{"id":340,"main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/06\/Distance-main-image.jpg","hero_image":null,"page_title_en":"The deadly distance: Rural health care in America","page_title_es":"La distance mortelle: les soins de sant\u00e9 en milieu rural en Am\u00e9rique","page_title_fr":"La distancia mortal: la atenci\u00f3n m\u00e9dica rural en Am\u00e9rica","page_content_en":"

Throughout the U.S., people living in rural communities are more likely to die and experience higher rates of poor health outcomes than those living in metropolitan areas.[1]<\/a> When compared to urban populations, there\u2019s a clear disparity in the mortality rates of heart disease and cancer, the two leading causes of premature death in America.[2]<\/a> \u00a0People in rural communities tend to die younger from seemingly preventable causes, and they also tend to suffer more from seemingly manageable conditions. Because of this, rural populations are referred to as a health disparity population, generally experiencing worse health outcomes than the national average.[3]<\/a><\/p>\n

Why does this happen?<\/p>\n

To start, let\u2019s get some context. Approximately 60 million people in the US are considered \u201crural\u201d \u2013 about a fifth of the country\u2019s population. However, according to the U.S. Census Bureau\u2019s 2017 American Community Survey, rural areas comprise 97 percent of US land mass. That means that four-fifths of our country live in about 3 percent of the country\u2019s land mass. Increasingly, the populations of rural counties are getting smaller \u2014 particularly those in the Midwest and Northeast of the U.S., which are losing people due to higher death rates than birth rates and more people moving away than moving in.<\/p>\n

Of those that still remain in rural communities, about 16 percent live in poverty \u2013 a figure about 3 percent higher than their urban counterparts.[4]<\/a> While this higher prevalence of poverty is significant enough to be a considerable factor, it alone does not explain why rural Americans are sicker than the rest of us. Why, then, is this happening?<\/p>\n

 <\/p>\n

Care is out of reach<\/strong><\/p>\n

Good health care policy cannot force a sick person to seek care, but it ensures that any individual, can, at minimum, reasonably access<\/em> the care they need to get better. A lack of access to health care is widely known to directly correlate to poorer health outcomes.[5]<\/a> This is perhaps the most obvious and significant issue facing rural Americans \u2013 the distance they may need to travel to get that care.[6]<\/a> The care they require is simply too far or unable to be reached, forcing patients to either forgo care or spend the extra time and money necessary to reach it.<\/p>\n

It\u2019s also important to note that distance is relative to the patient; some may struggle more than others to travel relatively shorter distances.[7]<\/a> The perception of how difficult it is to get care due to distance is just as likely to prevent a patient from seeking care as the actual difficulty of obtaining it. It\u2019s not hard to imagine this choice being an even greater burden on rural Americans, who may live in poverty, lack access to public transportation or rely on income from hourly or agricultural work.<\/p>\n

More problematic than just the physical distance to care is the lack of medical professionals in some rural communities. Rural areas are more likely to be medically underserved, with a shortage of health care professionals.[8]<\/a> In urban areas, on average there are 32.5 physicians per 10,000 residents of the community. In rural areas, there are only 12.7 physicians per 10,000 residents.[9]<\/a> It\u2019s not just hospitals or specialty care that rural patients lack access to \u2013 it\u2019s all aspects of the health system.<\/p>\n

The reason for this is multifold but generally centers around a key problem \u2013 recruitment. It\u2019s more difficult to entice physicians to rural communities, particularly if they have no family or previous history in the area. There may also be a shortage of academic medical programs, something many physicians may seek. Additionally, the spouses or significant others of physicians may struggle to find employment of their own in rural areas. Finally, culture often remains a barrier, as there tend to be fewer restaurants and entertainment options in rural areas. \u00a0And rural communities often do not have the religious diversity of more suburban or urban areas, providing fewer opportunities for physicians of different backgrounds to practice their faith.[10]<\/a><\/p>\n

 <\/p>\n

Cost of rural care<\/strong><\/p>\n

Cost is another factor that must be considered when discussing access to rural health care. It has been shown that rural health care is not necessarily any more expensive than comparative care in urban regions; in fact, it is sometimes cheaper.\u00a0However, rural people are less likely to have the means to afford health care at all. People in rural areas are more likely to refuse or delay health treatment due to financial constraints, resulting in worsening health outcomes.\u00a0There is also a known correlation between socioeconomic status and outcomes for health conditions.\u00a0As previously stated, rural areas have disproportionately high levels of poverty compared to urban areas, resulting in poorer health outcomes compared to urban\/wealthier counterparts.<\/p>\n

The number of uninsured adults between the ages of 18 and 64 is higher in rural areas, compared to urban populations. Twelve percent of people living in metropolitan areas are uninsured, compared to 13.5 percent of people in non-metropolitan areas.\u00a0Higher rates of uninsured patients generally mean higher rates of out-of-pocket payments for treatment, something that people living in poverty cannot afford, even though this population often requires the most amount of care.<\/p>\n

People living in rural areas struggle more to afford the cost of transportation to necessary health services.\u00a0This is compounded by the fact that a number of rural health centers are closing, increasing the distance and cost to reach medical aid. Thus, although healthcare itself might be relatively cheaper than in metropolitan areas, rural patients still cannot afford the associated transportation costs.<\/p>\n

\u00a0<\/strong><\/p>\n

Hospital closures<\/strong><\/p>\n

As if access to care wasn\u2019t already difficult for rural Americans, the increasingly high rates of hospital closures[11]<\/a> is only compounding the issue. Between 2005 and 2017, 124 rural hospitals closed.[12]<\/a> Since the passage of the Patient Protection and Affordable Care Act in 2010, states that did not expand Medicaid have seen the most closures. According to the North Carolina Rural Health Research Program, there have been 160 rural hospital closures since 2005, with 17 closures so far in 2019.<\/p>\n

These closures are concentrated heavily in states that did not expand Medicaid, which is evidenced in the six states with five or more rural hospital closures. They are, in order: Texas (15 rural hospitals closed), Tennessee (9 rural hospitals closed) and Georgia (7 rural hospitals closed). Alabama, Mississippi and North Carolina each had five rural hospitals closed.<\/p>\n

Additionally, the high rate of hospital closures is generally due to financial and market reasons. The hospitals that have closed tended to be less profitable and have fewer patients than those that remain open.[13]<\/a> Most rural hospitals run as nonprofit businesses,[14]<\/a> which are more likely to offer the type of unprofitable services that consumers need compared to for-profit hospitals.[15]<\/a> It\u2019s understandable why it\u2019s not financially feasible for these hospitals to stay in business, but it leaves rural patients without access to the care they need.<\/p>\n

It is expected that more and more rural hospitals will eventually shut down.[16]<\/a> A hospital shutting down in an already underserved rural community can leave a patient with no other nearby alternatives.<\/p>\n

Mergers and acquisitions (M&A) \u2013 which are increasing at a rapid rate \u2013 are often cited as a solution to lack of rural care. Health care organizations announced\u00a0115 M&A transactions\u00a0in 2017, the highest number in recent history. The usual reasons for M&A are to improve the affordability, convenience, and cost-effectiveness of health care while reducing pressures related to declining reimbursement rates, increasing operating expenses and promoting greater competition.[17]<\/a><\/p>\n

However, evidence supports the prevailing thought that M&A activity increases costs. For example, according to a 2012 Robert Wood Johnson Foundation (RWJF) study, consolidation of health systems increases health care prices \u2013 sometimes by more than 20 percent.[18]<\/a> Additionally, a 2016 study by the New York State Healthcare Foundation found that hospitals with greater market leverage (as is often the case for merged hospital systems) charged prices that were three to four times greater than those with less market power.[19]<\/a> In 2018, a University of California Berkeley study conducted for The<\/em> New York Times<\/em> found that M&A activity increased hospital admission costs from 11 to 54 percent throughout the country from 2012 to 2014, due to reduced competition.[20]<\/a><\/p>\n

Keep in mind, though, that these statistics look at all hospital mergers, not only rural hospitals. Rural hospitals carry with them certain situations \u2013 such as the socioeconomic issues already discussed \u2013 as well as shifting payor bases and increased volumes of uninsured patients. These factors make mergers the most viable option to continue providing services within a given community.<\/p>\n

 <\/p>\n

Potential solutions<\/strong><\/p>\n

Critical access hospitals<\/u><\/p>\n

Critical access hospitals can help ease issues of access in many communities. These hospitals must meet a number of different criteria to achieve critical-access status, such as being certain distances from other hospitals, providing emergency services, keeping patients at the hospital for no more than 96 hours and having no more than 25 beds.[21]<\/a> The designation of \u201ccritical access\u201d allows a hospital to receive Medicare cost-based reimbursements, which is a better financial option than the alternative hospital-based prospective payer system.[22]<\/a><\/p>\n

Data suggests that when critical access hospitals are within a 15-mile vicinity of another hospital, they have higher quality outputs and are more financially stable.[23]<\/a> This may be the result of increased competition, which can also reduce costs. Thus, an increase in critical access hospitals could both improve health care quality outcomes and reduce costs, making them a necessary component to improved rural health care.<\/p>\n

Telemedicine<\/u><\/p>\n

Like critical access hospitals, telemedicine is another community-driven intervention that has shown some promise in reducing health care inequities. The introduction of an online-based model of care allows caregivers to work directly with health professionals without needing to be in the same location. In one case, the system utilized the familial and social support systems on which patients already relied.[24]<\/a> The caregivers were provided some basic training and equipment at no cost to the patient.[25]<\/a> While it did not completely replace the need for health care providers, it was shown to improve outcomes[26]<\/a> and efficiency for receiving health care in rural areas.[27]<\/a><\/p>\n

It\u2019s reasonable to imagine how an increase in telemedicine or online care could help people in rural American communities \u2013 provided patients have access to quality internet services. If patients could simply call or FaceTime with a provider for certain health concerns, checkups or prescription renewals, they wouldn\u2019t face the transportation, access and cost barriers they do now. They could rely on a continuation of care and treatment that could improve their health care outcomes.<\/p>\n

Medicaid expansion<\/u><\/p>\n

An often-cited solution to issues of rural health care \u2013 particularly, hospital closures \u2013 is Medicaid expansion. Multiple studies have demonstrated the potentially positive impact Medicaid expansion has on a rural community, including a 2018 study published in Health Affairs<\/a> that concluded:<\/p>\n

\u201c[T]he ACA\u2019s Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion.\u201d[28]<\/a><\/p><\/blockquote>\n

This is backed up by the North Carolina Rural Health Research Program study referenced earlier that demonstrated rural hospitals in non-Medicaid expansion states are much more likely to close than those in states that did expand \u2013 which is no coincidence.<\/p>\n

To start, in expansion states, uninsured rates have dropped by as much as 20 percent, while uninsured rates in states that did not expand Medicaid have increased. This is due in large part to the limitations of Medicaid in non-expansion states. According to the Kaiser Family Foundation<\/a>, the median income limit for parents in these states was just 43 percent of the poverty line, or an annual income of $8,935 for a family of three in 2018. Childless adults are still ineligible in almost every one of the states that didn\u2019t expand Medicaid.<\/p>\n

Additionally, there is a catch-22 found with the ACA itself. Because the law is intended for all low-income people to receive coverage through Medicaid, it doesn\u2019t provide financial assistance to people below the poverty line for other coverage options. As a result, in states that do not expand Medicaid, many adults, including all childless adults, fall into a \u201ccoverage gap\u201d of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits.[29]<\/a><\/p>\n

This puts an incredible burden on rural hospitals to provide the financial assistance that is vital to these uninsured adults (and, if they are a nonprofit, required by federal law), and this increased demand for unpaid services is, in turn, contributing to the financial downfall of these hospitals.<\/p>\n

 <\/p>\n

Where do we go from here?<\/strong><\/p>\n

There are a number of different factors that contribute to the negative health care outcomes in rural communities within the United States, and they are all intrinsically linked. People in rural communities are more likely to live in poverty, and poverty is also a risk factor for poor health. The combination of being in poverty and living in a rural location often make it difficult for patients to be able to afford health care \u2013 both the treatment itself and the transport to the clinic or hospital location. A shortage of medical facilities and lack of insurance among rural populations also contribute to the crisis. These challenges are all complex and interwoven, compounding poor health outcomes in rural populations.<\/p>\n

Current research suggests the rural-urban health divide is only going to continue to increase. More action needs to be swiftly taken to reduce both the financial and physical barriers to health care that rural patients face. As the issues causing negative health outcomes in rural America are complex and multifaceted, there is no simple solution. However, based on research from overseas, there are a number of changes that can be made to the rural health system that would likely improve health outcomes for rural American patients.<\/p>\n

 <\/p>\n

References<\/em><\/p>\n

[1]<\/a> James, Cara V., Ramal Moonesinghe, Shondelle M. Wilson-Frederick, Jeffrey E. Hall, Ana Penman-Aguilar, and Karen Bouye. \u201cRacial\/Ethnic Health Disparities Among Rural Adults \u2014 United States, 2012\u20132015.\u201d MMWR Surveillance Summaries<\/em> 66, no. 23 (November 17, 2017): 1\u20139. Https:\/\/doi.org\/10.15585\/mmwr.ss6623a1<\/a>.<\/p>\n

[2]<\/sup><\/a> Purnell, Tanjala S., Elizabeth A. Calhoun, Sherita H. Golden, Jacqueline R. Halladay, Jessica L. Krok-Schoen, Bradley M. Appelhans, and Lisa A. Cooper. \u201cAchieving Health Equity: Closing the Gaps in Health Care Disparities, Interventions, And Research.\u201d Health Affairs<\/em> 35, no. 8 (August 1, 2016): 1410\u201315. https:\/\/doi.org\/10.1377\/hlthaff.2016.0158.<\/p>\n

[3]<\/sup><\/a> Matthews, Kevin A., Janet B. Croft, Yong Liu, Hua Lu, Dafna Kanny, Anne G. Wheaton, Timothy J. Cunningham, et al. \u201cHealth-Related Behaviors by Urban-Rural County Classification \u2014 United States, 2013.\u201d MMWR Surveillance Summaries<\/em> 66, no. 5 (February 3, 2017): 1\u20138. https:\/\/doi.org\/10.15585\/mmwr.ss6605a1.<\/a><\/p>\n

[5]<\/a> Benitez, Joseph A., and Eric E. Seiber. \u201cUS Health Care Reform and Rural America: Results from the ACA\u2019s Medicaid Expansions: Medicaid Expansion and Rural America.\u201d The Journal of Rural Health<\/em> 34, no. 2 (2018): 213\u201322. https:\/\/doi.org\/10.1111\/jrh.12284<\/a>.<\/p>\n

[6]<\/a> Buzza, Colin, Sarah S. Ono, Carolyn Turvey, Stacy Wittrock, Matt Noble, Gautam Reddy, Peter J. Kaboli, and Heather Schacht Reisinger. \u201cDistance Is Relative: Unpacking a Principal Barrier in Rural Healthcare.\u201d Journal of General Internal Medicine<\/em>26, no. S2 (2011): 648\u201354. https:\/\/doi.org\/10.1007\/s11606-011-1762-1<\/a>.<\/p>\n

[7]<\/a> Ibid.<\/p>\n

[8]<\/a> Benitez, Joseph A., and Eric E. Seiber. \u201cUS Health Care Reform and Rural America: Results from the ACA\u2019s Medicaid Expansions: Medicaid Expansion and Rural America.\u201d The Journal of Rural Health<\/em> 34, no. 2 (2018): 213\u201322.<\/a><\/p>\n

[10]<\/a> Hall, Kerri. \u201cAttracting and Retaining Physicians in Rural America.\u201d Becker\u2019s Hospital Review. 25 September 2017. Accessed online.<\/p>\n

[11]<\/sup><\/a> Kaufman, Brystana G., Sharita R. Thomas, Randy K. Randolph, Julie R. Perry, Kristie W. Thompson, George M. Holmes, and George H. Pink. \u201cThe Rising Rate of Rural Hospital Closures.\u201d The Journal of Rural Health<\/em>, January 1, 2016. https:\/\/doi.org\/10.1111\/jrh.12128<\/a>.<\/p>\n

[12]<\/sup><\/a> \u201cResource Details: Rural Health Research Recap: Rural Hospital Closures – Rural Health Information Hub.\u201d Accessed August 19, 2019. https:\/\/www.ruralhealthinfo.org\/resources\/9933<\/a>.<\/p>\n

[13]<\/sup><\/a>\u00a0\u00a0 Ibid.<\/p>\n

[14]<\/sup><\/a> Horwitz, Jill R., and Austin Nichols. \u201cRural Hospital Ownership: Medical Service Provision, Market Mix, and Spillover Effects: Rural Hospital Ownership.\u201d Health Services Research<\/em> 46, no. 5 (2011): 1452\u201372. https:\/\/doi.org\/10.1111\/j.1475-6773.2011.01280.x<\/a>.<\/p>\n

[15]<\/sup><\/a> Ibid.<\/p>\n

[16]<\/sup><\/a> Kaufman, Brystana G., Sharita R. Thomas, Randy K. Randolph, Julie R. Perry, Kristie W. Thompson, George M. Holmes, and George H. Pink. \u201cThe Rising Rate of Rural Hospital Closures.\u201d The Journal of Rural Health<\/em>, January 1, 2016. https:\/\/doi.org\/10.1111\/jrh.12128<\/a><\/p>\n

[17]<\/a> Herschman et al.<\/p>\n

[18]<\/a> Gaynor, Martin, and Robert Town. \u201cThe Impact of Hospital Consolidation – Update.\u201d Robert Wood Johnson Foundation: The Impact of Hospital Consolidation<\/em>, 1 June 2012, https:\/\/www.rwjf.org\/en\/library\/research\/2012\/06\/the-impact-of-hospital-consolidation.html.<\/p>\n

[19]<\/a> Gorman Actuarial. Why Are Hospital Prices Different? An Examination of New York Hospital Reimbursement<\/em>. https:\/\/nyshealthfoundation.org\/resource\/an-examination-of-new-york-hospital-reimbursement\/. Accessed 1 July 2019.<\/p>\n

[20]<\/a> Abelson, Reed. \u201cWhen Hospitals Merge to Save Money, Patients Often Pay More.\u201d The New York Times<\/em>, 14 Nov. 2018. NYTimes.com<\/em>, https:\/\/www.nytimes.com\/2018\/11\/14\/health\/hospital-mergers-health-care-spending.html.<\/p>\n

[21]<\/a> Casey, Michelle M., Ira Moscovice, G. Mark Holmes, George H. Pink, and Peiyin Hung. \u201cMinimum-Distance Requirements Could Harm High-Performing Critical-Access Hospitals and Rural Communities.\u201d Health Affairs<\/em> 34, no. 4 (2015): 627\u201335. https:\/\/doi.org\/10.1377\/hlthaff.2014.0788.<\/p>\n

[22]<\/a> Ibid.<\/p>\n

[23]<\/a> Ibid.<\/p>\n

[24]<\/sup><\/a> Barjis, Joseph, Gwendolyn Kolfschoten, and Johan Maritz. \u201cA Sustainable and Affordable Support System for Rural Healthcare Delivery.\u201d Decision Support Systems<\/em> 56 (2013): 223\u201333. https:\/\/doi.org\/10.1016\/j.dss.2013.06.005<\/a>.<\/p>\n

[25]<\/sup><\/a> Ibid.<\/p>\n

[26]<\/sup><\/a> Ibid.<\/p>\n

[27]<\/sup><\/a> Ibid.<\/p>\n

[28]<\/a> Lindrooth, Richard, et al. \u201cUnderstanding the Relationship Between Medicaid Expansions and Hospital Closures.\u201d Health Affairs <\/em>37 (2018): 111-120. . <\/em><\/p>\n

[29]<\/a>Garfield, Rachel, et al. \u201cThe Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid.\u201d Kaiser Family Foundation.<\/p>\n

 <\/p>\n