Rural Healthy People 2020

Researchers at the Southwest Rural Health Research Center have just published the results of their Rural Healthy People 2020 survey in The Journal of Rural Health.  

The study found that, just as when the study was first conducted a decade ago (as the Rural Healthy People 2010 study), “access to quality health services” was considered to be the single most important health priority for rural Americans. While lack of sufficient access to health care unsurprisingly remains the most salient hurdle to better health for rural residents, the survey also found that the Top 10 issues facing rural residents for the decade going forward have changed from a decade ago.  

Specifically, while issues of “nutrition and overweight” were not even listed in as a “Top 10” priority ten years ago, while it has moved into the second highest priority in the most recent survey.

 Another interesting finding is that while stakeholders responding to the survey a decade ago did not list “older adults” as a healthy priority to be addressed within rural America, in this latest survey, the majority of stakeholders ranked issues facing “older adults” in the top ten highest-priority issues. 

These are issues we all need to be aware of as important to rural practitioners and policy makers, and ensure that they do not get lost in the ongoing struggle for improved access.

Community Paramedicine

The SC Rural Health Research Center has a history of working with community partners, providers, and systems to analyze, evaluate, and otherwise aid in their operations. One such project is the Abbeville Area Medical Center's Community Paramedicine Project.  This pilot, spearheaded by David Porter (Director of Abbeville's EMS), utilizes paramedics to conduct home visits for medically indigent patients.  The two videos below summarize the program, introduce you to the EMTs and a couple patients, and discuss some of the outcomes from this innovative project.

King v. Burwell: Rural Implications?

Unless you live under the proverbial health policy rock, you know that today the Supreme Court will hear arguments on King v. Burwell (a brief history is here).  If the SCOTUS strikes down the subsidies provided in federally run exchanges, the impact will be significant:

• Approximately 7.2 million with insurance losing access to subsidized premiums; in other words, about 87% of those who obtained insurance via the exchanges
•  Substantial increase in the number of uninsured (due to the loss of subsidies, it is anticipated many would not be able to afford the full premium)
• Premiums (in the non-group market) would increase substantially, upwards of 35%

These changes have the potential to impact rural residents to a greater degree.  Rural residents have, on average:

• lower incomes
• reduced access to employer sponsored coverage
• more likely to live in a non-Medicaid expansion state
• have fewer enrollment options (plan and/or network choices) and higher premiums within the exchanges

If these subsidies are removed, it will further distance rural residents from the rest of the country in regards to insurance coverage, access to care, and equity in treatment.

Rural Hospitals in Critical Condition

A recent USA Today article highlighted the struggles facing rural hospitals.  Authors Jayne O’Donnell and Laura Ungar report that since 2010 43 rural hospitals have closed—with the number of closures seeming to increase every year, and still more currently in danger of closure.

“The Affordable Care Act,” the authors write, “was designed to improve access to health care for all
Americans…But critics say the ACA is also accelerating the demise of rural outposts that cater to many of society’s most vulnerable….Hospital officials contend that the law’s penalties for having to re-admit patients soon after they’re released are impossible to avoid and create a crushing burden.”

O’Donnell and Ungar also point to low Medicare and Medicaid reimbursements and high costs of EHR implementation as further blows to rural hospitals.  Rural hospital closures, the article explains, harm not just patients, who must now resort to long commutes to the closest hospital, often at times when every minute counts, but also the rural community in which the closure occurs, as rural hospitals are often an integral part of the local economy.

The authors note that struggling rural hospitals tend to face one of two options: either they must try to partner with larger, more financially-solvent health systems, or they must hope that local councils will implement increased taxes to provide the funds to keep the lights on.  Neither of these options, as O’Donnell and Ungar explain, has proven to be a satisfactory solution across the board.

While the article maintains that Medicaid expansion to all states would help, they also note that such expansion will not solve all of the problems facing rural hospitals, and the authors pass on this advice from stakeholders: “[A]dvocates say government can do more; state legislatures can adopt policies that bolster small hospitals, and the federal government can pay Medicare and Medicaid providers at least their costs and revamp the critical access program in light of the ACA.”

Characteristics, Utilization Patterns, and Expenditures of Rural Dual Eligible Medicare Beneficiaries

The SCRHRC released another report today, focusing upon rural Medicare beneficiaries also enrolled in Medicaid (a.k.a. dual eligible beneficiaries).  The graphic below highlights our major findings.

People living with HIV/AIDs in the Rural South

A recent article in the The Washington Post describes the difficulties faced by people living with HIV/AIDS (PLWHA) in the South. While nonprofit organizations, such as the Southern Aids Coalition, continue to advocate for increased awareness and funding, budget cuts threaten the availability of medical care and prescription drugs for PLWHA in the South.

The author, Teresa Wiltz, points to “social factors such as poverty, persistent anti-gay attitudes and a lack of transportation in rural areas” as leading factors that result in the higher rates of HIV in the South. A report released in 2013 by the SCRHRC on HIV/AIDS in Rural America found that in 2008, the South had the highest prevalence rate of PLWHA of the 28 states analyzed. 

Using 2010 data obtained by AIDSvu.org, we were able to map the rate of persons living with an HIV diagnosis by rurality (below). The dark shades of green (urban) and red (rural) indicate an above median rate of persons living with HIV. 

Map created by South Carolina Rural Health Research Center
Source: AIDSvu.org 2010 data

The map illustrates that Southern states are concentrated with high levels of HIV prevalence. As pointed out in the Washington Post article, an additional obstacle faced by Southern states is the decision to not implement Medicaid Expansion. This disproportionately impacts uninsured individuals, many of whom are minorities, as described in an infographic published by the Kaiser Family Foundation in JAMA. 

Access to care and the availability of discounted or free prescription drugs for PLWHA in the South continues to be of concern. Rural areas in the South are faced with the added barriers of lack of transportation, low awareness/education, and poverty.

Rural Medicare Advantage Enrollment--yet another disparity

Recently, Medpac released a statement debunking the thought that up to one-half of all new Medicare enrollees were choosing Advantage plans.  Their analysis indicates that this percentage is only 24%, with 28% of the overall Medicare population enrolled in Advantage plans.

This enrollment is much lower, however, among Rural populations  The RUPRI Center for Rural Health Policy Analysis estimate that less than 18% of rural beneficiaries are enrolled in Advantage plans, a majority of which are actually PPO plans.

Why is this lower percentage significant?  Advantage plans often offer additional benefits (such as dental or vision), care coordination, and lower out of pocket costs for their enrollees.  These benefits do come with a tradeoff in more restrictive networks and services, but it is one often beneficial to the individual.

Rural residents, much like everything else in health care, have a reduced access to Advantage plans.  An insurance industry analysis indicates that rural residents have fewer Advantage options, the premiums are higher, and have fewer benefits than those offered in urban areas.

While this may explain the lower enrollment proportion, it also indicates yet another area in which rural residents may be left behind.