Defining rural areas

Rural American communities are as diverse as the country itself. Each rural community has distinct characteristics and challenges that are a function of numerous factors unique to that area. For example, small towns in Appalachia are different in character from the farming communities and open plains of the Midwest; these characteristics reflect the economic, cultural, and social differences unique to each area. To understand the characteristics of rural health care, it is important to understand how different U.S. governmental agencies define “rural.”

Geographic isolation and population density represent two of the major features of a rural versus nonrural—or urban—envirionment:

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  The U.S. Census Bureau focuses on population density; however, the Bureau does not formally define “rural.” Instead, it is described as a population, housing, or territory that is not included in an urban area ( Fig. 52.1 ). Urban areas are defined as either an “urbanized area” with a concentration of 50,000 or more individuals, or an “urban cluster” with at least 2500 but fewer than 50,000 individuals. Any communities or areas not meeting these parameters would be deemed rural.

  
  

  
  

  
  

  

  
  

  
  

  
  

  (From the USDA Economic Research Service. U.S. Census Bureau urban and rural areas, 2012. United States Department of Agriculture. https://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/what-is-rural.aspx . Accessed May 16, 2019.)

  
  
  
  
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  The Office of Management and Budget delineates areas by county, with designations of metropolitan (50,000 or more population), micropolitan (10,000–49,999 population), or neither (less than 10,000 population). Nonmetropolitan areas are considered rural. Under this definition, after the 2010 Census, nonmetropolitan areas contained about 15% of the total population and covered 72% of the land area in the United States. “Noncore” counties are those that are not part of metropolitan or micropolitan areas ( Fig. 52.2 ).

  
  

  
  

  
  

  

  
  

  
  

  
  

  (From the USDA Economic Research Service. Metro, nonmetro micropolitan, and nonmetro core counties, 2013. United States Department of Agriculture. https://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/what-is-rural.aspx . Accessed May 16, 2019.)

  
  

Defining health care shortage areas

Health care shortages are typically more common in rural locales than urban areas. ^, Areas of the country with health care shortages may be eligible for federal and state benefits, such as grants or loan repayment programs, even if they are not classified as “rural” under the previously discussed definitions. The United States Health Resources and Services Administration (HRSA) relies on several formal designations to identify areas with significant shortages in one or more areas of health care, as follows:

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  Health professional shortage areas (HPSAs) indicate health care provider shortages in the disciplines of primary care, mental health, or dental health. A shortage may be designated for a specific geographic area, a given population group within a defined geographic area (e.g., low income, homeless), or a facility such as a correctional facility or state mental hospital. The determination of a HPSA typically follows in response to a submitted application by a community or institution seeking this designation.

  
  
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  Medically underserved areas (MUAs) identify geographic areas with a shortage of primary care health services, whereas medically underserved populations (MUPs) describe specific subgroups living in a defined geographic area who are subject to a shortage of primary care health services. The MUP designation is often granted to groups that face significant cultural barriers or economic difficulties that hinder access to health care. MUAs and MUPs are determined based on the population to provider ratio, the percent of the population below the federal poverty level, the percent of the population over age 65, and the infant mortality rate.

The definitions by the U.S. Census Bureau, the Office of Management and Budget, and the HRSA provide an introductory framework for identifying rural populations, as well as groups and areas affected by health care shortages. This framework is essential to the development of a deeper understanding of our rural health infrastructure.

Socioeconomic factors

Financial factors play a significant role in the availability of health care for rural Americans. A Robert Wood Johnson survey on rural health care revealed that 45% of the respondents cited that care was unaffordable. There are multiple aspects of affordability of health care for rural patients that should be considered when determining how best to provide care for these populations.

Rural Americans tend to have lower median household incomes than urban households. ^, In the Northeast and Midwest, the difference in average household income between urban and rural households is minimal; however, in other areas of the country there is a considerable difference between urban and rural household incomes. For example, rural households in Appalachia earn approximately 34% less than Appalachian households in metropolitan areas ($36,265 in rural households versus $54,743 in urban households). Moreover, the median household income in Appalachia is 19% lower than the national median. This dramatic difference once again underscores the importance of understanding the factors that may affect the practice of rural medicine.

Rural counties also consistently have the highest rates of poverty when compared with suburban and urban counties. ^, When considering areas of concentrated poverty, where at least one-fifth of the population is poor, rural areas once again top the list. In the United States about 31% of rural counties meet the criteria for concentrated poverty, whereas only 19% of urban and 15% of suburban counties fit this criteria. In 2017 the overall rural poverty rate was 16.4%, compared with 12.9% for urban areas; nevertheless, the poverty rate has improved over the last 4 years. Caucasians make up the largest percentage of rural individuals living in poverty (65%). ^, Rural poverty rates vary by ethnic population as well, however, with rural Black Americans being disproportionately affected when compared with other racial/ethnic groups.

The availability of affordable, quality health insurance continues to be an issue for many Americans. Not surprisingly, rural Americans struggle with lower rates of insurance coverage than their suburban and urban counterparts. In completely rural counties, approximately 12.3% of the population is uninsured, compared with 10.1% for counties with less than a 50% rural population. Nevertheless, in recent years the overall rate of uninsured individuals has been improving in both rural and urban areas. Medicaid plays a key role in reducing rates of uninsured rural Americans, and the expansion of Medicaid introduced by the Affordable Care Act (ACA) in 2010 had a considerable impact on rural populations, with an especially dramatic effect on juvenile populations. In 2015, Medicaid provided health care insurance for 45% of children and 16% of adults in rural areas, compared with 38% of children and 15% of adults in metropolitan areas. It is noteworthy that Medicaid coverage under the ACA was not approved by all states. In 2015 the rural populations of states without expanded coverage were found to have significantly higher rates of uninsured people at 27% versus 13% in the states with expanded coverage.

Numerous studies have demonstrated the positive impact of insurance coverage on health. ^, Even so, having insurance does not uniformly lead to accessibility of health care services. Nearly one in five rural patients report difficulty finding a provider willing to accept their health insurance. This may be in part because of the relatively high proportion of patients insured by Medicaid and the low rates of providers who will accept Medicaid. One survey found that only 70.8% of providers accept new patients with Medicaid coverage, compared with 85.3% who accept Medicare patients and 91% who accept new patients with private insurance.

Additional financial barriers faced by rural patients when accessing health care services go far beyond simply the affordability of office visits, diagnostic tests, or prescriptions. Rural patients may defer health care because of the possibility of lost wages associated with taking time off work to attend appointments; transportation costs of either personal or public travel; or other expenses such as childcare, utilities, or food costs that take priority over personal health.

Physical access to health care

Physical access to health care services is a significant barrier for many rural patients. Reliable transportation is essential for traveling to and from medical facilities but also impacts the ability to access other resources, such as exercise centers, grocery stores, and places of employment. The lower average income and higher rates of poverty noted in rural areas may impede access to reliable transportation. Moreover, public transportation is markedly limited in most rural areas. In 2017, less than 1% of rural residents used public transportation to travel to work, compared with 6.3% of urban residents. Only 60% of rural counties in the United States report availability of public transportation, and 28% of rural counties with public transportation reported very limited service. The service limitations and costs associated with rural public transit may be impractical for many individuals seeking transportation for medical care. For example, fixed-route services that run on regular schedules are common in metropolitan areas; however, many rural transit agencies only offer a demand-response service wherein patients must call and specifically request transportation to and from the health care facility. Additionally, the cost of this transportation may not be covered by health insurance. Public transportation may also not be adequate for the patient’s needs, especially if the rural public transportation system does not provide services outside the local area for appointments in larger cities.

The geographic isolation of many rural towns and communities can result in a significantly longer trip to access health care services, especially those provided by medical specialists. This leads approximately 23% of rural patients to report the distance to health care services as a significant challenge to receiving care. This isolation also leads to a limited number of choices with regard to health care facilities. Patients may have no choice but to see a provider based strictly on location, rather than other considerations, such as experience or subspecialization, simply because there are no other practical options.

Adding to the aforementioned issues, many rural areas struggle with roadways considered to be less safe and in worse conditions than roads elsewhere in the country. In 2015, 36% of major rural roads were rated in poor or mediocre condition, and 10% of rural bridges were rated as structurally deficient. Rural roadways are more likely to have hazardous features such as narrow lanes, limited shoulders, sharp curves, exposed hazards, pavement drop-offs, and steep slopes ( Fig. 52.3 ). As a result, rural, non-interstate roads have traffic fatality rates 2.5 times higher than other roadway categories. These less-than-ideal traveling conditions serve only to further deter patients from accessing necessary health care services.

A rural byway in southern West Virginia.

Cultural factors

There are some commonly held cultural beliefs and practices found in rural areas that may also affect the provision of health care. Awareness of the potential impact of rural culture, as well as an understanding of the unique viewpoints, values, attitudes, belief systems, and norms of patients in rural communities, is essential to building healthy patient-provider relationships.

Most patients from rural backgrounds place a high value on personal relationships and connection to the community. Moreover, rural patients are also more likely than those in urban or suburban settings to live in, or near, the areas in which they grew up. ^, Rural patients may be more accepting of providers who are perceived as part of the community. In fact, many rural providers experience overlap between the role of clinician and that of a community member. The overlap of these roles can help establish rapport with patients but may also lead to potential problems with blurring the boundaries of the professional relationship. Rural health care providers may be called upon for services such as free consultations, after-hours services, and volunteer work, all as a part of helping their “neighbors.”

The familiarity rural patients experience with people in their communities can also be problematic. Rural patients may avoid seeking care because of a perceived lack of privacy, despite the protective mandate of the Health Insurance Portability and Accountability Act (HIPAA). This may be particularly problematic for disorders that have historically carried a strong stigma, such as mental illness. Family members may contribute to this potential problem by perpetuating this stigma and encouraging the patient not to seek treatment. Rural health care practitioners may experience challenges when caring for these patients, with the need to provide treatment but also to protect their patient from the difficulties of carrying this diagnosis within a small, tight-knit community. Other conditions especially common in rural populations, such as obesity, tobacco use, and heart disease, may become normalized and result in patients failing to appreciate the severity of their condition or the need for intervention. ^,

Other cultural attributes commonly encountered in the rural setting include a strong sense of self-reliance, emphasis on the importance of family, conservative values, propensity for personal religious or spiritual beliefs, and a sense of fatalism. ^, Although these traits may not interfere with the delivery of care, there is the potential to deter patients from seeking health care. In the health care setting, these cultural values may lead to behaviors such as reduced reliance on health care or a belief that a higher power wants them to be sick or will heal them without the use of modern medicine. Additionally, there may be the sense that they are fated to be ill or to die and that seeking medical care is therefore pointless.

Traditional gender norms may also influence rural patient views on the roles and responsibilities of health care providers. Rural patients may tend to see women as better suited for support roles (such as nursing and clerical positions) and to see men as better suited for traditional leadership roles (such as those of a physician or administrator), regardless of the individual’s actual education or experience. These views, in turn, may present challenges to provider-patient rapport and the general effectiveness of delivering care in rural settings.

Health care system factors

The United States is presently experiencing an overall shortage and maldistribution of health care workers. Current estimates predict a shortage of 46,900 to 125,900 physicians by 2032. In all, there are 2.3 million projected new jobs in health care by 2026, with an estimated overall shortage of 670,500 workers. This shortage is expected to be more pronounced in rural areas, which typically have difficulty attracting and retaining health care workers. In the rural setting, there tend to be fewer health care workers in occupations that require higher levels of education and training, such as physicians, PAs, and advanced practice nurses (APNs). Rural areas also tend to have lower numbers of workers per capita in oral health and behavioral health, regardless of the level of training.

Although approximately 20% of the U.S. population resides in rural areas, only 8.9% of physicians, 15.6% of PAs, and 15.7% of APNs practice in these locations. There are only 55 primary care physicians per 100,000 rural residents, compared with 79 primary care physicians per 100,000 urban residents. This disparity widens considerably when considering specialists, with there being approximately 30 specialists per 100,000 rural patients and 263 specialists per 100,000 urban patients. This discrepancy is believed to result from multiple factors, including the urban-centric focus of many health care education programs, which may provide inadequate preparation for working with rural populations. Moreover, students from rural backgrounds have fewer possibilities and limited affordability of educational opportunities. Furthermore, rural health care workers experience increased workloads and increased demands because of the poorer overall health of the rural population. Finally, health care workers have limited opportunities for advancement in rural settings. These factors will be discussed later in the chapter.

The limited number of providers and facilities in rural settings has multiple implications for rural health care. As discussed previously, many rural patients only live within practical traveling distance of one or two providers in a given field, thus limiting their options for care. In addition, providers in rural areas experience tremendous demand and have long wait times for open appointments. Open-access scheduling is a clinic management method that leaves about half the day open for patients to call in for same-day appointments on demand. Emerging research has shown that alternative scheduling methods, such as open-access scheduling, may be beneficial in the rural setting. ^, For most rural patients, however, getting timely appointments remains difficult and may lead to an increased reliance on local emergency departments or failure to seek care altogether.

Rural hospitals

Patients in rural communities may not have convenient access to hospitals, and geographic isolation may impact the availability of specialty services provided. Indeed, rural hospitals are often the center of medical care in the communities, providing primary care, pediatric medicine, internal medicine, OB/GYN services, mental health services, urgent care, emergency care, and surgical services. Out of necessity, these institutions often also provide skilled nursing facilities. Specialty medical services may be limited because of the often-low prevalence of specialist providers in rural areas, leaving rural communities with highly variable rates of medical specialty care.

The past decade has seen the closure of many rural hospitals because of unsustainable economics resulting, in part, from the uncompensated care of uninsured and underinsured patient populations. To improve the economics of health care delivery, increasing numbers of rural hospitals have merged with other institutions or have been acquired by larger health care systems. The mergers and acquisitions may result in the revitalization of struggling rural hospitals and perhaps allow for the expansion of services, but in some cases, closure is inevitable.

In response to the increasing numbers of hospital closures, the Centers for Medicare and Medicaid Services (CMS) created the designation “critical access hospital” (CAH) through the Balanced Budget Act of 1997. Hospitals meeting specific criteria may be awarded this designation and the ensuing benefits. According to the Rural Health Information Hub, eligible hospitals must meet the following conditions to obtain CAH designation:

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  Maintain no more than 25 acute care inpatient beds.

  
  
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  Be located more than 35 miles from another hospital (some exceptions may apply).

  
  
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  Maintain an annual average length of stay of 96 hours or less for acute care patients.

  
  
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  Provide 24-hour emergency care services 7 days per week.

Some of the benefits of CAH designation include:

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  Cost-based reimbursement from Medicare. In some states, CAH designees may also receive cost-based reimbursement from Medicaid.

  
  
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  Flexible staffing and services, to the extent permitted under state licensure laws.

  
  
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  Capital improvement costs included in allowable costs for determining Medicare reimbursement.

  
  
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  Access to educational resources, technical assistance, and/or grants.

Rural clinics

Health care in rural areas may also be provided through a variety of facilities carrying specific designations. Examples of these specific designations include rural health clinics (RHCs), federally qualified health centers (FQHCs, which may include community health centers and migrant clinics), frontier health care clinics, and frontier extended stay clinics (FESCs).

The RHC program is administered by the CMS. Eligible public, nonprofit, and for-profit facilities receiving this designation provide improved access to health care and receive increased reimbursement rates from Medicare and Medicaid. To qualify as an RHC, a clinic must be located in a rural, underserved area; be staffed at least 50% of the time with a PA, nurse practitioner (NP), or certified nurse-midwife; and provide team-based, outpatient, primary care services as well as basic lab services.

Facilities designated as FQHCs by the Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC) are located in areas where economic, geographic, or cultural barriers may limit access to affordable health care services. Operating funds for these facilities come from Medicare and Medicaid, as well as from patient fees and private insurance. Some, but not all, qualified FQHCs receive federal grants to provide services designed to improve the health of vulnerable and underserved populations. Benefits of a FQHC designation for health centers include enhanced reimbursement from Medicare and Medicaid in addition to assistance with the recruitment and retention of primary care providers through the National Health Service Corps (NHSC). These health centers may also receive federal loan guarantees for capital projects and improvements. Possible benefits to providers working within such facilities include access to malpractice insurance coverage and loan repayment for commitment to service. Patients receive care at these facilities regardless of their ability to pay and are typically charged for services on a sliding fee scale. All FQHC facilities provide underserved and vulnerable patients with access to primary care and ancillary services, which may include telemedicine, discounted pharmaceutical products, and free vaccines for uninsured and underinsured children. Populations served by FQHCs also may include migratory workers, homeless individuals and families, and qualified residents of public housing.

On the scale of rurality, frontier areas are the most sparsely populated, remote areas in the United States. Frontier area residents live farther than most U.S. residents from all necessities, such as schools, stores, hospitals, and other health care facilities. The NRHA considers several factors when defining a “frontier.” These factors include population density, functional association with other places, travel time and distance from a population center or service, availability of paved roads, and seasonal access to services. Health care facilities in frontier areas can qualify for several rural-specific health-related funding programs. In addition to the possibility of obtaining “frontier” designation, health care facilities in remote areas may also gain access to grants and enhanced reimbursement through HPSA and MUA designations. The ACA has specific provisions and protections for hospitals and clinicians in eligible frontier states. At least 50% of the counties in a state must have an average population density of six people or fewer per square mile for the state to be eligible. Presently the states of Alaska, Montana, Nevada, North Dakota, South Dakota, and Wyoming meet this designation.

Safe travel to medical centers within frontier areas may be impacted by adverse weather conditions and long distances. The designation of FESC was created for facilities to provide short-term monitoring of patients when a transfer to another facility is not medically indicated or when transfer to a hospital may be delayed because of travel conditions. A recently completed 3-year study of five clinics demonstrated that stays of 4 to 48 hours for short-term monitoring prevented the unnecessary use of emergency medical services and emergency room visits. Nevertheless, a bill that would have helped to provide Medicare and other reimbursement for FESCs failed to pass through Congress. Despite the absence of federal reimbursement, many frontier clinics have elected to continue providing these services for patients.

Reimbursement for rural health services

Many rural hospitals and clinics struggle to remain financially solvent. Over 470 rural hospitals have closed in the last 25 years. For many rural health care facilities, finances related to reimbursement remain a major barrier to the recruitment and retention of a consistent rural health care workforce. Moreover, rural health care centers provide care for a population that is older, poorer, and has higher rates of chronic disease than suburban and urban groups.

Health care facilities, and the providers that work in rural areas, must provide complex and comprehensive care in the face of well-established barriers; however, insurance reimbursement in rural areas is often lower than the reimbursement rates identified in suburban and urban clinical settings. This discrepancy may be explained in part by the fact that the rural health care workforce historically received lower wages than those working in suburban and urban areas. This would, in theory, result in lower operating costs for rural centers. Recent studies, however, have shown that these lower adjusted reimbursement payments may not be appropriate in light of local labor prices. There are current proposals to readdress the reimbursement rates of rural health care facilities, but the fate of these proposals has yet to be determined. Moreover, would the proposed changes enable rural health care facilities to become financially solvent?

Rural patients are more likely to be uninsured, less likely to access health care services, and more likely to struggle to pay for essential services and prescription medicines. Rural Americans who are insured are more likely to rely on government insurance programs, such as Medicare or Medicaid. Financial losses on the part of the health care facilities arise in the provision of care to indigent and underinsured patients. The historically low rates of reimbursement from Medicaid may contribute to financial difficulties for providers who accept Medicaid and likely contributes to the low rates of clinics and providers willing to see patients covered by Medicaid. This trend has persisted even with the temporary increase in primary care reimbursement rates created by the ACA. Many rural patients, however, do not qualify for federal insurance coverage. Unfortunately for these patients, commercial insurance options are often markedly limited. The typically suboptimal economies of rural settings may support fewer career options that offer medical, vision, and dental insurance as benefits of employment. Rural patients with commercial health insurance typically have higher insurance premiums and limited choices of insurers. With fewer providers and facilities in rural areas, there are fewer insurance networks. These factors may lead commercially insured rural patients to travel longer distances to access a facility or provider that will accept their insurance. These reimbursement considerations collectively serve to add further strain to rural health care systems and patients.

Factors in the rural medical provider shortage

The increasing median age of the rural U.S. population begets the need for quality, accessible, medical care in these areas; however, the number of clinicians practicing in rural areas has been declining for decades, and the Association of American Medical Colleges (AAMC) has projected that by 2032 there will be a cumulative shortage of between 47,000 and 122,000 doctors.

Why are the numbers of rural primary care physicians dwindling? In rural areas there are lower rates of individuals completing higher education, and there are fewer rural applicants to health care training programs ^, ( Fig. 52.4 ). Historically, few U.S. medical schools have focused on rural health care, and many physicians have chosen specialties outside of primary care, let alone rural care. An additional concern is the finite number of rural residencies available for graduating physicians; for example, one study found that only 7.5% of family medicine residencies are offered in rural locations. Financial constraints of rural facilities limit the number of residencies that are offered, and this in turn limits the number of physicians going into practice.

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