Rural Health Outcomes - Setting the Table
Health care workforce shortages, long travel distances to care, an increasingly aging population, patients with multiple complex chronic conditions, health facility closures, and health costs that grow further out of reach - these factors and more contribute to the troubling health outcomes in rural communities across our country.
According to the Centers for Disease Control and Prevention (CDC), rural Americans are more likely to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than their urban counterparts. Unintentional injury deaths are approximately 50 percent higher in rural areas than in urban areas, partly due to motor vehicle crashes and opioid overdoses.
The Commonwealth Fund’s 2020 International Health Policy Survey found that the United States had more geography-based health disparities than ten other high-income countries. Highlights from this report include higher rates of chronic disease, suicide, maternal health disparities, and limited access to care in American rural areas. The report attributed these disparities to affordability of care, which often leads rural residents to delay or skip routine care.
Affordability and Access
Rural residents are more likely to experience employment insecurity, often working in lower-income jobs that do not offer full health insurance coverage. This, coupled with higher rates of complex health issues, create a strain on our rural health infrastructure and jeopardize their ability to adequately meet the needs of communities and improve health outcomes.
The Affordable Care Act (ACA) aimed for all Americans to be able to access health care coverage, regardless of having pre-existing conditions. Prior to the ACA, the security of affordable and meaningful health insurance was often unreachable.The state- and federally-operated Marketplaces provide a way for those not offered employer-sponsored coverage to compare and price shop for the plan that is best for their family. In addition to the patient protections put in place by the ACA, nearly 12.5 million Marketplace enrollees qualified for premium assistance based on their income and family size in 2022 to make coverage more affordable.
Additionally, the Medicaid program plays a critical role in increasing access to care for rural populations. As many as one in four rural nonelderly rural individuals have coverage through Medicaid; this number can reach 50 percent in some areas. States that opted to expand Medicaid through funding from the Affordable Care Act have experienced lower rates of uninsured residents and a slower rate of hospital closures, with a significant decrease in uncompensated care.
Mental and Behavioral Health and Substance Use Disorders
COVID-19 strained our collective mental and behavioral health and led many people to rely more on substances to cope with this unprecedented pandemic. Social isolation, working and schooling from home, the loss of income, and the loss of loved ones increasingly taxed our resources. But the pandemic only exacerbated the underlying crisis we were already experiencing through lack of adequate mental and behavioral health services and the growth of substance use disorders (SUDs). This was felt more acutely in rural areas that already struggled to meet the needs of their communities. Alcohol and methamphetamine use already plagued many communities before the scourge of opioids and fentanyl arrived to lead to a growing increase in deaths of despair.
Based on data from the Centers for Disease Control and Prevention (CDC), rates of alcohol-induced deaths rose the fastest among people of color and people living in rural areas during the pandemic. Death rates were already higher in rural than metropolitan areas before the pandemic (14.5 percent versus 11.5 percent in 2019) but grew at a higher rate after (to 21.1 percent versus 15.6 percent in 2021).
Additionally, the CDC also found children in rural areas with mental, behavioral, and developmental disorders face more community and family challenges than their urban counterparts. Our next generation, and those raising them, deserve to be equipped with the tools to address childhood trauma, connect to appropriate professionals, and ensure a bright future.
Telehealth and integrated primary care have been incredible tools to ensure timely and accessible delivery of mental and behavioral health and SUD services during and after the pandemic. Rural areas utilized this care more than urban areas, demonstrating how telehealth can close the gap on access to services and address the unmet needs in our rural communities. Increased flexibility during the pandemic for coverage of telehealth, particularly by the Medicare program, has made this possible and must continue.
According to an analysis from the Kaiser Family Foundation, death rates by suicide in 2021 were highest among American Indian and Alaska Native (AI/AN) people, males, and people who live in rural areas. In rural areas, suicide death rates increased 25.5 percent from 2011 to 2021, compared to 12.4 percent in metro areas; states like Alaska, North Dakota, and South Dakota experienced increases around 50 percent. This is incredibly troubling and truly a public health crisis for rural America.
If you or someone you know is struggling with suicidal thoughts, please reach out to the National Suicide Prevention Hotline at 988 to connect with a professional waiting to help you.
Clearly we need to do more, and that starts with continuing to support policies that recognize and address what is contributing to statistics in our rural regions, expand early intervention and screenings, increase access to appropriate care and treatment, and erase the stigma for people in our communities who need our support.
Telehealth
Telehealth provides a lifeline to care for rural patients, from basic primary care to specialty services to chronic disease management to mental and behavioral health. These virtual visits reduce missed appointments, enable providers to more efficiently reach their patients, and reduce travel times, particularly in geographically remote areas where transportation is a significant barrier to care.
The easing of federal restrictions and reimbursement requirements for telehealth care resulted in a surge in utilization during the coronavirus pandemic as doctors’ offices and health clinics suspended in-person appointments and subbed in a more socially distanced solution. Both providers and patients grew more accustomed to this delivery model
While telehealth can increase access to life-saving care, challenges remain. According to a report from AARP, about one-fifth of rural adults don’t have access to high-speed internet, and rural adults age 70 or older with lower incomes and poorer health are least likely to have access. What’s more, a significant share of AARP’s survey respondents aren’t sure if their doctor offers telehealth or if their insurance covers it. Significant investments in broadband infrastructure were included in federal legislation since the pandemic began, but we have a long way to go to connect patients to this incredible technology to address rural health challenges.
Financial Stability
Compounding the demographic and geographic challenges that rural providers face in keeping communities safe and healthy, federal payment policies often threaten their financial future to continue providing life-saving care.
Rural providers rely on a collection of Medicare payment policies that attempt to account for the added costs to providing care under challenging conditions. Generally, the largest patient payor mix for these facilities is the federal government, making Medicare and Medicaid reimbursement rates (which are much lower than private insurance) even more important for these facilities’ bottom line to also balance out uncompensated patient care. Unfortunately, Medicare add-on payments for rural ambulance, rural home health, and physician reimbursement in our least populated regions are not a long-term solution and still leave some rural providers struggling to make payroll. And on top of that, these policies are subject to semi-annual or annual extension by Congress which does not create a sustainable or reliable financial future.
Congress is currently considering policy proposals that would cut billions in payments to hospitals and health systems through a misguided “site-neutral” policy. As they face workforce, vital service line, and financial hardships, proposals to cut payments by billions of dollars would further jeopardize hospitals’ ability to provide 24/7 access to emergency care, disaster response capability and capacity, and serve the most vulnerable patients. When hospitals are forced to close or convert to a different provider model, patients lose access to critical services in that area.
Additionally, the 340B Prescription Drug Program provides a lifeline of funding through rebates from pharmaceutical drug manufacturers to health care providers on select drugs. This program has enabled facilities to provide uncompensated care as well as keep their doors open in communities that might not otherwise have the services they need. Recently, after tireless advocacy from policymakers and providers and court rulings finding cuts to the program unlawful, the Centers for Medicare and Medicaid Services (CMS) have proposed to repay reductions in 340B payments for the last four years through a lump sum payment to the impacted providers, correcting course in the program and ensuring a continuity in services.