Transportation is vital for access to health care, especially in rural areas, where travel distances are great and access to alternative modes such as transit is less prevalent. This study estimated the impacts of transportation and travel distance on the utilization of health care services for older adults in rural and small urban areas. With data collected from a survey, a model was developed on the basis of the Health Behavior Model, which considered transportation and distance as factors that could enable or impede health care utilization. A random sample of individuals age 60 years and older living in the rural Upper Great Plains states of Montana, North Dakota, South Dakota, and Wyoming were surveyed by mail. Responses were received from 543 individuals (20% response rate). Probit models were used to estimate trip frequency and the likelihood that an individual would miss or would delay a health care trip. Distance and transportation variables were not found to influence significantly the total number of routine or chronic care trips made overall, while emergency care visits were affected by the availability of transportation options. Additional results showed that those who could not drive made more trips if someone in the household could drive and that distance and access to transportation affected the difficulty reported in making trips and the likelihood of missing or delaying a trip. The greatest problems for people using public transportation for health care trips were inconvenient schedules, the need to match transit and medical schedules, and infrequent service.

The true value of transit systems in rural and small urban areas in the United States has been largely unmeasured, and there are often effects that go unidentified. Many studies have documented the benefits of urban transit systems with benefit–cost analysis. However, not many have looked into the benefits of transit in rural and small urban areas, where there is a great need for public transit, especially for transportation-disadvantaged individuals. This study focused on evaluating the qualitative and quantitative benefits of rural and small urban public transit systems and analyzed the benefit–cost ratio for rural and small urban transit areas for fixed-route and demand-response services in the United States. Data for rural and small urban transit systems from the national transit database (NTD) and rural NTD were used for calibrating the transit benefits and costs. Results were presented at a national level to show the effects of transit investments in rural and small urban areas nationally. Transit benefits in the United States for 2011 were found to be $1.6 billion for rural transit and $3.7 billion for small urban transit, not including the economic effects. Results showed a benefit–cost ratio of 2.16 for small urban transit and 1.20 for rural transit in the United States. Sensitivity analysis showed that increasing the percentage of forgone trips to 50%, increasing the cost of forgone medical and work trips by 25%, and increasing the percentage of medical trips to 30% substantially increased the total transit benefits by 88%, 20%, and 158%, respectively.