Rural communities in the United States are suffering a healthcare crisis. The biggest healthcare concerns in these areas include lack of access to hospitals and clinics, a shortage of doctors, and lack of financial resources. The impacts of these issues include a disparity in healthcare outcomes, higher mortality rates, and lower overall quality of health. Government officials and healthcare industry experts are working to improve healthcare in small towns and rural areas across the country. However, the problem is complex and the challenges steep.
The State of Healthcare in Rural Communities
The statistics tell the story: By several important health metrics, people who live in rural areas have higher mortality rates and worse health than their urban counterparts. For example:
- Overall mortality. Although mortality rates have dropped for both urban and rural areas, they are still far higher in rural areas, according to this pre-COVID 19 study in the Journal of the American Medical Association. In 2019, urban areas had a mortality rate of 664.5 per 100,000 people; rural areas had a mortality rate of 834 per 100,000 people.
- COVID-19. As of December 2021, the case rate and mortality rate from the coronavirus was higher in rural counties than in urban counties — 287.55 deaths per 100,000 in rural areas compared to 221.54 per 100,000 in cities and towns, according to the Rural Policy Research Institute.
- Diabetes. Diabetes is more prevalent in rural areas than in urban areas. Rural patients are less likely to comply with checkups and preventive treatments and showed less improvement in their disease than urban patients, according to the journal Diabetes Care.
- Heart disease. Heart disease-related deaths were higher in rural areas compared to urban areas — 160 per 100,000 people compared to 114.5 per 100,000, according to the CDC.
- Opioid overdoses. While urban areas saw higher overdose rates in general, rural areas saw higher rates of opioid overdoses, especially among women, the CDC reports.
- Suicide. The suicide rate in rural communities is 20.1 per 100,000 — twice as high as for large cities, according to CDC research.
What’s Driving Poor Rural Health?
According to health experts, a number of factors drive poor health in rural communities. Some of these are behavioral, some financial; other factors result from geography. Factors include:
One of the most significant influences on poor health in rural communities is rural hospital closures. According to the National Institutes of Health, 171 rural hospitals closed between 2005 and 2020. The top reason for closure is financial — many rural hospitals operate at a loss. When hospitals close, communities lose access to physicians, nurses, specialists, community health educators, and other health resources.
Physician and Provider Shortages
According to the Health Resources and Services Administration, 85 million Americans live in an HPSA, or health provider shortage area. Rural communities are more likely to be designated an HPSA than urban areas. Reasons for these shortages are numerous.
- Demographics. Doctors are retiring, leading to a shortage nationwide that is especially impacting rural areas.
- Decline in rural medical students. Most physicians who practice in a rural area also grew up in a small-town environment. However, there have been declining numbers of medical students from small communities over the past 15 years, according to the journal Health Affairs.
- Hospital closures. When hospitals close, physicians and other providers leave.
- Work-life balance. Doctors who work in rural areas speak of being on call almost constantly because of high demand from patients.
- Lack of interest. According to a 2019 survey by physicians staffing firm Merritt Hawkins, only 1% of final-year medical students wanted to practice in a rural community.
According to the U.S. Department of Agriculture, the U.S. poverty rate was nearly 16% in rural communities, compared to nearly 12% in urban and suburban areas. Poverty and poor health correlate in some key metrics, including increased risk for mental illness, chronic disease such as heart disease and diabetes, and lower life expectancy.
During the 12 months between April 2020 and 2021, more than 75,000 Americans died of opioid overdoses, according to the Centers for Disease Control and Prevention. In 2015, that figure was 33,000. Rural communities have been hugely impacted by the opioid epidemic, The cause of the opioid epidemic is complex and involves a number of different factors, including overprescribing and the rise of synthetic street drugs such as fentanyl.
Poor General Health
Some 15% of the U.S. population lives in rural areas. In addition to the health challenges listed above, these 46 million Americans are at risk of a number of healthcare issues. They are more likely to die in a car crash. They have higher rates of nicotine use including cigarettes and chewing tobacco. Children are more likely to have mental health disorders. Rural residents may have lower health literacy.
Health literacy means knowledge of the healthcare system and the basics of health maintenance and disease prevention. Lower health literacy in a community, often a consequence of inequities in the social determinants of health of the community, has been linked to higher rates of COVID-19 infections because people with lower health literacy may not know or understand key facts about COVID-19 precautionary measures, vaccines, and boosters.
Rural Health Challenges and Solutions
Government officials, healthcare regulators, and healthcare industry experts have proposed several solutions to these healthcare challenges. These solutions must address the financial, political, health, and socioeconomic considerations that make rural health disparities such a thorny problem.
- Financial barriers. Many rural hospitals can’t be run profitably due to financial constraints, primarily from low Medicare reimbursement rates but also because rural patients may lack insurance or are unable to pay copayments. Other financial barriers include unemployment, low wages, poor chronic health, or other socioeconomic factors within the community.
- Policy roadblocks. A variety of studies found that Medicaid expansion under the Affordable Care Act was associated with better hospital financial performance. States that declined to expand Medicaid were more likely to see hospital closures.
- Social determinants of health. Population health experts use social determinants of health to analyze and predict health outcomes based on geography, wealth, education, and the environment. In rural areas, inequities in the social determinants of health of the community include limited transportation, long distances to the nearest hospital or clinic, limited internet access, and high poverty rates.
A variety of programs focus on ways to improve healthcare in rural areas, including:
Full Practice Authority for Nurse Practitioners
Some two dozen states allow nurse practitioners to have full practice authority, meaning they can see patients, prescribe medications, and order tests without being overseen by a physician. Nurse practitioners are more likely to work in underserved areas, in hospitals, clinics, and private practice. They provide healthcare at a cost savings compared to physicians. Some health experts see nurse practitioners as part of the solution to the shortage of healthcare providers in rural areas.
Rural communities could benefit from telemedicine, which solves the problem of rural patients having to drive long distances to see a doctor. During the COVID-19 pandemic, telemedicine allowed doctors to continue to see patients without risk of infection.
Telemedicine has traditionally been a cost savings compared to in-person doctor visits. However, the cost savings are no longer as dramatic since doctors have been cleared to charge their full fee for a telemedicine consultation. Another issue is internet access, which is not always reliable in rural areas.
Rural communities have been creative in coming up with incentives to bring physicians to small towns and remote regions. According to the New England Journal of Medicine, rural doctors are paid 5% to 10% more than their urban counterparts. Signing bonuses (in some cases $100,000 or more), relocation allowances, and education loan forgiveness are just some of the other financial perks.
Federal Government Loan Forgiveness
The National Health Services Corp Rural Community Loan Repayment Program will reimburse education loans for qualified healthcare providers who practice in rural communities. The goal of the program is to bring in doctors, nurses, and other clinicians to treat rural patients with opioid abuse disorder.
A public-private partnership in Oklahoma funded by the state’s Tobacco Settlement Endowment Trust is offering up to $16,000 in medical school loan repayment assistance to doctors who practice in underserved areas. The goal of the initiative is to help patients quit smoking and improve their overall health.
Improving Health Literacy
Improving health literacy may have a positive impact on rural populations. Health literacy includes the ability to understand the doctor’s advice and treatment plans. It also includes understanding how to navigate the healthcare system, from making an appointment to getting reimbursed by a health insurer. It can help patients comply with medical advice and prescriptions. Experts believe that improving health literacy can improve the health of rural populations.
Moving from a fee-for-service model to value-based care may help improve overall healthcare in rural populations and help hospitals remain financially stable. Value-based care ties payment to patient outcomes.
Medicare’s hospital readmissions reduction program is an example of value-based care. Hospitals that reduce readmissions through better procedures and care coordination are rewarded with incentive payments. Value-based care has long been linked to lower cost care and better population health.
Hospital executives say that loosening regulations will help rural hospitals become profitable. Industry researchers say that some Medicare regulations, such as how long a patient can stay in the hospital, are too restrictive.
Some experts advocate changes, such as allowing rural regions to repurpose large critical-access hospitals so they can be used as small emergency centers or outpatient care centers, depending on need. Other issues include determining how providers should be paid for their services, how to communicate with patients, and how long patients should stay in the hospital.
Improving Rural Healthcare and Health Disparities
The stakes are high for rural communities. They suffer from a shortage of providers, hospital closures, low incomes, and many other barriers to healthcare. The disparity in health outcomes between rural and urban areas is a stark reminder of the inequities that rural populations face. It’s essential that healthcare industry leaders seek to improve healthcare in rural areas. While the issues are complex, the healthcare industry has an obligation to provide quality, affordable medical services to underserved communities.