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As health care
reform emerges
as a national
issue once
again, it seems
advisable to
take a look at
how these things
play out away
from the major
cities, state
capitals and
Washington, D.C.
Ensuring access
to needed health
care services in
rural areas has
long been a
challenge. As a
former Governor
of South
Carolina and now
as chair of the
National
Advisory
Committee on
Rural Health and
Human Services,
I’ve seen this
first hand. On
a more personal
level, my wife
and I and our
four kids live
in a rural area
of South
Carolina. It is
critical for me
to know we can
get to a doctor
or an emergency
room if we need
it, and we
inevitably do.
At a recent
meeting of the
Committee, which
advises the
Secretary of the
U.S. Department
of Health and
Human Services (HHS)
on rural issues,
we took some
time to reflect
on what’s
happened in
rural health
care over the
past 20 years,
while also
discussing some
of the key
challenges that
lie ahead.
There have been
some real
successes since
1987. Twenty
years ago, rural
America was in
trouble. The
farm crisis was
in full swing.
When farms shut
down, we lost
other rural
businesses. We
also lost a
significant
number of the
low-wage
manufacturing
jobs that played
a crucial role
in rural
economies. And
this was as true
in South
Carolina as it
was anywhere in
the country. At
the same time,
some 400 rural
hospitals closed
between 1983 and
1987, due in
part to changes
in the way
Medicare paid
hospitals that
were designed on
an urban-based
model.
Either issue in
and of itself
would have been
cause for
alarm. Taken
together, these
situations were
causing problems
in America’s
heartland. That
got the
attention of
policymakers
because rural
hospitals are
the linchpin of
a local health
care system. If
you don’t have a
local hospital,
it’s hard to
attract
physicians and
other health
care providers.
There was a
genuine concern
that rural
residents were
facing a crisis
in access to
health care
services.
Something had to
be done.
We’ve also
learned that
health care and
rural economic
development are
tightly tied.
If you don’t
have adequate
health care
services in a
town, it’s hard
to attract new
jobs and
industries to
that area. So,
on a variety of
levels, it was
clear that
something had to
be done to help
rural
communities.
Luckily, the
issue got the
attention of
lawmakers. The
Congress and the
Reagan
administration
worked together
to create an
Office of Rural
Health Policy
within HHS to
make sure there
was a rural
voice within the
policymaking
process. They
also worked to
create a program
that established
a State Office
of Rural Health
in each of the
50 States.
Over the next 20
years, rural
health
advocates,
lawmakers and a
number of
Administrations
worked to
identify the
problems facing
rural health
care providers.
Slowly,
policymakers
began to
understand the
special
challenges of
providing health
care services in
small and often
isolated rural
areas. Through
a number of
legislative and
regulatory fixes
over the years,
things are
looking better
for rural
hospitals and
the communities
they serve. One
of the more
significant
changes came in
1997 with the
creation of the
Critical Access
Hospital (CAH)
designation,
which allowed
the smallest and
most vulnerable
rural hospitals
some relief by
paying them on a
cost basis and
allowing for
staffing and
regulatory
flexibility
needed to give
these facilities
a chance to
succeed
economically.
There are now
1,283 of these
facilities
nationally.
We’ve also seen
tremendous
growth in the
number of Rural
Health Clinics
and Community
Health Centers
that have been
established in
rural areas.
Medicaid is also
an important
payer in rural
communities.
The 1997
legislation that
created the CAH
designation also
made key changes
to Medicaid –
changes that
provided greater
flexibility to
States in terms
of managed care
options and also
in reforms to
Medicaid
Disproportionate
Share payments.
That made it
easier for
Governors to
adapt Medicaid
to the
particular needs
of their States.
In 2003,
Congress also
included $25
billion worth of
reimbursement
increases for a
range of rural
health care
providers in the
legislation that
created the
Medicare drug
benefit. This
investment was
the latest in a
series of
legislative
fixes between
1997 and 2003
that helped to
begin addressing
some
long-standing
reimbursement
rural-urban
inequities in
the Medicare
program.
Still, many
challenges
remain, and
we’ve seen and
continue to hear
about them when
the Committee
holds its
meetings in
rural areas
across the
country.
While rural
hospitals have
stabilized, some
are still
struggling and
have negative
operating
margins. Rural
areas also still
struggle to
attract and keep
health care
providers,
particularly
physicians.
There are now
3,782 primary
health care
professional
shortage areas –
or HPSAs – in
rural areas,
compared to
1,911 in urban
areas. The
shortages are
even more
challenging for
dentists and
mental health
care providers.
We’re now
starting to hear
about the
struggles of
community
pharmacists and
discussed this
issue at length
in our 2006
Report to the
Secretary (http://ruralcommittee.hrsa.gov).
Americans in
rural areas also
face a number of
other health
care
challenges.
Rural residents
are more likely
to have chronic
conditions than
those who live
in urban and
suburban areas.
Rural Americans
have higher
rates of obesity
and limitations
on activities of
daily living due
to health care
problems. Rural
residents have
higher rates of
unintentional
injury and
higher death
rates than folks
who live in
urban areas.
What’s worse is
that these
statistics have
held steady for
the past 20
years.
It’s also
important to
provide some
context for all
of these
issues. Rural
areas face some
distinct
socio-economic
challenges, with
slightly higher
poverty rates
and an economy
that has not had
the same growth
as urban and
suburban areas.
These factors
become even more
of a concern if
you drill down a
bit. Rural
areas along the
U.S.-Mexico
border, the
Delta region and
the Appalachian
region, for
example, face
even larger
economic and
health
disparities.
In my work with
the Committee,
I’ve had the
opportunity to
see how diverse
the issues are
for rural
America. Each
year, we do site
visits to rural
communities to
gather
information on
the ground for
our reports to
the Secretary.
Although many
different parts
of our country’s
rural areas face
some common
challenges, they
also have some
very unique
circumstances.
What has been
amazing is to
see how
communities are
able to overcome
these challenges
despite the many
obstacles.
We’ve seen this
in places like
Bisby, Arizona,
Tupelo,
Mississippi and
Nebraska City,
Nebraska, just
to name a few.
The key takeaway
in all of these
communities is
that they’re
working across
multiple sectors
to address
problems.
They’ve realized
that, given the
limited
economies of
scale in rural
communities,
they have to
work together to
survive.
They’ve grown
their own local
leaders, and
that investment
is paying off.
These folks
realize that
there is no
single
solution. They
understand there
are government
programs that
can help, but
that ultimately
problems are
best addressed
at the local
level.
Policymakers
would do well to
remember that
rural America
makes up roughly
80 percent of
our country’s
land mass and is
home to about 20
percent of the
population. As
they get more
involved in
talking about
how to tackle
health care
issues more
comprehensively,
it is important
to remember that
regardless of
what approach
ultimately
emerges, any
solution should
capitalize on
the creativity
and
problem-solving
approaches we’ve
seen in rural
America. It is
also critical
that we adopt
approaches that
emphasize local
and State
flexibility,
because we’ve
seen first hand
that what works
in Vermont may
not necessarily
work in South
Carolina.
--###--
David Beasley
served as
Governor of
South Carolina
from 1995-1999.
Since 2002, he
has served as
chair of the
National
Advisory
Committee on
Rural Health and
Human Services,
which analyzes
rural policy
issues for the
Secretary of the
U.S. Department
of Health and
Human Services.
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