Poverty, Rurality, and Emergency Department Utilization: Implications for Rural Health Access

Background and Purpose: Emergency departments (ED) often function as the primary safety net for low-income and rural populations, yet frequent ED use can indicate gaps in primary and preventive care. Existing research has linked poverty and rural residence to higher ED use, but the independent contributions of poverty depth and rurality, when controlling for gender, race, education, and insurance, remain unclear. This study tests whether deeper levels of poverty and rural residence independently predict ED visits among adults below the federal poverty line, aiming to inform social work interventions and policies to enhance rural health equity.

Methods: Data were drawn from the 2023 National Health Interview Survey and included 2,752 adults with family incomes below 100% of the federal poverty threshold. The dependent variable was self-reported ED visits within the past 12 months. Independent variables were poverty levels (0 to 49 percent, 50 to 74 percent, 75 to 99 percent) and rural versus non-rural residence. Controls included gender, race/ethnicity (White, Black, Asian, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, Other), education (less than high school, high school graduate, some college or more), and insurance status (insured vs. uninsured). A logistic regression model estimated odds ratios with 95 percent confidence intervals to assess each predictor’s association with ED use. A limitation of using NHIS data is potential selection bias, as survey participation may differ systematically from the broader low-income population.

Results: Neither poverty depth nor rural residence independently predicted ED use after accounting for demographic and insurance variables. Adults at 50 to 74 percent poverty had similar odds to those below 50 percent (OR = 1.08, 95% CI 0.88–1.32, p = .45), and those at 75 to 99 percent showed comparable odds (OR = 1.02, 95% CI 0.84–1.22, p = .82). Rural residence had no significant effect (OR = 1.02, 95% CI 0.83–1.26, p = .86). Insurance status was the strongest predictor; uninsured adults had 39 percent lower odds of ED visits than insured adults (OR = 0.61, 95% CI 0.46–0.81, p < .001). Gender and race also significantly influenced utilization. Women had 30 percent higher odds of ED visits than men (OR = 1.30, 95% CI 1.10–1.55, p = .002), and Asian adults had 59 percent lower odds compared to White adults (OR = 0.41, 95% CI 0.26–0.64, p < .001).

Conclusion and Implications: Findings indicate that among low-income adults, insurance status and demographic factors influence ED use more than poverty level or rural residence. These unexpected findings suggest that policy interventions should prioritize expanding insurance access through targeted outreach and sliding-scale clinics. Social work practice can enhance rural health access by integrating community health workers, mobile clinics, and telehealth services. Culturally responsive education and navigation support can improve equitable care for women and racial minorities. These targeted strategies, combined with supportive policy reforms, can advance health equity in low-income and rural communities.