We’re talking about the particular challenges faced by rural communities when it comes to accessing health care.
What counts as “rural” can vary greatly depending on the context, but the general, broad, definition is basically anything left over after “urban” is defined.
For our purposes let’s just assume we’ll use the census bureau’s definition of “open country and settlement with fewer than 2,000 housing units and 5,000 people.”
While many such communities used to be larger, formerly thriving regions of industry boom (such as railroad, mining, or agriculture epicenters), shifting priorities and business practices have left many of these areas behind.
Though the difference in income inequality between rural and urban communities has been declining since the 1960s, many rural areas have poverty rates nearly 30% higher than their metropolitan counterparts.
And many of the nation’s poorest areas, where one in five people live below the poverty line, are clustered right here in the Southeast.
Rural communities often struggle with high rates of mental health disorders, obesity, heart disease, and dementia. And many lack the resources to diagnose and treat these conditions.
It seems obvious, but people who live far from cities also often live far from health centers and are more likely to have to travel long distances to access services, particularly subspecialist services.
Unlike in urban areas that have varying levels of public transportation, people in rural communities must provide their own, which can be a significant barrier to care.
Rural dwellers, on average, travel twice as far to reach medical and dental services, and they are more likely to cite the cost of gas as a barrier to care.
And that’s assuming there’s even care to access. Over 66% of the areas deemed to have a shortage of health care workers are found in rural locations.
According to the National Rural Health Association, urban areas have around 263 specialists per 100,000 population. Rural areas have about 30.
People in rural areas are also more likely to be uninsured than people in urban areas, which can put a financial burden on hospitals and health care centers when services can’t be reimbursed.
The financial strain and lack of staffing has resulted in 136 hospitals in rural communities closing between 2010 and 2021.
Safety net programs to insure low-income families and individuals, like Medicaid and the Children’s Health Insurance Program, are far more utilized in rural areas than they are in metropolitan areas, even though, overall, they cover one-fourth of all residents and over half of all children in the country.
Every looming threat to the funding of safety net programs means rural communities face increasing health care costs.
People within such communities are more likely to report issues paying for health care or delaying care all together as a result of cost.
It seems like a good solution to a lack of access to care would be an increase in the use of telehealth, but 53% of rural residents don’t have internet with the proper bandwidth.
These limitations add up:
Early death from the top five leading causes of death is more common in rural areas than urban areas.
Rural residents are less likely to be non-smokers, maintain a normal body weight, or meet physical activity goals.
They’re also 9% more likely to report a disability and 24% more likely to report three or more disabilities.
Fifty percent of vehicle-crash-related fatalities happen in rural areas, despite less than a third of total miles being driven there.
It’s not only health care infrastructure that suffers when the industries that once supported rural communities dry up: It also impacts people’s daily lives.
Farm consolidation has been increasing over the last several decades.
The days of the family farm are gone as mid-sized farm plots get consolidated into large-scale farming operations.
Between 1987 and 2017, the percentage of cropland operated by large scale farms has increased from 15% to 41%.
And these large, single crop operations mean that people living in agricultural areas can no longer feed themselves with what they grow.
Whereas farms of yore might have had access to fresh vegetables, chickens, or cows, a farm that produces only wheat, for example, can’t be used to sustain a family.
Instead, they need to get their food from grocery stores, which can be a problem in rural areas that aren’t big enough to support a fully stocked store.
So, people must do their shopping from convenience stores or gas stations, which tend to lack nutritious options like fruits and vegetables.
There are also environmental exposures that can impact health in rural areas.
For the agricultural industry this includes things like exposure to high levels of farm chemicals like pesticides, fuel, and fertilizers. It could also include increased exposure to dust which can contain mold or bacteria.
Dairy farm workers are particularly at risk for bird flu infections right now.
In areas where farming has been replaced by factories, local communities can be exposed to high levels of chemical runoff, contaminated water sources, and exposure to harmful pollution.
In Louisiana, the 85-mile length of the Mississippi River populated by various factories is known as “cancer alley” because residents are 95% more likely to develop cancers as a result of exposure to industrial waste.
When it comes to the legacy of coal mining communities, there’s the issue of coal workers’ pneumoconiosis, or “black lung”—a disease that occurs when repeated inhalation of dust causes scarring in the lungs, making it difficult to breathe.
While you might think black lung is a problem of the past, a 2018 study found that 1 in 5 long term coal miners in central Appalachia are afflicted with the disease, and prevalence has been increasing for the last 25 years.
The opioid epidemic has impacted rural areas, including those known for mining, particularly hard.
Those who work in the mining industry already have high rates of substance use, be it alcohol or illicit drugs. Mining is extremely stressful work, and it can be very physically demanding, leading to injury.
Couple that with a lack of access to health care, and the risk for self-medication or prescription misuse is high.
One in 100 workers in the mining industry report having an opioid use disorder, which is higher than the national average. And those who work in the extraction industry (which includes mining, quarrying, and oil and gas) have some of the highest opioid overdose rates of any occupation.
Opioid use in rural areas in general is higher than in urban areas, and its impact is being felt in the pregnant portion of the population as well.
Babies born in rural areas have disproportionately higher rates of neonatal opioid withdrawal syndrome, indicating maternal opioid use is also higher.
Injecting or snorting opioids can put anyone at a higher risk for infection with things like HIV or hepatitis C, but the risk is particularly concerning for pregnant people who can pass the infections on to the infants.
One study found that maternal rates of hepatitis C in rural areas were nearly 4 times higher than in urban areas.
Getting help for substance use disorders is no easy feat. It’s estimated 80% of pregnant people in rural areas face barriers to accessing treatment.
Many people do not receive behavioral health counseling, which is a recommended part of comprehensive treatment.
The lack of mental health care isn’t exclusive to the treatment of substance use disorders.
Though the prevalence of mental health issues is similar between rural and urban populations, people in rural communities are less likely to receive mental health treatment or treatment with an appropriate level of training.
If rural communities face barriers to accessing general care, you can bet they face barriers to accessing mental health care.
65% of rural communities don’t have a psychiatrist and 47% of rural communities lack a psychologist.
Because rural communities have such a small population, word can spread quickly, and stigma about mental health needs or a lack of privacy when accessing care can be additional barriers.
Rates of suicide are twice as high in rural areas compared to metropolitan, and people under 34 have suicide rates almost four times higher than people over 34.
Emotional stress causes strain on the body, increasing inflammation and putting people at greater risk for health complications.
Those who live in rural areas are at a 19% higher risk of developing heart disease than those in urban areas.
And women in rural areas specifically face higher rates of cardiovascular disease compared to their urban counterparts.
There could be many reasons for this disparity. Rural women might have fewer educational and career opportunities and have the added burdens of low wages and childcare.
Rural women also report higher rates of intimate partner violence while living further from resources to address it.
Rural areas also have older populations with higher rates of dementia and Alzheimer’s, which contributes significantly to mortality.
And because the elderly face all the same challenges in accessing care, the question becomes: How do we provide home health services to such a scattered population?
A larger portion of rural communities than urban communities aren’t served by a home health agency.
And many people covered by Medicaid either don’t know to ask for services to support them with aging in their own homes or don’t want to utilize or navigate the complex system of insurance.
As a result, many people in rural areas rely on what’s known as the “grey market” of care—friends, neighbors, or community members who are paid under the table to provide home assistance for the elderly.
It’s estimated that people with dementia in rural communities are five times more likely to rely on these informal networks for care.
And the market is only likely to continue to grow. The number of people with Alzheimer’s is projected to nearly double from 7 million today to 13 million by 2050.
