We Need to Talk About Rural Health

 I don’t believe that anyone can have a well-informed discussion about healthcare policy without first turning an eye towards rural health in the U.S. There are many different ways to define an area as “rural.” Still, it’s fair to say that 15-20% of America’s total population lives in a rural area. I am in that 15-20% segment of the population, and I happen to work in health insurance/healthcare, which explains my interest in health literacy and rural health.

At County Health Rankings and Roadmaps, I entered the county that I live in, and this is what I found:

  • 17% of people who live in my county describe themselves as having “poor or fair health.” In top-performing counties in the U.S., 12% of the population represents themselves this way.
  • In the county where I reside, 21% of adults smoke. In top-performing counties, only 14% do.
  • In the county where I live, 34% of adults are obese, and in top-performing counties, 26% are.
  • Maybe part of the reason why obesity is a more significant problem here is that only 53% of the population has access to exercise opportunities. In the top-performing counties, 91% of the population has access.
  • In my county, 18% of the population has a problem with excessive drinking, while 12% do in top-performing counties. Also, 32% of auto-related deaths cite alcohol as a factor here, while only 13% do in top-performing counties.
  • There are 2,170 people for every primary care physician here and 820 people for every one mental health provider here. If I lived in a top-performing county, those numbers would be 1,040:1 for primary care physicians and 360:1 for mental health providers.
  • The unemployment rate here is 6.3%, and 21% of children live in poverty. In top-performing counties, the unemployment rate is 3.3%, and 12% of children live in poverty.

I do not live in the lowest-ranked county in my state. There are counties in far worse shape in this state and all over the nation.

Many Republican-leaning governors in rural states didn’t sign on for the Medicaid expansion under ObamaCare. In 2017, about 41% of all rural areas on the exchanges only had one insurer. The fear that these few insurers could exit marketplaces and leave this segment of the population without any carriers is legitimate. In August of 2016, Aetna pulled out of Arizona’s ObamaCare marketplaces, which left Pinal county with no insurer selling plans on the exchanges. Luckily, Blue Cross Blue Shield picked up the county. Suppose rural areas have no options on the insurance exchanges. In that case, patients will be charged higher out-of-pocket costs (a significant proportion of which will go unpaid). Hospitals will be forced to provide care without compensation and will eventually have no choice but to close their doors.

If you’re wondering why this issue is urgent right now, it’s partly because more than 75 rural hospitals have closed since 2010, and 673 more are vulnerable and could close. This would represent 1/3 of all rural hospitals in the U.S. The Save Rural Hospitals Act (H.R. 3225)  is meant to stop Medicare cuts to rural hospitals and to offer a novel delivery model for rural healthcare.

Unfortunately, many doctors won’t accept all Medicaid and all Medicare insurances because of inadequate reimbursement. Nearly 25% of rural residents rely on Medicaid. Rural health clinics in medically underserved areas get Medicare reimbursement based on the cost to the clinic, not what Medicare says that it should cost. Being deemed a “Federally Qualified Health Center” gives that center enhanced reimbursements for Medicare and Medicaid patients and offers national malpractice insurance coverage and extra specialist care. For areas that aren’t designated as medically underserved and don’t have a Federally Qualified Health Center, the emergency room is often the only option.

There are many, many obstacles to overcome when you talk about health disparity in rural areas. These include the poverty rate, the lack of physicians and pharmacists willing to practice in rural settings, the travel time necessary for individuals seeking care, the lack of reliable transportation for many people, and the unavailability of phone and Internet service to name just a few. These aren’t new problems – certainly not – but they are problems that must be considered now more than ever, with the impending changes to federal health care legislation. If you want to learn more about the exciting things that organizations and practitioners are doing to improve the delivery of care (better patient care, improved community health, and lower per capita costs) in rural areas, please visit Rural Health Value. If you would like to read about some suggestions for improving rural residents’ care, read the 2016 Update: Improving Rural Health: State Policy Options.