The urban-rural gap in older Americans' healthy life expectancy.

Purpose: Estimate health-quality-adjusted life expectancy (QALE) for Americans nearing retirement age and assess rural-urban disparities in QALE.

Methods: We used a dynamic microsimulation model based on Health and Retirement Study data to estimate the quantity and health quality of expected future life years for rural and urban Americans ages 59-60 in 2014-2020.

Findings: Cohort life expectancy at age 60 (LE) for urban and rural men was 22.9 and 20.9, respectively; for urban and rural women, LE was 25.6 and 25.0, respectively. Adjusting future life years to quality-adjusted life years, QALE was 17.5 versus 15.7 for urban versus rural men, and 19.3 versus 18.7 for women. Compared to a cohort in 1994-2000, the urban-rural QALE gap in 2014-2020 grew substantially for men; changes for women were smaller. Average QALE masked heterogeneity by race/ethnicity, education, and Census region. Counterfactual scenarios suggested eliminating smoking and managing obesity and prevalent heart conditions would be particularly beneficial for increasing rural QALE and reducing the urban-rural gap.

Conclusions: Expected health quality, in addition to longevity, is an important factor when assessing rural disparities in older Americans' future life outcomes. Current chronic disease disparities are expected to translate to a widening urban-rural gap in QALE, particularly for men. Interventions earlier in life may be needed to fully address disparities in QALE at older ages.