PROJECT SUMMARY/ABSTRACT In the US, working-age adults (age 20 to 64 years) in rural areas experience significantly higher cardiovascular (CV) mortality rates than their urban counterparts due to worse access to care and a greater burden of risk factors. The COVID-19 pandemic threatens to further widen these differences. The pandemic has resulted in enormous delays in outpatient care for chronic conditions, as well as unemployment, economic loss, and disruptions in insurance coverage, all of which have disproportionately affected rural communities. Together, these spillover effects may worsen access to care and increase CV morbidity and mortality long after the pandemic is over. Given these concerns, there is a pressing need to identify policy strategies to improve access to care and health for rural working-age adults in the post-pandemic era. One such strategy that has recently gained substantial public support is to lower the age of eligibility for Medicare. Doing so could have major implications for the CV health of rural working-age adults, whom are more likely to be uninsured and experience barriers in access to care. Telemedicine may be another way to address gaps in care for rural communities, but nearly in 1 in 3 rural persons lack broadband internet access– a significant barrier to telemedicine use. In 2021, the federal government devoted $65 billion to expand broadband in rural communities. It remains unclear whether this substantial investment will improve telemedicine use, access to care, and CV health in rural America. The goal of this proposal is to understand changes in access to care, as well as in the epidemiology of CV risk factors, CV hospitalizations, & deaths among rural working-age adults before and after the pandemic, and to evaluate distinct policy strategies to improve access to care and CV health in rural communities in the post-pandemic era. In Aim 1, we will use a unique combination of national datasets to characterize changes in access to care, as well as in the prevalence of CV risk factors, incidence of CV hospitalizations, and mortality in rural working-age adults, overall and compared with their urban counterparts, in the years that follow the pandemic. In Aim 2, we will determine the effects of Medicare on health care access, screening for CV risk factors, and the treatment & control of CV risk factors in rural working-age adults using a regression discontinuity design. In Aim 3, we will create a new, multidimensional data-source to evaluate if access to medical care, including telemedicine use in the outpatient and hospital settings, and CV outcomes improve in rural communities that expand broadband access using a difference-in-differences analysis. This research will advance our understanding of changes in the CV health of >40 million younger rural adults, in whom the onset of CV risk factors results in substantial loss of years of life. The identification of policies to improve access, preventive care, and treatment for younger rural populations could have major public health implications as the US emerges from the pandemic, and ultimately, improve CV health nationwide.

PROJECT NARRATIVE In the United States, working-age adults (age 20 to 64 years) in rural areas experience significantly higher cardiovascular mortality rates than their urban counterparts due to worse access to care and a higher burden of risk factors, and there is concern that the spillover effects of the COVID-19 pandemic (disruptions in care, unemployment, financial strain) will further widen these differences for years to come. We will use a combination of national datasets to understand changes in access to care and cardiovascular health for rural working-age adults after the pandemic, determine the potential effects of changing the age of Medicare eligibility on access to care and the screening, treatment, and control of cardiovascular risk factors for this population, and evaluate whether the expansion of broadband internet in rural areas leads to increased telemedicine use and improvements in cardiovascular health. The identification of policies that improve access, care delivery, and cardiovascular health in rural communities could have major public health implications, and ultimately inform strategies to improve cardiovascular outcomes nationwide.