rural-Urban Continuum shows the draw of cities and the abandonment of rural outposts.

The Rural-Urban Continuum is the federal government's way of classifying counties by their degree of urbanity. The continuum is a scale ranging from 1 (the most urban counties, in metropolitan areas of 1 million or more) to 9 (the most rural counties, lacking any settlements of 2,500 or more people and not adjacent to a metropolitan area). If you sort the nation's 3,143 counties by their rank on the continuum, then measure population change between 2010 and 2012 for each rank, this is the result...

County population change 2010-2012 by Rural-Urban Continuum Rank
1: 2.2%
2: 1.7%
3: 1.2%
4: 0.2%
5: 0.8%
6: -0.4%
7: -0.2%
8: -0.9%
9: -0.5%

The most urban counties (a 1 on the scale) grew faster than any other type of county between 2010 and 2012. The most rural counties (8 and 9 on the scale) experienced the biggest declines. This is an interesting twist in the age of the Internet, when location is supposed to be increasingly irrelevant.

Source: USDA, Economic Research Service, Rural-Urban Continuum Codes and Census Bureau, American Factfinder, County Population Estimates

Metro Advantages

The larger the metro, the more likely college graduates are to land a job that makes use of their degree and college major. This is the unsurprising finding of a Liberty Street Economics analysis of the skills match between college graduates and jobs.

Among employed Americans with a bachelor's degree in 2010, 62 percent had a job that required a college degree and 27 percent had a job that matched their college major, according to the researchers. (Both numbers are remarkably low, but that's another story.) The bigger the metro, the better the match between education and job--although the improvement is not all that impressive. As metropolitan size rises from the 50th to the 99.9th percentile (think Syracuse versus New York), the percentage of employed college graduates with a job that requires a college degree increases from 61.1 to 64.5 percent. The probability that college graduates will work in jobs related to their college major rises from 26.7 to 29.1 percent.

If the comparison had been between college graduates in metro versus nonmetro areas, it's likely the differences would be more impressive. The emptying out of the nation's nonmetropolitan counties over the past few years (see post here) is evidence that college graduates in nonmetro areas are seeking better opportunities elsewhere.

Source: Federal Reserve Bank of New York, Liberty Street Economics, Do Big Cities Help College Graduates Find Better Jobs? 

Nonmetro Counties Are in Decline

A record number of nonmetropolitan counties are losing population, according to the USDA's Economic Research Service. Between 2010 and 2012, fully 1,261 nonmetropolitan counties lost a combined 302,000 people. The decline is occurring in nearly two-thirds of the nation's nonmetropolitan counties.

Behind the decline is ongoing outmigration to metropolitan areas and the baby bust. In many nonmetropolitan counties, deaths now exceed births. Coupled with outmigration, the consequence is population loss. About 300 counties experienced "natural decrease" for the first time during the 2010-12 time period. For a map of these counties, click on the link.

Source: USDA Economic Research Service, Recent Population Change