Health in America
When we consider inequity in American healthcare, what comes to mind? As a society, we are aware of separate and unequal access to healthcare based on race and gender. Some less “obvious” aspects of healthcare accessibility that circulate popular understanding are immigrant status, socioeconomic class, and highest level of education achieved. Still, we miss one critical determinant of whether or not an individual sees a doctor, and what caliber of care they receive if they do go to the hospital: geographic location. Specifically, there is a disparity in healthcare access between those who live in urban versus rural areas. To illustrate this, allow me to pose the following question: if we hold all predictors of healthcare accessibility equal for two individuals, but one lives in Queens, NY and the other in California’s Central Valley, who would be expected to have better access to healthcare?
There are certain fundamental realities of serving sparsely-populated areas that contribute to the healthcare access disparities among rural populations. Still, recent trends suggest something deeper related to this issue. A recent report from the Rural Health Research Gateway showed that rural hospitals have shown an alarming rate of closures nationwide in the past decade. In fact, the University of North Carolina’s Rural Health Research Program reports there have been 95 rural hospital closures since 2010 in the United States, with the vast majority of these closures concentrated in the Southeastern and Midwestern states. Hospital closure is not the only metric used to evaluate the status of healthcare in a given community. Some struggling rural hospitals have opted to discontinue various services as a means for ensuring financial survival. For example, in the 10-year period from 2004 to 2014, 179 rural counties experienced a loss of obstetric services. By 2014, it was reported that among stratified rural counties, only 30-77% had access to obstetric services. The contraction of rural healthcare, then, appears to be a very real phenomenon. But what are its underlying causes?
The Business of Health
The average income of those who live in rural areas is 20% lower than that of the average urban resident. It should come as no surprise that rural hospital reimbursements are generally lower than those from hospitals that serve urban populations. According to the Sheps Center for Health Services Research, financial insolvency is the main driver of hospital closure. Hospitals that rely primarily on Medicare have the highest risk of closing their doors, and of hospitals designated “high risk” using the Financial Distress Index, the highest proportion were found in the Southern United States, a region which has high poverty rates. The clear relationship between low income and healthcare inequity in rural areas means that the most vulnerable among us are at the highest risk of missing out on access to healthcare.
Struggling rural hospitals have a story to tell as well. Hospitals that rely on one or a few large insurance companies for reimbursements tend to have weak negotiating power when it comes to contracts. This was the exact situation for one struggling health center in rural Texas. When their primary reimbursement provider, Blue Cross, tried to renegotiate their contract, talks stalled. The insurance provider temporarily stopped providing reimbursements, and individuals who had Blue Cross were forced to travel dozens of miles for care. The already struggling hospital was forced to cave to community panic and sign a contract that left them in even worse financial straits than they had been in before the renegotiation. Ultimately, Blue Cross reduced the amount they would have to reimburse on laboratory tests, one of the financial life bloods of the hospital. It was no accident that Blue Cross came upon this hospital when they did with the offer they did. While the predatory nature of some insurance providers is not unique to rural areas, rural hospitals are highly vulnerable to this type of behavior due to the fact that they often serve low-income populations. If insurance companies continue to leverage their superior financial positions against rural hospitals, we are sure to see more closures in the future.
This begs the question, what is being done to fill the gaps in coverage for rural areas? While the United States Office of Health and Human Services (HHS) has open grants for studies on the topic, the apparent interest in addressing this issue is relatively sparse. Still, there is hope in the way of innovative solutions oriented at driving down the costs of healthcare. Telehealth is one such solution. Telehealth capitalizes on advances in technology to bring advanced diagnostics to patients where they are. Physicians can read scans, evaluate histological slides, and even guide non-specialists to perform important exams, all via an internet connection. Although it requires a large initial investment, telehealth could prove to be an incredibly powerful force for good among rural populations.
The World Health Organization frames access to adequate healthcare not as a privilege, but as a fundamental and inalienable human right. In this context, the issue of shrinking access to healthcare in rural America moves beyond the realm of economics or even public health, and becomes an issue of ethics and of institutional justice. The effects of a struggling rural healthcare system are felt most by the people themselves. As Americans, this should concern us all.