Rural Health, Universality, and Legislative Targeting

31 Pages Posted: 31 Jul 2018 Last revised: 28 Feb 2019

See all articles by Nicole Huberfeld

Nicole Huberfeld

Boston University - School of Public Health; Boston University School of Law

Date Written: July 10, 2018


This essay was part of the symposium Revitalizing Rural America. The paper demonstrates a spiral of rural health challenges that cannot be addressed without defining rural health, yet federal agencies do not agree on one definition of "rural". The paper finds that space and population are key features of rurality, and that decreasing population and increasing space contribute to worsening health disparities. As compared to urban areas, rural communities have smaller patient populations with lower paying jobs, which means more Medicaid and uninsured patients, which decreases payments to health care providers, which leads to hospital closures and physician shortages, which leads to worsening care for rural communities (and raises special concerns for women's health). After exploring the cycle of rural health disparities, the paper considers efforts to address persistent problems in U.S. health care through legislation such as the ACA, which was designed to improve health broadly and gave rural communities tools to address some long-standing health problems by expanding health insurance coverage, which facilitates better access to health care and more consistent payment for providers. But, some rural states have rejected the ACA's universal coverage while supporting targeted federal legislation to fill gaps left by that choice. The paper considers whether, in light of rural states' rejection of the ACA's broader health reform, targeted legislation can improve the health of rural populations. Drawing on Theda Skocpol's classic theory of successful social policies - "targeting within universalism" - the paper situates the ACA among other health reform efforts such as Medicare, which demonstrates intentional universalism through a uniform, nationwide program; and Medicaid, which achieved unplanned universalism despite being designed as targeted legislation for the "deserving poor." The ACA falls somewhere in between, weaving together public and private health insurance to create a principle of universality but without an underlying uniform program. The literature indicates that the ACA is measurably successful in improving health, except in states that have opted out of Medicaid eligibility expansion, which are disproportionately rural. The paper concludes that targeted legislation intended to improve rural health will be largely ineffective unless a universal baseline such as the ACA first exists; but, targeted legislation may still be necessary to address unique rural health needs tied to population and space. Many more questions remain to be answered, such as: Does targeted legislation at the state level demonstrate any greater chance of diminishing disparities? How can the success of targeting within universal legislation be empirically measured? What has been the impact of targeting rural needs within the ACA? Do Medicaid waivers play any role in the success or failure of the ACA's universalism? Would federalizing Medicaid address these questions? This paper indicates that much work remains to be done.

Keywords: health reform, ACA, Obamacare, rural, universal, targeted, legislation, statutes, health law

JEL Classification: I1, I10, I13, I14, I18, K32, R5

Suggested Citation

Huberfeld, Nicole, Rural Health, Universality, and Legislative Targeting (July 10, 2018). Harvard Law & Policy Review, Vol. 12, 2018, Available at SSRN:

Nicole Huberfeld (Contact Author)

Boston University - School of Public Health ( email )

715 Albany Street
Boston, MA 02118
United States

Boston University School of Law ( email )

765 Commonwealth Avenue
Boston, MA 02215
United States

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