Rural health

One in five Americans lives in a rural area. The definition of "rural" varies, but generally it is understood to mean a sparsely populated nonurban area.Rural populations are very different one from the other, as is the geographyof the regions they live in. For example, rural populations include seasonalfarm workers, Native American and Alaskan populations, and so-called frontiercommunities, those with fewer than six residents per square mile. The diversity of rural populations presents unique challenges in terms of health care.But all these communities have some things in common.

First, the decline of traditional rural occupations such as farming, mining,and timber has reduced employment opportunities for rural residents, contributing to poverty. Because poverty narrows the economic base from which healthcare delivery services are funded, rural residents have reduced access to essential health care services. Second, there is a higher concentration of elderly people in rural areas than in urban areas. And this number is increasing,as young adults move to urban areas to look for work. Third, the two most dangerous occupations are farming and mining, both of which are rural industries. Rural residents have higher rates of occupational injury. And finally, poverty and self-employment make it more likely that rural residents will be uninsured or underinsured. People without insurance are less likely to have moneyto spend on preventive health care, which means that when they do go to thedoctor, their illnesses are usually more serious.

In rural areas, the ratio of primary care physicians to patients is 1 to 3,500, substantially under the ratio recommended by the U.S. Department of Healthand Human Services. Because rural physicians do not make as much money as physicians working in urban areas, work longer hours per week, and are professionally isolated, it is very difficult to hire and keep them. To offset this problem, nonphysician providers such as clinical nurse specialists, nurse practitioners, certified midwives, and physician assistants are increasingly taking on more of the primary care responsibilities for rural residents. Unfortunately, rural states have historically had the most restrictive laws governingthe services of nonphysican providers. Over 50% of reimbursements to rural physicians for the care they provide to patients are made through public programs at rates substantially less than private payment. Limited opportunities to consult with colleagues and inadequate backup are additional difficulties that rural physicians and doctors for the rural poor must contend with. As hospitals merge or close to cut costs, such constraints worsen.

Many of the health-care problems currently experienced by rural hospitals canbe traced to the fact that the United States, in the absence of a national health policy, has adopted a market-driven, for-profit, health-care system. For-profit Health Maintenance Organizations (HMOs), which now dominate the market in urban areas, have not migrated (and will not migrate) to rural areas because HMOs need a young, healthy population to subsidize care for the sick, and rural areas do not have those populations. Another problem is that primarycare physicians, who provide most rural health care, are being lured to cities by HMOs, leaving the rural hospitals without adequate staffing.

Rural health care providers treat a higher percentage of Medicare and Medicaid patients than do urban providers. (There is actually more poverty in ruralareas than in urban ones, according to a 1996 study by the Department of Agriculture.) Reimbursement to health-care providers has been complicated by thefact that Medicare sets the payment rates for Medicaid, and Medicare reimbursements to health care providers have been scheduled for a $115 billion reduction (over a five-year period) by President Clinton's Balanced Budget Act of 1997. Because 75 to 95 percent of the patients in rural areas are on Medicareor Medicaid (compared to only 40 to 50 percent of the patients in cities), rural hospitals have been hit harder than urban ones by these budget cuts. Consequently, as medical technology continues to explode, rural hospitals find themselves at a disadvantage when it comes to investing in new technology.

Despite the fact that the largest percentages of Medicare and Medicaid patients reside in rural areas, many rural hospital administrators have found thatthey have little opportunity to influence national health care policy, because the absolute numbers of constituents in rural areas are not large enough toinfluence legislators in Washington.

Rural communities are also home to large numbers of working poor. There are relatively few high tech corporate jobs that offer full-coverage health plansto be found there. Farm workers, ranch workers, loggers, housekeepers, waitresses, and carpenters, for example, are not eligible for health plans. If a carpenter is hurt on the job, he files for worker's compensation; similarly, ifa waitress suffers a non-job-related injury or if her child becomes sick, she applies for Medicare or Medicaid assistance.

In 1998, 17 of the 40 hospitals that serve rural areas in Washington State were on the verge of closing their doors; in Montana, half of the 60 rural hospitals had lost money, and the other half had barely broke even; in Wyoming, the federal government designated 80 percent of the state as medically underserved; and in Texas, the financial condition of many of the state's 180 ruralhospitals was in rapid decline. In California, 60 percent of the 72 hospitalsthat serve rural populations lost money in 1997; in a three-year period beginning in 1996, five rural hospitals closed; five others went into bankruptcy;and another three were in the planning stages of bankruptcy.

In response to these challenges, the federal government has set up a number of programs to address some of the health issues and problems facing rural America. Proposed measures include financial incentives to physicians and nonphysician providers who work in underserved areas, training opportunities for students, and grants and funds to develop innovative health care delivery models and to support rural health research centers. Information technology holdsparticular appeal for rural medicine. Telemedicine refers to the use of electronic communication to provide clinical care, for example, 24-hour emergencyconsultation, medical support, and weekly instructional seminars and continuing medical education.

The proportion of inhabitants in other developed countries who live in rural,remote, and underserved communities is similar to that in the United States.The problems of these populations--the decline of traditional industries andan aging population owing to migration of the young to the cities--are alsosimilar. Although fewer data are available for Europe, evidence indicates that, like their counterparts in the United States, rural physicians in Canada and across Europe suffer high workloads, limited access to training, isolation, poor morale, and a decline in recruitment. In countries long used to the particular demands of a vast geography such as Australia, New Zealand, and Canada, rural health has been better developed than in Europe. For example, since1928, the Australian Royal Flying Doctor Service has provided a full range of medical services to rural residents for whom a visit to the doctor might otherwise entail a 400- to 600-mile (650 to 970 km) round trip.

Developing countries must cope with a chronic shortage of physicians and equipment, drugs, buildings, and nurses and other health staff. Those living in rural areas in developing areas are poor, and they cannot get medical attention unless it is paid for by the state. The quality of this medical care is often of low quality, and in remote regions it may be lacking completely. Poor infrastructure, for example, roads, telephones, emergency services, and per capita medical personnel, exacts a greater toll in developing than in developedcountries. Rural health services in developing countries, of which India andTanzania are typical examples, depend heavily on rural health centers and dispensaries, which are designed to provide comprehensive health services for the community. Staff are often nonphysician providers, and the emphasis is ondiagnosis, treatment, and referral (to higher-level facilities), as well as arange of health promotion and disease prevention activities. These include maternal and child health, environmental health, and health education. Villages may be served by a village health post staffed by health workers supervisedfrom centers in the primary health system. Because the quality of infrastructure and the ability to provide health services are directly related, the World Health Organization and the World Bank have increasingly linked improved health to development and alleviation of poverty.

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