The authors explored how discontinuous insurance coverage affect actual utilization of services, subset by rural residence. From the abstract:
"Health insurance continuity was significantly associated with several measures of health service utilization, including more ER visits for individuals with gaps in health insurance (IRR [incident risk ratio] = 1.29; 95% CI: 1.16-1.42) and fewer inpatient discharges for individuals without insurance (IRR = 0.50; 95% CI: 0.43-0.57) when compared with individuals with continuous insurance. Individuals who were discontinuously insured or uninsured had significantly fewer office-based visits. They also had significantly fewer dental visits, prescription fills, and home health visits; moreover, the magnitudes of these associations were generally significantly greater for residents of nonmetropolitan areas."
In short, living in a rural area meant lower utilization, particularly among those discontinuously insured. Hopefully, full implementation of the ACA will help to reduce this discontinuity; Adriana McIntyre over at Vox describes how the ACA has shown evidence of reduced churn. If the ACA truly does reduce those who drop (or are dropped from) insurance coverage, then these impacts will be mitigated. However, given evidence of rural residents falling trhough the cracks of ACA implementation (see the Kaiser Family Foundation's report here), it is clear more work needs to be done to ensure rural residents have adequate access to health care.