Rural health care in the united states

Defining rural areas

Rural American communities are as diverse as the country itself. Each rural community has distinct characteristics and challenges that are a function of numerous factors unique to that area. For example, small towns in Appalachia are different in character from the farming communities and open plains of the Midwest; these characteristics reflect the economic, cultural, and social differences unique to each area. To understand the characteristics of rural health care, it is important to understand how different U.S. governmental agencies define “rural.”

Geographic isolation and population density represent two of the major features of a rural versus nonrural—or urban—envirionment:

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  The U.S. Census Bureau focuses on population density; however, the Bureau does not formally define “rural.” Instead, it is described as a population, housing, or territory that is not included in an urban area ( Fig. 52.1 ). Urban areas are defined as either an “urbanized area” with a concentration of 50,000 or more individuals, or an “urban cluster” with at least 2500 but fewer than 50,000 individuals. Any communities or areas not meeting these parameters would be deemed rural.

  

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  The Office of Management and Budget delineates areas by county, with designations of metropolitan (50,000 or more population), micropolitan (10,000–49,999 population), or neither (less than 10,000 population). Nonmetropolitan areas are considered rural. Under this definition, after the 2010 Census, nonmetropolitan areas contained about 15% of the total population and covered 72% of the land area in the United States. “Noncore” counties are those that are not part of metropolitan or micropolitan areas ( Fig. 52.2 ).

  

Defining health care shortage areas

Health care shortages are typically more common in rural locales than urban areas. ^, Areas of the country with health care shortages may be eligible for federal and state benefits, such as grants or loan repayment programs, even if they are not classified as “rural” under the previously discussed definitions. The United States Health Resources and Services Administration (HRSA) relies on several formal designations to identify areas with significant shortages in one or more areas of health care, as follows:

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  Health professional shortage areas (HPSAs) indicate health care provider shortages in the disciplines of primary care, mental health, or dental health. A shortage may be designated for a specific geographic area, a given population group within a defined geographic area (e.g., low income, homeless), or a facility such as a correctional facility or state mental hospital. The determination of a HPSA typically follows in response to a submitted application by a community or institution seeking this designation.

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  Medically underserved areas (MUAs) identify geographic areas with a shortage of primary care health services, whereas medically underserved populations (MUPs) describe specific subgroups living in a defined geographic area who are subject to a shortage of primary care health services. The MUP designation is often granted to groups that face significant cultural barriers or economic difficulties that hinder access to health care. MUAs and MUPs are determined based on the population to provider ratio, the percent of the population below the federal poverty level, the percent of the population over age 65, and the infant mortality rate.

The definitions by the U.S. Census Bureau, the Office of Management and Budget, and the HRSA provide an introductory framework for identifying rural populations, as well as groups and areas affected by health care shortages. This framework is essential to the development of a deeper understanding of our rural health infrastructure.

Socioeconomic factors

Financial factors play a significant role in the availability of health care for rural Americans. A Robert Wood Johnson survey on rural health care revealed that 45% of the respondents cited that care was unaffordable. There are multiple aspects of affordability of health care for rural patients that should be considered when determining how best to provide care for these populations.

Rural Americans tend to have lower median household incomes than urban households. ^, In the Northeast and Midwest, the difference in average household income between urban and rural households is minimal; however, in other areas of the country there is a considerable difference between urban and rural household incomes. For example, rural households in Appalachia earn approximately 34% less than Appalachian households in metropolitan areas ($36,265 in rural households versus $54,743 in urban households). Moreover, the median household income in Appalachia is 19% lower than the national median. This dramatic difference once again underscores the importance of understanding the factors that may affect the practice of rural medicine.

Rural counties also consistently have the highest rates of poverty when compared with suburban and urban counties. ^, When considering areas of concentrated poverty, where at least one-fifth of the population is poor, rural areas once again top the list. In the United States about 31% of rural counties meet the criteria for concentrated poverty, whereas only 19% of urban and 15% of suburban counties fit this criteria. In 2017 the overall rural poverty rate was 16.4%, compared with 12.9% for urban areas; nevertheless, the poverty rate has improved over the last 4 years. Caucasians make up the largest percentage of rural individuals living in poverty (65%). ^, Rural poverty rates vary by ethnic population as well, however, with rural Black Americans being disproportionately affected when compared with other racial/ethnic groups.

The availability of affordable, quality health insurance continues to be an issue for many Americans. Not surprisingly, rural Americans struggle with lower rates of insurance coverage than their suburban and urban counterparts. In completely rural counties, approximately 12.3% of the population is uninsured, compared with 10.1% for counties with less than a 50% rural population. Nevertheless, in recent years the overall rate of uninsured individuals has been improving in both rural and urban areas. Medicaid plays a key role in reducing rates of uninsured rural Americans, and the expansion of Medicaid introduced by the Affordable Care Act (ACA) in 2010 had a considerable impact on rural populations, with an especially dramatic effect on juvenile populations. In 2015, Medicaid provided health care insurance for 45% of children and 16% of adults in rural areas, compared with 38% of children and 15% of adults in metropolitan areas. It is noteworthy that Medicaid coverage under the ACA was not approved by all states. In 2015 the rural populations of states without expanded coverage were found to have significantly higher rates of uninsured people at 27% versus 13% in the states with expanded coverage.

Numerous studies have demonstrated the positive impact of insurance coverage on health. ^, Even so, having insurance does not uniformly lead to accessibility of health care services. Nearly one in five rural patients report difficulty finding a provider willing to accept their health insurance. This may be in part because of the relatively high proportion of patients insured by Medicaid and the low rates of providers who will accept Medicaid. One survey found that only 70.8% of providers accept new patients with Medicaid coverage, compared with 85.3% who accept Medicare patients and 91% who accept new patients with private insurance.

Additional financial barriers faced by rural patients when accessing health care services go far beyond simply the affordability of office visits, diagnostic tests, or prescriptions. Rural patients may defer health care because of the possibility of lost wages associated with taking time off work to attend appointments; transportation costs of either personal or public travel; or other expenses such as childcare, utilities, or food costs that take priority over personal health.

Physical access to health care

Physical access to health care services is a significant barrier for many rural patients. Reliable transportation is essential for traveling to and from medical facilities but also impacts the ability to access other resources, such as exercise centers, grocery stores, and places of employment. The lower average income and higher rates of poverty noted in rural areas may impede access to reliable transportation. Moreover, public transportation is markedly limited in most rural areas. In 2017, less than 1% of rural residents used public transportation to travel to work, compared with 6.3% of urban residents. Only 60% of rural counties in the United States report availability of public transportation, and 28% of rural counties with public transportation reported very limited service. The service limitations and costs associated with rural public transit may be impractical for many individuals seeking transportation for medical care. For example, fixed-route services that run on regular schedules are common in metropolitan areas; however, many rural transit agencies only offer a demand-response service wherein patients must call and specifically request transportation to and from the health care facility. Additionally, the cost of this transportation may not be covered by health insurance. Public transportation may also not be adequate for the patient’s needs, especially if the rural public transportation system does not provide services outside the local area for appointments in larger cities.

The geographic isolation of many rural towns and communities can result in a significantly longer trip to access health care services, especially those provided by medical specialists. This leads approximately 23% of rural patients to report the distance to health care services as a significant challenge to receiving care. This isolation also leads to a limited number of choices with regard to health care facilities. Patients may have no choice but to see a provider based strictly on location, rather than other considerations, such as experience or subspecialization, simply because there are no other practical options.

Adding to the aforementioned issues, many rural areas struggle with roadways considered to be less safe and in worse conditions than roads elsewhere in the country. In 2015, 36% of major rural roads were rated in poor or mediocre condition, and 10% of rural bridges were rated as structurally deficient. Rural roadways are more likely to have hazardous features such as narrow lanes, limited shoulders, sharp curves, exposed hazards, pavement drop-offs, and steep slopes ( Fig. 52.3 ). As a result, rural, non-interstate roads have traffic fatality rates 2.5 times higher than other roadway categories. These less-than-ideal traveling conditions serve only to further deter patients from accessing necessary health care services.

Cultural factors

There are some commonly held cultural beliefs and practices found in rural areas that may also affect the provision of health care. Awareness of the potential impact of rural culture, as well as an understanding of the unique viewpoints, values, attitudes, belief systems, and norms of patients in rural communities, is essential to building healthy patient-provider relationships.

Most patients from rural backgrounds place a high value on personal relationships and connection to the community. Moreover, rural patients are also more likely than those in urban or suburban settings to live in, or near, the areas in which they grew up. ^, Rural patients may be more accepting of providers who are perceived as part of the community. In fact, many rural providers experience overlap between the role of clinician and that of a community member. The overlap of these roles can help establish rapport with patients but may also lead to potential problems with blurring the boundaries of the professional relationship. Rural health care providers may be called upon for services such as free consultations, after-hours services, and volunteer work, all as a part of helping their “neighbors.”

The familiarity rural patients experience with people in their communities can also be problematic. Rural patients may avoid seeking care because of a perceived lack of privacy, despite the protective mandate of the Health Insurance Portability and Accountability Act (HIPAA). This may be particularly problematic for disorders that have historically carried a strong stigma, such as mental illness. Family members may contribute to this potential problem by perpetuating this stigma and encouraging the patient not to seek treatment. Rural health care practitioners may experience challenges when caring for these patients, with the need to provide treatment but also to protect their patient from the difficulties of carrying this diagnosis within a small, tight-knit community. Other conditions especially common in rural populations, such as obesity, tobacco use, and heart disease, may become normalized and result in patients failing to appreciate the severity of their condition or the need for intervention. ^,

Other cultural attributes commonly encountered in the rural setting include a strong sense of self-reliance, emphasis on the importance of family, conservative values, propensity for personal religious or spiritual beliefs, and a sense of fatalism. ^, Although these traits may not interfere with the delivery of care, there is the potential to deter patients from seeking health care. In the health care setting, these cultural values may lead to behaviors such as reduced reliance on health care or a belief that a higher power wants them to be sick or will heal them without the use of modern medicine. Additionally, there may be the sense that they are fated to be ill or to die and that seeking medical care is therefore pointless.

Traditional gender norms may also influence rural patient views on the roles and responsibilities of health care providers. Rural patients may tend to see women as better suited for support roles (such as nursing and clerical positions) and to see men as better suited for traditional leadership roles (such as those of a physician or administrator), regardless of the individual’s actual education or experience. These views, in turn, may present challenges to provider-patient rapport and the general effectiveness of delivering care in rural settings.