As of late, rural health has been a hot topic and buzzword in the public health and health policy spheres. Health Affairs recently published an entire issue related to topics on rural health. The American Journal of Public Health recently issued a call for manuscripts for a special issue dedicated entirely to rural health. Rural health issues were also well represented at the 2019 American Public Health Association Annual Meeting. Within the Medical Care Section there were over 15 presentations focused on rural health that covered topics from reproduction to prevention.
The reason for its popularity? 
The health of rural populations is continuing to decline and mortality rates are continuing to increase, especially among the middle-aged. Rural populations face higher mortality rates from “deaths of despair” such as opioid overdoses, suicides, and alcohol abuse. Deaths of despair are often linked to the detrimental social determinants of health with which rural areas are disproportionately burdened. For example, rural populations have lower educational attainment and fewer employment opportunities. These have negative implications for their income and earning potential. Moreover, employment in rural areas is often seasonal, which has implications for insurance.
Because there are fewer opportunities for employment, rural individuals travel longer distances [PDF] for work. This negatively impacts rural health because it leads to increases in traffic accidents and sitting for long periods of time. Poor social ties and social support, coupled with financial burden, often lead to poor coping mechanisms. These include higher rates of tobacco use, opioid addiction, and alcohol abuse. Substance abuse can often lead to gun violence and domestic abuse. Finally, poorer health outcomes are the result of food deserts and/or insecurity and a lack of affordable, quality housing.
A weakening rural health care system
In addition to these social determinants of health and behavioral health issues, rural health care systems are crumbling around them. In the last 10 years, over 120 rural hospitals have closed and an additional 673 are at risk of closing [PDF]. This further exacerbates access-related barriers to care caused by a lack of providers. Rural hospitals that have joined a health system to avoid closure, have tended to find greater financial stability, but are producing poorer quality outcomes.
Moreover, rural areas have fewer primary care and specialty providers. Rural populations often travel long distances to receive care, especially specialty care. The closure of rural hospitals has made this problem worse. Provider retention is another issue. Although there are programs to place or train providers to practice in rural areas, they have been largely underfunded and unsuccessful. Fewer than half of providers (43%) choose to continue to practice at their rural obligation clinic five years after their commitment is over.
The high rate of rural physician turnover leads to discontinuity in care for rural patients. All-in-all, there simply aren’t enough steady providers to ensure that patients receive the routine and acute care they need. In fact, a recent poll [PDF] confirms that 26% of rural Americans have needed healthcare care in the past year, but could not access the healthcare system when they needed it.
Health insurance options are limited in rural areas
In addition, there are fewer health insurance plans serving rural areas. This causes rural individuals to pay more for less insurance or to be uninsured. Medicare and Medicaid are major players covering rural populations. Because rural populations have a higher proportion of individuals over the age of 65, Medicare is one of the largest payers. Moreover, Medicaid covered nearly 45% of all children and 16% of adults [PDF] in rural areas in 2015. Thus, states with large rural populations that have not expanded Medicaid and states that are planning to further restrict or eliminate their Medicaid expansion program, could reduce access to care and contribute to further hospital closures.
A lingering national challenge
The issues faced by rural populations are not being addressed on a national scale. For example, there aren’t any Healthy People goals that are specifically aimed at improving rural population health. Due to the unique challenges rural populations face, goals specific to rural health are necessary. Furthermore, it’s likely that the solutions that have worked for urban populations will not work for rural populations.
With the start of a new decade, public health professionals look forward to working to achieve the goals defined in Healthy People 2030 that are currently being developed. The current popularity of rural health and the dawning of a new decade has created a window of opportunity to build on earlier Rural Healthy People [PDF] goals that were developed outside of the federal government. Perhaps it’s time to formalize these kinds of rural health goals directly in Healthy People 2030.
