Introduction

Army-Baylor University Graduate Program in Health Care Administration

A Literature Review on Rural Health Care in the United States

Presented to MAJ Patrick

In partial fulfillment of the requirements for

HCA 5301, U.S. Health Care Systems

CPT Alan A. Jones

Ft. Sam Houston, TX

25 August 2005

Introduction

The death rate for children and adolescents in the United States is disproportionably higher in rural areas than it is in urban and suburban areas (Eberhardt, Ingram, Makuc et al., 2001). This disturbing statistic indicates just one of the many challenges that rural health care poses in the United States. In recent years, these challenges have been extensively studied in an attempt to find solutions that will ensure the survival of rural health care. The purpose of this literature review is to define the composition of rural Americans, to summarize the current challenges of rural health care, and to review policy initiatives intended to support rural health care.

Demographics

Shi and Singh (2004) classify Americans as rural if they live in a county outside of a metropolitan statistical area (MSA). Rural Americans make up 20% of the U.S. population (Eberhardt et al., 2001). The demographic make up of rural Americans differs from that of urban and suburban Americans. The rural population is composed of a greater percentage of poor and elderly Americans compared to urban and suburban populations. Ormond, Wallin, and Goldenson (2000) state that 16.5% of the rural population is living below the poverty line compared to 14.1% in urban areas. Likewise, the elderly make up 14.8% of the rural population compared to 12.3% of the urban population. Rural Americans also have more lifestyle related risk factors. According to a 2001 study, the CDC found rural Americans were more likely to smoke, to be overweight, and to be injured in motor vehicle accidents when compared to urban and suburban populations (Eberhardt, et al.). These statistics, along with an uninsured population 5.5% higher than that of urban areas, demonstrate the immense challenge that the rural population poses on the U.S. health care system.

Current Challenges

The U.S. health care system has unique challenges in providing for rural America. The current challenges include financially burdened rural hospitals, a lack of physicians and support staff, and access to care issues.

Financially Burdened Hospitals

Alexander, D’Aunno, and Succi (1996) state that rural American hospitals are placed at great financial risk due to the disproportionate number of underinsured patients in these areas. The hospitals are often unable to recapture money for the services rendered to the poor, elderly, and uninsured populations. The elderly often require numerous medications and procedures that require expensive equipment. Although many of the elderly are able to pay using Medicare or private insurance, the cost of maintaining the services and equipment to provide proper care involves a large percentage of the hospital budget. Rural hospitals must also keep pace with technology so that they can provide health care that is comparable to the health care provided in the urban hospitals of the country. The difficulty with maintaining the technology is that new technologies are very expensive to implement especially with an operating budget that is not comparable to that of urban hospitals. The expenses not only include the cost of the equipment but also the maintenance, training, and specialists to operate it. Ormond et al. (2000) state that rural hospitals who fail to invest in medical technologies often lose paying patients to hospitals that provide those technologies and services.

The financial burden that is placed on rural hospitals often forces them to close or convert their services. Alexander (1996) states that rural hospitals with heavy financial difficulties must change their organizational mission in order to stay open. The difficulty with conversion is that hospitals must abandon providing acute care services. Alexander states that when a rural hospital converts to another facility the local community loses crucial access to basic health care services (1996).

Lack of Physicians

According to Shi and Singh (2004), the United States has a surplus of physicians. The irony, according to Weiner (1995), is that rural areas have less than half the physicians per capita as urban areas. While urban areas enjoy the benefits of an oversupply of physicians, such as allowing diverse choices of providers and specialists, rural areas suffer from a lack of physicians. The Health Professions Educational Assistance Act of 1976 defines populations that have a beneficiary to physician ratio of 3500 to 1 or greater as having high need (Shi and Singh). Shi and Singh (2004, p. 128) state that the reason so many physicians decide to practice in metropolitan areas as opposed to practicing in rural areas is that they receive “higher income, professional interaction, access to modern facilities and technology, continuing education and professional growth, higher standards of living, and such social amenities as cultural diversity, recreational activities, and quality of education for children.” The maldistribution of physicians places the burden of recruitment on rural communities. However, the benefits of metropolitan practice make it difficult for rural hospitals to attract physicians. In fact, Roth (1986) states that rural hospitals fail each year to recruit the necessary amount of physicians needed to fill rural health care positions. According to Ormond et al. (2000), rural hospitals must recruit in order to have the necessary supply of physicians to maintain their services. They further point out that rural hospitals spend in excess of $30,000 each year for physician recruiting. The dilemma for rural hospitals is that they have little financial means to pay for recruiting, but they must budget funds each year to ensure they have a supply of physicians. Conversely, metropolitan hospitals that have more money at their disposal do not have to spend very much on recruitment. To provide more effective care, rural hospitals try to recruit generalists such as family practitioners. The generalists are able to provide a wider range of services that are required to treat the needs of the diverse population in a rural health care setting. Historically, rural hospitals enjoyed more success with recruiting generalists but now the trend is reversing. According to Weiner (1995), metropolitan hospitals are hiring a growing number of generalists because of their role in managed care. The increased demand for generalists in metropolitan areas has made recruiting them for rural hospitals even more difficult.

Patient Access

The third challenge for rural health care is patient access. According to a study of rural Americans in Montana, patients only seek services when those services address their needs and are congruent with their lifestyle (Weinert & Long, 1987). Many rural Americans are involved in agriculture. Due to their lifestyle, many rural Americans see a physician only after being unable to perform their work duties (Weinert & Long). The study of rural Americans in Montana illustrates that there is a lack of preventive medicine practiced in rural health care. The lack of preventive medicine means that many patient visits require more intense medical interventions. The maldistribution of specialists also presents a barrier to care. Access is further diminished by the fact that rural patients often have to travel distances in excess of 50 miles to see a specialist.

Government Policies

The U.S. government has created many policies in an effort to counteract the barriers associated with providing rural health care. The role of the government in creating and implementing policies is vital for the existence of rural health care. The measures taken to improve access for rural health care include the National Health Service Corps (NHSC), the Health Professions Educational Assistance Act of 1976, the federal Health Maintenance Organization (HMO) grant program, and community and migrant health centers.

The National Health Service Corps was created in 1970 to help recruit and retain physicians for designated medically underserved areas. In 1972, the program was expanded to include a scholarship program for health care providers who volunteered to serve in needed areas. According to Shi and Singh (2004), over 20,000 health care providers have volunteered since 1972 to practice in medically underserved areas. In addition, the National Health Service Corps received additional funding in President Bush’s 2002 budget. The $44 million increase is expected to provide scholarships to 1800 medical professionals (Shi and Singh).

The Health Professions Educational Assistance Act of 1976 formally designated medically underserved areas. The designations were based on geographic areas, population groups, and medical facilities. Once designated as a Health Manpower Shortage Area (HMSA), facilities were entitled to additional government support. As of 1989, 1337 designations were in rural areas (Shi and Singh, 2004).

The federal Health Maintenance Organization (HMO) grant program was signed into law in 1973. According to Shi and Singh (2004, p. 448), the act mandated that “federal support for HMOs be targeted to applicants with at least 30% of their membership in medically underserved areas.” Areas could be designated as underserved by using the Index of Medical Underservice which was based on four variables: percentage of population below poverty income levels, percentage of population age 65 and older, infant mortality rate, and primary care physicians per 1000 population (Shi & Singh).

The community health and migrant health centers are government funded health facilities that provide care in areas that the government has designated as medically underserved. Shi and Singh (2004) state that these health centers provide care to approximately nine million patients annually. In addition, they state that the majority of these health centers are located in rural areas and provide care to mostly minority populations (Shi and Singh).

Conclusion

Rural America poses an ongoing challenge for the U.S. health care system. It’s unique demographic composition and culture creates challenges in many areas such as finances, physician recruitment, and access to care. Many new health care policies that provide benefits to metropolitan areas have resulted in unintended consequences for rural health care. The government has implemented control measures intended to ensure the survival of rural health care. If these measures fail, the consequences for the elderly and poor would be very serious. Therefore, solutions must be made to fit each unique area or the future of rural health care may be in jeopardy.