I. Statement of the Problem
Many changes in the provision of rural health care have occurred since the last APHA rural health position paper, "Improving Health Services for Rural America," was adopted in 1982.1 The 1982 position paper conveyed a sense of optimism. In the decade from 1970 to 1980, rural health services had increased to provide health care to a rapidly changing rural population.
Since 1982, rural health has achieved some gains, but it has also suffered some major losses. While the need for rural health has increased, federal funding has decreased markedly as many rural programs were phased out during the budget cuts of the 1980s. The most recent cuts come from Congressional budget decisions reducing funding for rural programs to balance the budget.
On the positive side, rural constituencies are today better organized. The National Rural Health Association, the DHHS Office of Rural Health Policy, the establishment of 50 state offices of rural health, a growing number of state rural health associations, and congressional coalitions and caucuses on rural health have generated a national recognition of rural health issues and developed a constituency for rural health at both the federal and state levels. Numerous federally sponsored programs have been initiated that, although modest in scope, have indicated a promising direction for federal efforts.
Public health has played a vital role in protecting and promoting the health of rural communities across the nation. In many of these communities, public health offices and personnel are the only providers of health services. As the existing infrastructure erodes, additional and greater demands are being made on an already underfunded and understaffed public health system to meet both its core functions and provide clinical care.
Major disparities exist between rural and urban populations in areas such as access to care, staffing, service availability, community composition, and financial resources.
Access to Care:
Access to public health and medical care for the 27 percent of the population, including Native Americans, living in rural areas of the United States persists as a critical issue. Without action, this issue is unlikely to be resolved. Self-employment is higher in rural areas and self-employed people face higher insurance costs. In addition, rural employment is often based on farming, ranching, fishing, forestry, mining, or other small industries that generally pay low wages, pose higher risk, and do not provide health insurance coverage. Because much rural work is seasonal, many local residents are employed only part of the year or are migrant workers. These facts support recent studies indicating that access to care for rural poor, minority, migrant, and farm populations has deteriorated since 1982.2
A disproportionate share of rural, compared with urban, populations are Medicare or Medicaid recipients. A third of the nation's elderly population live in rural communities. Proposed budget cuts and elimination of public funding programs, therefore, have particularly devastating effects in these geographic areas, sometimes causing essential services and facilities to be eliminated.
The impact of budget cuts to rural health care providers extends beyond immediate health care problems. Because rural health care providers are often the highest employers in many communities, budget cuts translate to job loss, inability to attract new industry, loss of productive workforce, and loss of health infrastructure as it pertains to emergency medical and other critical health services.
Health Care Staffing in Rural Areas:
There are worsening shortages of health, mental health, and allied health personnel in rural areas. Currently, family practice, obstetric, pediatric, geriatric, emergency, and mental health practitioners are in extremely short supply.4 It is estimated that 45 percent of family and general practitioners in rural areas will retire in the next ten years. Many physicians who had previously provided obstetric care have ceased to do so because of high malpractice costs, leaving large geographic areas without any prenatal or obstetric care providers.3Recent infant mortality rates for the United States already lag behind many industrialized countries, and those rates are even higher in rural areas (10.8 versus 10.4 per 1,000 births in 1987). For rural minorities, the situation is even more alarming: the infant mortality rate is as high as 19.6 in some states.4
The professional skills needed for public health and medical practice in rural areas are as great as those required in urban areas, but the workloads are greater and the opportunities for continued medical education are fewer. More attention must be paid to addressing this, or rural practitioners will find it increasingly difficult to maintain their skills and knowledge base.
Lastly, past and current shortages of primary care practitioners are likely only to be exacerbated by the increased competition from managed care entities for these providers.
Service Availability in Rural Areas:
Emergency medical services are critical in rural areas. Nationally, more than 60 percent of motor vehicle deaths occur in rural America, and at least 10 percent of rural employees are engaged in the most hazardous occupations-farming, forestry, and mining. Rural emergency medical services have already suffered from reduced funding and problems in retaining high quality personnel. In fact, most rural emergency medical services (EMS) providers are volunteers.
There is a need for long-term facilities in rural areas. Too few resources are available for the elderly and disabled. Chronic illness and disability affect a greater proportion of rural populations than urban ones (14 versus 12 percent).4
The lack of mental health care is alarming. Rural areas have a disproportionate share of populations that are at high risk for mental illness, yet mental health services in rural areas are usually nonexistent.5 Only 13 percent of nonmetropolitan counties and 7 percent of counties with small urban populations have an inpatient mental health facility.4 Alcohol and drug abuse programs are likewise lacking.4 Recent funding cuts have exacerbated this by forcing rural community mental health services to focus on treating only the most severely ill, leaving few resources for treating less serious or chronic mental illnesses.4
Rural hospital closings have made emergency, obstetric, and long-term care unavailable to many rural residents. From 1985 to 1989, a total of 196 financially distressed rural hospitals closed.2,4 Similarly, many rural clinics have closed due to the unavailabilty of resources to maintain them. This trend has been accelerated by reductions in the National Health Service Corps (NHSC) over the past decade. Many clinics closed when NHSC personnel were no longer available.
Despite well-intentioned federal and state programs designed to improve access to public health and medical care in rural areas, rural health care systems are still mainly patchwork, piecemeal, and underfunded.
Rural communities do not share a single profile; they range in population size, density, and location from small cities and towns with as many as 20,000 persons to sparsely populated, geographically remote frontier areas with far fewer inhabitants. Understandably, these communities are not amenable to a "one size fits all" strategy.
Towns and their catchment areas can be defined by utilization and shopping patterns. Regional public health planning agencies and local communities, who are well aware of their catchment areas and the nature of their rural sectors, can facilitate this process. The US Census County Divisions could also be used to classify rural into categories such as small city, small town, remote, and frontier area. It is worth considering whether these categories could be added to the Year 2000 Census to make better data available for rural areas.
Rates of reimbursement to rural providers should be at least equal to or greater than those of urban providers. Costs are actually higher in many cases for rural providers because of greater coverage areas, higher transportation costs, inability to purchase in bulk, and the additional costs of attracting health personnel to rural areas. There are no economies of scale available in rural areas resulting in higher costs per unit of service.
II. Purpose and Objectives
Rural health and rural public health are once again at a cross-roads. Efforts at the federal and state level to cut costs must not be achieved at the disproportionate expense of rural Americans. Funding cutbacks and the creation of incentives for new health service delivery mechanisms must be responsive to the unique conditions of rural areas.
The likelihood that increased reliance on market competition will drain health professionals from rural areas must be anticipated in health policy. All rural communities at a minimum must have access to public health and emergency medical services. Primary care at reasonable cost and distance in rural areas should also be a part of our national health policy.
Mental health services should be integrated into primary care. Family health care, obstetrics, pediatrics, mental health, and long-term care should be available closer to home. Physicians, nurse practitioners, physicians assistants, and other essential non-physician practitioners should be equitably compensated for providing these services. Linkages between preventive and primary care and referral levels of services should be routine, continuous, and firmly established in policy.
The American Public Health Association will press for federal and state action to address these concerns.
III. Actions Desired
The American Public Health Association is calling for the development of a rural health program of vision and clarity for the 27 percent of Americans living in rural areas. The need for a rural vision is made even more critical by efforts to balance the national budget, reduce the deficit, and reform the health care system. Across-the-board budget cuts, including but not limited to agriculture, trauma, Medicare, and proposed Medicaid block grants, jeopardize the health and economic infrastructures of rural communities.
- The American Public Health Association endorses the following activities in support of rural health:
- The development of explicit national standards for public health and medical care for rural health care, beginning with the delineation and classifications of rural areas in the Year 2000 Census.
- The development of reimbursement methodologies for rural health care, including cost-based reimbursement, to assure that the costs of providing care are covered.
- The inclusion of permanent incentives to assure recruitment and retention of rural providers, such as refundable and non-refundable tax credits and other financial incentives.
- The development of a national policy with specific goals and objectives for achieving access to public health services and physical and mental health care, the recruitment and retention of personnel, and the integration and coordination of public health and medical care to include transportation, bilingual, and outreach services.
- The development of national criteria for the designation of essential community providers so that goals for adequate levels of care can be met.
- The development and expansion of innovative rural health delivery systems and financial support for those systems.
- The initiation and maintenance of comprehensive health education campaigns and provision of services to prevent disease and injury.
- The specific inclusion of local rural communities in the surveillance, planning, monitoring, evaluation, and enforcement of programs and services that effect them, including the development of national policy.
- The preservation and expansion of the current rural health care system, including local and regional health agencies, to assure access to public health and medical care services for rural populations, including increased attention to migrant, Native American, and other special populations.
- The expansion of funding for surveillance and research for rural health problems.
- American Public Health Association Policy Statement 8222(PP): Improving Health Services for Rural America. Washington, DC: American Public Health Policy Statements, 1948 to present, current volume.
- Office of Rural Health Policy, HRSA, DHHS, State Approaches to Solving Rural Health Problems, Workshop Summary, Prepared by the National Rural Health Association, June 1990.
- Robert Wood Johnson Foundation. Special Report on Access to Health Care in the United States. Princeton, NJ, 1987.
- US Congress, Office of Technology Assessment. Health Care in Rural America, OTA-H-434 USGPO, Washington, DC, September 1990.
- Wagenfeld MO, Murray JD, Mohatt DF, DeBruyn JC. Mental Health and Rural America: 1980-1993. Office of Rural Health Policy, HRSA, and Office of Rural Mental Health Research, NIMH, NIH, 1994.
- Office of Rural Health Policy, HRSA, DHHS. Rural Health News, Intergovernmental Health Policy Project, July 1991.
- Manages PA. Emergency Medical Services in a Rural America: New Solutions to Urgent Needs. Office of Rural Health Policy, HRSA, DHHS, June 20, 1991.
- Whitehead M, Dahlgren G. What can be done about inequalities in health, Lancet, October 26, 1991;338:1059-1062.
- Campion DM, Lipson DJ, Elliott RM. Networking for Rural Health: The Essential Access Community Hospital Program. A report from the Technical Resource Center on Alternative Rural Hospital Models. Washington, DC, Alpha Center, March 1993.
- Christianson J, Moscovice I. Health reform and rural health networks. Health Affairs, Fall 1993;58-80.
- Fuchs B. Health Care Reform: Managed Competition in Rural Areas. Congressional Research Service, Washington, DC, April, 1994.
- Kellog RL, Maizel MS, Goss DW. Agricultural Chemical Use and Ground Water Quality: Where Are the Potential Problem Areas? Report by USDA-SCS, Washington, DC, 1990.
- McRae R, et al. Farmscale and agronomic and economic conservation from conventional to sustainable agriculture. Advanced Agronomics. 1990;43:155-198.
- Weiner J. Rural primary care. Annals of Internal Medicine. March 1, 1995; 122(5):380-390.
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