Rural health

Rural health refers to the special challenges and needs of receiving health care in rural areas and the medical programs adopted to meet them. A large portion of the population of the United States lives in areas with few or no physicians and medical facilities. Many of these people experience financial difficulties and may be un- or underinsured. The physicians who treat them often must do so without ready access to more advanced medical care support, such as testing facilities and specialists. In some cases, even hospital access is many miles away. As a result, special steps are necessary to help ensure adequate access to medical care for people in rural populations.

Background

The US Census Bureau defines rural areas by what they are not. A rural area is any area that is not an urbanized area (an area with a core of about 50,000 or more people and a population density of at least 1,000 people per square mile) or an urban cluster (a core area of less than two square miles with a population density of at least 1,000 people per square mile and a total population of at least 2,500 but fewer than 50,000 people). Other government agencies use different definitions of rural, but they reach a general consensus about the rural population: about 15 to 20 percent of the American population lives in rural areas. According to the Census Bureau’s American Community Survey, rural areas were home to 19.3 percent of the population, some 60 million people, between 2011 and 2015. Some estimates put the number as high as 25 percent. The difficulty in determining an exact number often comes from the fact that a large city might be surrounded by a large area of much lower population. The population of the larger city can affect whether the area is considered rural.

Regardless of how rural is defined, the sparse population of these areas often means that fewer health care professionals are nearby. For instance, according to the National Rural Health Association, urban areas have an average of about fifty-three physicians per one hundred thousand people compared to fewer than forty per one hundred thousand in rural areas. The areas are often lacking in other medical services as well, including specialists, testing facilities, pharmacies, and dentists. The lack of convenient health care facilities means that people in rural areas are often more seriously ill before they seek attention.

According to the American Community Survey, between 2011 and 2015, adults living in rural areas had lower rates of poverty, with a poverty rate of 11.7 percent compared to 14.0 percent for adults in urban areas; the poverty rate for children in rural areas was comparatively lower too, at 18.9 percent compared to 22.3 percent of children in urban areas. However, the American Community Survey found that 7.3 percent of rural children were uninsured, compared to 6.3 percent of urban children. Between 2011 and 2015, the median household income in rural areas was $52,386 compared to $54,296 in urban areas, and about 16 percent of the people in rural areas qualify for government assistance for groceries. People living on lower incomes tend to have more health problems brought on by poorer nutrition, lack of preventative care, and financial impediments to getting health care.

Other problems faced by rural residents that impact health include a higher number of smokers, lack of adequate Internet access to seek information about health concerns, lower rates of insurance due to unemployment or self-employment, and larger numbers of vehicle accidents that result in injury as compared to urban areas. Mental health is also a concern due to a lack of access to mental health providers in rural areas. In addition, a 2017 study by the CDC showed that children with mental, behavioral, and developmental disorders face more community and family challenges in rural areas.

Overview

Since researchers began tracking the numbers of providers in rural areas more than eighty-five years ago, they have determined that a shortage of physicians in rural communities exists. Beginning in the 1970s, the US government took steps to increase the number and type of practitioners in rural health settings. The Rural Health Clinic Services Act of 1977 started a process that resulted in more than 4,500 rural health clinics being operational in 2018. The act provided guidelines and financial incentives for physician offices to operate in rural or underserved areas. It encouraged the placement of nurse practitioners and physician’s assistants in these clinics to further improve the availability of care. In August 1987, the establishment of the Office of Rural Health Policy (ORHP) by the Health and Human Services Administration further improved the quality and availability of health care in rural areas.

The guidelines for a rural health clinic include requirements to have a physician, a nurse practitioner, and a physician’s assistant on staff for specified amounts of time. The clinics must provide for a certified nurse-midwife, a clinical psychologist, and a clinical social worker. They must have available the supplies and equipment these professionals need to perform their functions. Routine lab work must be performed at the clinic, and the clinic must be equipped with drugs, biological agents, and equipment that might be necessary in common emergencies. The clinic also must have an arrangement with a nearby hospital to provide services that are not available at the clinic.

These clinics still face significant challenges in providing care. They see higher numbers of patients receiving government benefits such as Medicare and Medicaid, which see very little increase in reimbursements. This means that the clinics operate on tighter budgets than urban clinics. They often have facilities that date back to their founding thirty or more years ago and need repairs or renovations for which the clinics do not have sufficient funding. Health care increasingly depends on technology for communication between practitioners and with patients, for electronic prescribing, and for telenursing. Such technology requires new equipment that is difficult for rural clinics to afford. The fact that many of the estimated 60 million people who live within rural health clinic territories are often sicker than the average person in an urban area means that the clinics must see more seriously ill patients with fewer resources than clinics in more populated areas. In addition, people in rural areas tend to not seek treatment until advanced stages of illness because of the difficultly accessing clinics.

Rural clinics continue to have difficulty recruiting qualified personnel to work in these areas as well. To combat this, a number of programs provide scholarships, grants, or tax-free student loan forgiveness to medical professionals willing to work in rural settings. Despite these efforts, a shortage of clinicians in rural areas persists.

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