November 20, 2018 Substantive Law

Health Equity Challenges in Rural America

By Erika Ziller and Andrew Coburn

Reprinted with permission from Human Rights (43:3), at 10-12. ©2018 by the American Bar Association. Reprinted with permission. All rights reserved. This information or any or portion thereof may not be copied or disseminated in any form or by any means or stored in an electronic database or retrieval system without the express written consent of the American Bar Association.

Reflecting across our more than 20-year collaboration of studying rural health issues, we can’t help but observe that interest in the health and well-being of rural U.S. residents appears to be at an all-time high. It’s not that the problems are new; data on the relatively poorer health of rural people have been available and of concern throughout our careers and in the many decades prior. Still, we understand why much of these data have received limited attention over the years. Studies of rural health escape general attention in much the same way that rural places themselves tend to exist beyond the public view— down dirt roads, amid croplands, in desert borderlands, or under a very big sky.

Yet, over the past year we have found ourselves increasingly called upon to speak to national audiences about rural places and to discuss the role of rural culture in health. Whether driven by rural contributions to the current opioid crisis, new data on the growing gap between rural and urban life expectancy, or even the 2016 election, we welcome this attention and hope it translates into sustained interest and investment in the health of rural people.

Growing evidence indicates that a significant rural-urban disparity in life expectancy exists in the United States, driven largely by urban longevity gains that have not been shared among those living in rural places. A recent study of the five leading causes of death in the United States (heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke) found that the age-adjusted death rate for each was higher among rural residents. Perhaps more disturbingly, the rate of potentially excess deaths in rural communities was also consistently higher. The federal Centers for Disease Control and Prevention consider excess deaths to include those that “might . . . be prevented through improved public health programs that support healthier behaviors and neighborhoods or better access to health care services.”

Part of the challenge for understanding and improving the health of rural populations lies in disentangling the underlying causes of their ill-health and death, which is further complicated by the socioeconomic and geographic heterogeneity of rural places and populations. Exacerbating efforts to tease out these differences, rural health experts have noted increasingly poor access to data on rural health, as financial issues and concerns for privacy have limited the availability of geographic indicators in many federal health surveys. Still, across the country, we have observed that many rural communities actually do embody the small town Rockwellian image that is often equated with life outside the city— places with county fairs, church dinners, strong bonds between neighbors, and children thriving under the collective community eye. However, many others suffer economic and environmental hazards and adverse health outcomes—like infant and maternal mortality—that rival lesser developed nations.

While there is substantial variation across the country, rural residents are more likely on average to live in poverty and to lack formal education; these interrelated social determinants are known contributors to sickness through a complicated pathway of poor health care access, health behaviors, and exposure to toxic levels of stress. In recent years, the rising mortality rate for rural working-class whites has been driven by what some researchers have begun calling “despair deaths.” These deaths represent those from suicide, liver disease, and accidental poisonings (including opioid and other drug overdose) and may be associated with economic, mental, and family distress. In 2014, the rate of suicide was 54 percent higher for those living in remote rural counties than for their urban counterparts.

These poorer economic circumstances of many rural populations and places relate to a host of downstream sequelae that have important implications for rural health. For example, while the Flint, Michigan, water crisis has sparked understandable outrage among public health and social justice advocates, rural places face their own challenges with potable drinking water. Runoff from rural industries, including mining and agriculture, has resulted in contaminants leeching into rural public and private water supplies across the country. Many rural households obtain their water from private wells, which may be affected by a range of different contaminants. In 2011, the Environmental Protection Agency reported that more than 2,000 rural communities were in serious violation of the Safe Water Drinking Act and estimates suggest that more 6 million rural residents have some problem with water contamination. On the housing side, a report by the U.S. Census Bureau indicates that rural residents are more likely than urban residents to have problems with the physical integrity of their homes, including serious structural issues like leaking or sagging roofs.

These underlying socioeconomic and environmental conditions are exacerbated by poorer health care access among rural residents and a more anemic rural health services infrastructure. Prior to passage of the Affordable Care Act (ACA), data across nearly four decades demonstrated that rural residents are more likely than urban residents to be uninsured. This has been particularly true in the southern and western Unites States, where as many as 25 percent of those under age 65 lacked health insurance in 2011. Even when rural residents have private health insurance, the coverage tends to be poorer and creates conditions under which rural residents are more likely to face high out-of-pocket costs for care. While the ACA held promise for reducing these disparities in coverage, the Supreme Court decision that made Medicaid expansion optional has resulted in uneven impact across the country. States with substantial rural population have been less likely to expand Medicaid under the ACA so that, overall, rural places have not experienced the same decline in uninsured rates as urban places.

Compounding these financial barriers to care, rural residents face access problems because many of their communities lack a sufficient number of health care professionals. Compared to large urban counties, remote rural places have less than half the per capita rate of primary care providers; that is, providers who provide day-to-day checkups, screenings, and chronic disease management. Because of the lower availability of health care providers within rural communities, many rural residents must travel great distances to seek health care.Given these travel requirements, reliable transportation is critical for ensuring rural health care access; however, many rural residents (particularly those at lower incomes) face transportation challenges including poor road conditions, unreliable vehicles, or difficulty affording gasoline.

This rural-urban difference in availability of health care professionals is particularly pronounced for specialty care providers. Compared to rural counties, urban counties have nearly nine times the per capita number of specialists. Specialty care providers include mental health professionals, which tend to be severely lacking in rural places. Around 60 percent of rural residents live in a designated mental health professional shortage area, meaning that there are insufficient providers (maybe even zero providers) available to address the mental health needs of that community. More than half of rural counties have no health care professional licensed to provide medication-assisted treatment for opioid dependence.

In addition to a lack of mental health service providers, the emotional well-being of rural populations may be affected by sociocultural barriers to mental health services use. For example, some rural health experts suggest that concerns about privacy in small communities may impede rural residents’ use of services even when they do exist. Also, cultural norms of personal responsibility that may be stronger in rural areas could contribute to concerns of stigma associated with use of mental health care. Yet, the need for mental health services in rural places is clear. As noted previously, the so-called despair deaths that are growing among white rural residents (e.g., liver disease, overdose, and suicide) have an obvious connection to behavioral health concerns, including addiction and depression. Among children, those living in rural areas are more likely to experience Adverse Childhood Experiences (ACEs), including exposure to domestic violence and/or living with a parent who has been incarcerated or who has a behavioral health problem. Without appropriate intervention, including child-focused mental health services, these children are at greater risk for a lifetime of poorer economic and health consequences that may spill over into the next generation.

The economic trends affecting many rural communities, the more limited participation in the ACA by rural states, and provider shortages are all believed contributors to another rural health crisis: the loss of certain types of hospital services or the complete closure of rural hospitals. In the past 15 years, more than 120 rural hospitals have closed, and the rate of closure has increased in the current decade. Another 9 percent of rural hospitals are at high risk of closure in the near future based on estimates of their financial health. According to researchers at the University of North Carolina who monitor the well-being of rural community hospitals, the people most adversely affected by the closures include impoverished individuals, racial and ethnic minorities, and sick elderly adults who need ongoing care for chronic illness.

In addition to outright closures, some rural hospitals find themselves unable to sustain certain services that are vital to the well-being of rural populations and places. For example, researchers at the University of Minnesota found that 9 percent of rural counties lost their hospital obstetric unit in recent years, leaving more than half of all rural counties without access to inpatient labor and delivery services. Any mother- to-be can relate to the trepidation that surrounds the birth process, even in the best of circumstances. Add to that the need to travel 10s or 100s of miles, in all weather conditions, on roads that are unevenly maintained, and it’s hard to argue that this nation is doing its best for our rural mothers and babies. Certainly, the outcomes for mothers and babies are of concern. In 2015, the rate of remote rural mothers who died from pregnancy or birth-related causes was more than 60 percent higher than that of urban mothers (29 per 100,000 rural live births versus 18 in urban). While we can’t specifically link these maternal deaths to travel distances, it is clear that the last thing rural mothers need is another barrier between them and healthy pregnancies and births.

As noted previously, rural communities are heterogeneous, and studies of rural health may mask important regional and intra-rural differences. Key among these are the consistently poorer conditions and outcomes experienced by racial and ethnic minorities who live in the rural United States. For example, counties with substantial minority populations are more likely to lack access to hospital obstetrics, and rural black mothers are at particularly high risk for poor birth outcomes. While the death rate has been growing among rural whites, minorities still account for more rural deaths relative to their white, non-Hispanic counterparts; nationally, the relative rate of death for rural whites is about three-fourths that of rural blacks. Because of their concentration in southern states that have not expanded Medicaid, rural minorities—particularly blacks—are less likely to have benefited from health insurance coverage gains under the ACA. Housing and water quality issues in rural minority communities, including those with migrant workers, are less likely to be addressed. Rural communities of color have higher rates of chronic illnesses or debilitating health conditions. American Indians and Alaskan Natives, many of whom live in rural places, experience some of the highest rates of mental and emotional distress of any racial or ethnic group. Yet, rural persons of color tend to have poorer health care access and quality of care when compared to rural whites.

Given the extensive evidence of ruralurban health disparities, it is clear that a social justice agenda focused on health must consider how to improve conditions and outcomes for the nearly 20 percent of the U.S. population who lives in a rural place. To achieve this, policymakers and public and private funding organizations will need to implement an intentional, sustained, and multipronged approach to investing in rural communities. By intentional, we mean strategies that are developed specifically with and for rural communities and not simply the translation of smaller-scale urban strategies to rural places. By sustained, we are expressing our hope that interest in rural places will last beyond the next news, economic, or political cycle.

Because the ill-health of rural people is almost certainly linked (at least in part) to higher rates of poverty, rural economic development will need to be a key component of this effort. This includes targeted strategies to increase rural economic and employment growth. It also includes concurrent investment in rural infrastructure, including housing, water, roads and transit, and broadband internet access. Together, these infrastructure pieces may contribute directly to the health of rural populations by reducing harmful exposures and improving access to information and care. They may also contribute indirectly by improving the overall social determinants of health for rural people.

Investment in the health care infrastructure of rural places is also critical. States with substantial rural populations need to expand access to health insurance, including Medicaid, rather than implement potentially harmful initiatives, such as work requirements. To address provider shortages and facility closures, health care delivery experts must explore and evaluate potential innovations for meeting the health care needs of diverse rural populations. This could include investments in telehealth or other distance options, many of which are beginning to have an evidence base. It should also consider alternative models of health care delivery in rural places that reflect the impracticality of maintaining full-service hospitals in every small community, yet ensure that rural people receive essential services close to home. When rural people need to travel for care, payers and health systems could collaborate to support them and their families through travel and short-stay housing options.

Rural community leaders could also work to engage and train members of their communities to support each other through initiatives like Mental Health First Aid, birth doulas, or community health worker programs. These initiatives enable lay professionals from affected communities to obtain skills and knowledge to meet some of the educational and supportive health needs of their families and neighbors. Policymakers, grant makers, and insurance payers can ensure that training for, and delivery of, these supportive services are covered through a variety of funding streams. While not a substitute for medical care, these programs can expand the reach of services to rural populations at risk for poor health outcomes. At the same time, individuals providing these services would gain skills and employment opportunities that support both the health and social well-being of rural places. Finally, these programs build on one of the greatest self-described strengths of rural communities—the sense of social connectedness among members that has evolved from cooperation between families and neighbors, sometimes spanning generations. Rural places and people have strong roots that should be nurtured for optimal results.

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Erika Ziller

Erika Ziller is an assistant professor of public health in the University of Southern Maine’s Muskie School of Public Service. She is also deputy director of the Maine Rural Health Research Center, where her work focuses on health care access for rural and other vulnerable populations.

Andrew Coburn

Andrew Coburn is a professor of public health and director of the Maine Rural Health Research Center in the University of Southern Maine’s Muskie School of Public Service.