Rural Americans clearly face a large number of social determinants that contribute to poor health status, increased risks, and less-than-optimal outcomes. However, they also face significant challenges with their actual health care infrastructure, creating challenges with access to quality health care.
According to the Institute of Medicine, access to health care means having “the timely use of personal health services to achieve the best health outcomes.” 12 Health insurance facilitates entry into the health care system. Those without insurance or with inadequate coverage are less likely to receive care. As noted earlier in the chapter, economic instability is one of the challenges faced by rural Americans. Compared to those in metropolitan areas, rural populations have lower incomes, making it more difficult to afford health insurance coverage. Additionally, workers in rural areas are less likely to have employer-sponsored health insurance. According the Henry J. Kaiser Family Foundation, “among workers, those in rural areas are more likely to work in blue collar jobs (jobs outside of managerial, business, and financial occupations) than workers in metropolitan areas (71% versus 63%). Blue-collar workers tend to earn less and have fewer overall benefits than white-collar workers. Half of all rural workers work in ‘Low ESI industries,’ or industries in which less than 80% of workers are covered by employer-sponsored insurance coverage.” 13 Further exacerbating this issue, rural individuals are also more likely to live in states that have chosen not to adopt Medicaid expansion.
Nationally, the country is experiencing a health care workforce shortage. Rural communities are even more challenged. In the United States, 2,157 health professional shortage areas (HPSAs) are rural, compared to 910 urban. Rural communities frequently have difficulty attracting and retaining health care providers due to competition from urban facilities and practices who are able to offer better compensation and/or working conditions. By 2030, the proportion of Americans who are over 65 years old will be one in five, compared to one in eight today. The lack of an adequate workforce is magnified in rural areas because the elderly population is growing more rapidly in rural than in urban areas. The demand for services increases as the population ages. Among the aging population in rural areas are also the health care providers themselves, many of whom are expected to reach retirement age in the next 5 years. The loss of a single provider in a rural community could have potentially devastating effects in some rural communities.
Rural hospitals are typically the economic foundation of their communities, with every $1.00 spent generating about $2.20 for the local economy. Unfortunately, more than 75 rural hospitals have closed since 2010—and many more may be headed down the same path. Rural hospital closure rates are increasing nationally, and these closures may affect access to basic inpatient, outpatient, and emergency medical services. The average distance of the closed rural hospital from the nearest remaining hospital is around 15 miles. Research findings indicate that 8% of rural hospitals (approximately 180) were at high risk of financial distress in 2013. 14
A number of factors affect a hospital's decision to close or suspend operations, including low patient volume, declining inpatient utilization, and inadequate payer mix. Rural hospitals are typically not as well resourced as larger regional or urban hospitals and thus have been unable to make enhancements and improvements to its physical plant. As a result, rural residents with private insurance tend to travel to larger, newer hospitals outside the community, weakening the rural hospital's payer mix. In addition, small rural hospitals typically are not able to attract specialty care providers, thus forcing patients to travel to larger regional hospitals when their conditions require the services of a specialist or subspecialist. These factors combined put many small rural hospitals, which were already operating on very thin margins, at significant financial risk.
The closure of a rural hospital creates a major barrier to care, including emergency care. In addition, many physicians and other providers leave communities immediately following a rural hospital closure. Rural hospital closures also exacerbate gaps in access to specialty care. 15
Emergency Medical Services
Timely access to emergency care is a major issue for rural residents. Response times by emergency medical personnel and transport times via ambulance to hospitals are notably greater than in urban areas due to geographic barriers, including distance, terrain, and weather conditions. In addition, the majority of emergency medical services (EMS) first responders in rural areas are volunteers, making recruiting, training, and retaining a qualified EMS workforce particularly challenging. Although relying on an unpaid volunteer workforce is more cost effective for underresourced rural areas, it creates challenges in maintaining “24/7” coverage because the volunteers also have other jobs. These other commitments also make it hard for volunteers to keep up with their training requirements.
Rural residents face significant issues with their health care infrastructure. Although continued efforts to increase access to quality health care and transform the health care delivery system in rural areas are critically important, improving population health in rural areas will also require broader approaches that address the social, economic, and environmental social determinants of health.