Over the past 17 years, 124 rural hospitals across the U.S. have closed their doors. And over 80 facilities have been forced to reduce their services — including eliminating in-patient care, according to the North Carolina Rural Health Research Program. A separate report published in February 2020 by the Chartis Group revealed a total of 453 rural hospitals had been deemed financially vulnerable and were at risk of closing. It’s a grim reality that highlights the lack of access to health care in rural areas and the need for intervention.
Rural communities on average have significantly less access to healthcare services than their urban counterparts. Access to health care can prevent disease by early detection and treatment and offer a higher quality of life — while increasing life expectancy — for those in the community. Government officials and medical professionals are exploring ways to improve health care in rural areas and promote healthcare equity. By reviewing common challenges concerning access to health care and possible solutions, healthcare administrators can discover means of improving access to health care in rural areas.
Underlying Social Conditions
When compared to urban communities, rural populations experience higher rates of chronic illness and poverty and are more likely not to have health insurance. In addition, these populations often face severe shortages of primary care providers.
Living in the rural United States comes with the risk of having restricted access to medical facilities. Even when health care is available in rural communities, residents may face unique challenges that stem from the lack of:
- Trust and confidence in their caregivers
- Financial means to pay for health or dental insurance covered by their healthcare provider
- Means of transportation to reach services
- Adequate time off to commute and have services performed
Lack of access often means patients arrive at healthcare facilities with ailments further developed than those with access to preventative care. A study done by Medicaid and CHIP Payment and Access Commission (MACPAC) found that between 2013 and 2015, 43.5 percent of Medicaid patients in rural areas made at least one visit to the emergency room, while only 34 percent of Medicaid patients in urban areas did the same.
A similar pattern is seen in private and uninsured patients: Individuals in rural areas are more likely to visit the emergency room than those in urban areas. The study suggests this discrepancy could be a result of rural residents lacking a usual source of care or forgoing minor medical problems until they become dangerous. When people lack access to health care, they are less likely to undergo preventive and screening services that could deter future medical issues.
Addressing the challenges of healthcare equity requires thoughtful and strategic leadership from health administrators.
Challenges in Receiving Health Care for Rural Residents
The challenges residents in rural areas face are unique due to the scarcity of resources and personnel. The long distances between medical facilities, the shortage of healthcare professionals, and low rates of health literacy are just a few obstacles rural residents face when seeking access to health care.
One of the biggest healthcare challenges rural residents face is the lack of reliable transportation. Residents in rural areas typically have to travel significantly farther distances to visit their primary care doctor or specialist. Many rural areas lack public transportation, thus patients must resort to their own means to attend doctor visits and checkups.
Since rural communities tend to have a higher percentage of older adults, this can create a serious impediment as older patients often rely on others for transportation. Distance between residents and the nearest healthcare facility also poses an issue as visiting medical professionals requires more commute time for rural residents.
Healthcare Worker Shortages
Even if individuals do have reliable transportation to and from a healthcare facility, this does not ensure one is available nearby. The Bureau of Health Workforce Health Resources and Services Administration identifies Primary Care Health Professional Shortage Areas (HPSAs) throughout the United States to determine areas that are experiencing a severe shortage of primary care providers. As of September 2022, 65.6 percent of HPSAs were located in rural areas.
This lack of healthcare professionals becomes exacerbated by the need for existing medical facilities to hire short-term travel nurses and doctors and pay overtime to existing staff. Funds are also directed to recruiting and retainment efforts, which results in healthcare facilities being less financially viable. Mediating the healthcare worker shortage is one of the ways to improve health care in rural areas.
If a resident has transportation, and the local healthcare facility is staffed with healthcare professionals, that still leaves the question of whether residents can afford medical treatment. A report published by the U.S. Department of Health and Human Services in 2022 claims 14.4 percent of rural residents under 65, and over five percent of children under 17, are uninsured.
The reasons rural residents are more likely to be uninsured than their urban counterparts are not strictly financial. Insurers participating in the Health Insurance Marketplace, for example, often offer much fewer insurance options to rural communities — and often at a higher price.
In addition, a report by the Maine Rural Health Research Center found that rural residents have less confidence in determining the maximum out-of-pocket costs for health insurance plans and were less familiar with the Affordable Care Act’s insurance mandate or availability of subsidies. A sign of another unique challenge for rural residents: health literacy.
Generally, rural communities can have decreased access to health education and higher rates of poverty, which can mean lower levels of health literacy. Low health literacy is also partially due to a lack of broadband internet access, which limits access to health information that might prove vital to a patient’s well-being.
To address this issue, Congress passed the Consolidated Appropriations Act in 2021(H.R. 133) to provide $300 million to expand broadband internet access in rural areas. Lawmakers hope this addresses the lack of broadband access in rural communities: as of 2020, 22.3 percent of residents in rural communities lack access to the internet in their homes — far exceeding the rate of urban residents.
Lack of Specialized Health Care
A number of important but specialized healthcare services — some of which can be life-saving — are rare if not absent in rural communities. Home health, which brings health care to the patient’s place of residence, is especially limited in rural areas, with one study suggesting 10.3 percent of rural zip codes lack access to home health care.
Mental health care is also in short supply in rural communities. The HPSA report indicates rural areas account for 60 percent of mental health shortage areas in the U.S. as of October 2022. While rural communities lack access to other specialized services, the lack of access to mental health services is acute.
Other types of care that may be difficult to access in rural communities include:
- Hospice and palliative care. A combination of factors, such as healthcare worker shortages, limited broadband access, and reimbursement challenges create barriers for hospice and palliative care centers in rural areas, which means it’s harder to effectively treat community members with chronic or terminal illnesses.
- Substance use disorder services. Despite the increasing need for substance abuse services in rural areas, treatment centers in rural areas have fewer highly trained counselors when compared to urban treatment centers, according to an American Journal of Drug and Alcohol Abuse article. Additionally, rural centers have limited access to medication for opioid use disorder (MOUD).
- Reproductive, obstetric, and maternal health services. According to a 2020 issue brief by the Kaiser Family Foundation, women in rural areas were less likely to have access to health care providers who addressed issues related to reproductive health with them. Additionally, rural areas were more likely to face the loss of obstetric services between 2012 and 2019, according to a 2022 Center for Economic Analysis of Rural Health policy brief.
- Oral health services. Several factors compound to create limited access to oral health services in rural areas, despite their importance. According to a 2021 National Institutes of Health report, rural residents are less likely to have dental insurance than urban residents. There are also fewer oral health professionals in rural and underserved areas than in urban areas, making services more difficult to access.
Possible Solutions for Improving Health Care in Rural Communities
Given the lack of healthcare resources for individuals living outside of cities and suburbs, many have explored ways to use technology to expand access to physical and mental health care for rural residents. Technologies like telehealth and mobile health providers can increase patient access, alleviating the need for residents to visit healthcare facilities.
Mobile Health Care
Some healthcare professionals have studied how mobile health clinics can improve access to health care, including methods that would specifically improve health care in rural communities. These “clinics on wheels” can help solve the issue of transportation many rural citizens face. Mobile health clinics are also significantly less expensive for both patients and providers as the infrastructure costs are dramatically reduced.
While offering potential cost savings to patients and insurers, mobile clinics can also assist in building relationships and increasing health literacy in rural areas for women and minorities. A study published in the International Journal of Equity in Health conducted in 2020, which reviewed several mobile healthcare initiatives, found that over half of mobile healthcare clients are women (55 percent) and racial/ethnic minorities (59 percent). Most of those who received care were either uninsured or had some form of public insurance. The majority of these mobile clinics received some form of financial support from philanthropy.
Like many philanthropic-related initiatives, mobile healthcare solutions often begin at the grassroots level. Such is the case with the Mobile Healthcare Association Coalitions. These coalitions serve specific regions and share ideas, strategies, and resources. Regional coalitions of mobile healthcare providers help build awareness of mobile clinics in rural communities, offer collaborative working relationships to find creative solutions to local problems in rural communities, and create a network of mobile healthcare providers that can support organizations interested in launching mobile health clinics.
Another solution for increasing access to health care in rural areas is through telehealth. Telehealth can include videoconferencing, streaming media, and cellular communication to administer and support a patient’s health. Telehealth has seen significant growth since the start of COVID-19 and will likely remain a vital aspect of the health industry going forward.
The Health Resources and Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration.
The kind of care one can access with telehealth includes:
- Mental health treatment such as therapy and counseling
- Treating skin conditions
- Reviewing urgent care issues such as colds, coughs, and stomach bugs
- Post-surgical follow-ups
- Monitoring services for chronic conditions like high blood pressure, high cholesterol, and diabetes
Given the problems of health literacy in rural areas, incorporating telehealth may invoke skepticism concerning patient privacy. A report from the Center of Connected Health Policy as well as information provided by the Rural Health Information Hub, for example, indicate that privacy and security concerns are among those expressed by both patients and providers. Thus, healthcare providers must assure remote patients of the health provider’s secure use of each patient’s health data.
Virtual visits offer numerous benefits specific to rural residents. Virtual visits ensure health care to anyone with access to reliable internet while shortening the wait time for appointments and increasing access to specialists.
Collaborating with Larger Healthcare Networks
By affiliating with larger healthcare systems in more urban settings, rural healthcare facilities can improve health care in rural communities by offering their patients improved infrastructure and resources that are more financially viable. Collaborating with larger healthcare organizations can also bring more specialized and expansive healthcare services to rural areas.
A report published by the RUPRI Center for Rural Health Policy notes a trend of rural hospitals increasing their affiliation with other hospital systems. The report offers several benefits rural hospitals can receive by collaborating with other hospital systems, such as:
- Improved technology
- Improved performance and services
- Greater flexibility in payment models
- Larger recruiting and retention efforts for staff
Through collaboration with larger legacy institutions, smaller healthcare facilities can lower their costs and increase their reach in rural communities.
Increase Healthcare Access in Rural Communities
Doctors, nurses, physicians, and other medical professionals are the foundation for health care in both rural and urban communities. It’s no question we rely on their medical expertise to improve the health of rural residents.
However, solving the lack of health care access in rural communities depends on strategic and well-trained administrators. These administrators must be trained in leadership, ethics, social justice, economics, and even data management to be able to effectively extend healthcare access to those who need it. A Master of Health Administration program, such as the one offered by Tulane University’s School of Public Health and Tropical Medicine, can equip future healthcare administrators with the leadership skills they need to improve community health, especially in rural communities.