This study provides evidence of lower quality postdischarge care for Medicare beneficiaries in rural settings. As readmission penalties expand, hospitals serving rural beneficiaries may be disproportionately affected. This suggests a need for policies that increase follow-up care in rural settings.

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The NCHC has successfully improved access to care for its enrollees.

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Interviews with state Medicaid officials reveal that although managed care programs have been implemented in rural areas, participation remains behind that of urban areas. Many states aim to create a statewide Medicaid managed care program and are struggling to overcome barriers that are greater in rural areas, including providers' resistance, lack of commercial managed care, and inadequate supply of providers. Many have modified contracting strategies and shown flexibility regarding interpretations of travel standards, twenty-four-hour coverage requirements, and primary care case management requirements, to implement programs in rural environments.