Rural/Urban Differences among American Indian/Alaska Native Peoples in Health Care Access and Outcomes, 2019–2023

Health challenges affecting American Indian/Alaska Native (AI/AN) individuals are well-documented, but rural/urban differences remain understudied. This analysis describes health and health care access for rural and urban AI/AN adults, with attention to the role of the Indian Health Service (IHS), which primarily serves rural areas. Using 2019-2023 National Health Interview Surveys, we included adult respondents identifying as AI/AN, regardless of other reported races and ethnicities. County of residence was classified as urban (metropolitan) or rural (non-metropolitan). Outcomes included usual place of care, cost-related underuse of care, emergency room visits, clinic visits, worries about paying medical bills, and self-rated health. We found that AI/AN rural residents had greater socio-economic risks (lower education and higher poverty levels), but more access to IHS than urban AI/AN adults (p < .01, all comparisons). Rural-residing AI/AN individuals were more likely than urban AI/AN people to have a usual place of care (93.8% vs. 84.8%, p < .01) and to avoid cost-related underuse of care (75.9% vs. 65.3%, p < .01). Nearly 3 in 4 AI/AN adults -rural and urban - described their health as excellent, very good, or good; however, this was higher for urban (78.5%) vs. rural (73.8%) respondents (p =.015). Rural and urban AI/AN adults with IHS were more likely to have a usual place of care and lower cost barriers than those without IHS (p <.01, all comparisons). Socio-economic risks are higher for rural vs. urban AI/AN adults, but care was more accessible and affordable among rural AI/AN adults, who had comparatively greater access to IHS care.