Exposing some important barriers to health care access in the rural USA

Highlights

• Barriers in access to health care significantly impact the health outcomes of rural patients.

• Improvements must be specifically tailored to the needs of individual rural populations.

• Partnerships with local communities are essential for effective healthcare reform.

• Even after the Affordable Care Act, healthcare inequalities remain.

• The needs of rural communities must be better represented at state and national levels.

Abstract

Objectives

To review research published before and after the passage of the Patient Protection and Affordable Care Act (2010) examining barriers in seeking or accessing health care in rural populations in the USA.

Study design

This literature review was based on a comprehensive search for all literature researching rural health care provision and access in the USA.

Methods

Pubmed, Proquest Allied Nursing and Health Literature, National Rural Health Association (NRHA) Resource Center and Google Scholar databases were searched using the Medical Subject Headings (MeSH) ‘Rural Health Services’ and ‘Rural Health.’ MeSH subtitle headings used were ‘USA,’ ‘utilization,’ ‘trends’ and ‘supply and distribution.’ Keywords added to the search parameters were ‘access,’ ‘rural’ and ‘health care.’ Searches in Google Scholar employed the phrases ‘health care disparities in the USA,’ inequalities in ‘health care in the USA,’ ‘health care in rural USA’ and ‘access to health care in rural USA.’ After eliminating non-relevant articles, 34 articles were included.

Results

Significant differences in health care access between rural and urban areas exist. Reluctance to seek health care in rural areas was based on cultural and financial constraints, often compounded by a scarcity of services, a lack of trained physicians, insufficient public transport, and poor availability of broadband internet services. Rural residents were found to have poorer health, with rural areas having difficulty in attracting and retaining physicians, and maintaining health services on a par with their urban counterparts.

Conclusions

Rural and urban health care disparities require an ongoing program of reform with the aim to improve the provision of services, promote recruitment, training and career development of rural health care professionals, increase comprehensive health insurance coverage and engage rural residents and healthcare providers in health promotion.

Introduction

Over 51 million Americans (one-sixth of the population of the US) live in rural areas.¹

The topic of health care access for these citizens continues to fuel debate and requires more attention, especially in the light of recent health care reform.² There is clear evidence for the existence of disparities in access to quality health care services in rural as compared to urban areas, with comparatively higher levels of chronic disease, poor health outcomes and poorer access to digital health care (ironically hailed, initially, as a possible bridge to the gaps in rural health care provision) as a result of poor rural broadband internet connectivity.3, 4, 5, 6, 7 As the Committee on Health Care for Underserved Women reports, rural women have poorer health than their urban counterparts, suffer higher rates of unintentional injury and greater mortality as a result of road traffic accidents, cardiovascular disease and suicide.⁸ These women are more likely to smoke cigarretes, suffer greater substance abuse, are more obese and have a higher rate of teenage pregnancy and cervical cancer (and a lower rate of cervical cancer screening).9, 10, 11

While the definition of a rural population is not precise, there is consensus that this should include the sparseness of population. Most recently, the US Census Bureau ‘adopted the urban cluster concept, for the first time defining relatively small, densely settled clusters of population using the same approach as was used to define larger urbanized areas of 50,000 or more residents, and no longer identified urban places located outside urbanized areas.’¹² The Rural Development Act of 1972 defines ‘rural’ or ‘rural area’ as an area of no more than 10,000 residents. In either case, rural communities have clearly been demonstrated to have ‘poorly developed and fragile economic infrastructures, [and] substantial physical barriers to health care.’¹³ In 2010, despite 17% of the United States' population living in rural areas, only 12% of total hospitalizations, 11% of days of care, and 6% of inpatient procedures were provided in rural hospitals.¹⁴ The Patient Protection and Affordable Care Act, was implemented in 2010 with the aim of ‘quality, affordable health care for all Americans.’

All the authors of this paper are Gobal Health practitioners with a particular interest in health disparities and universal health coverage. In this paper we explore the disparities between urban and rural health care provision, citing examples of cultural differences among patients and inequalities in the level of provision of services. The goals of the Patient Protection and Affordable Care Act will never be accomplished as long as these inequalities in provision and utilization of universal health services exist.2, 15

According to the most recent data from the Health and Human Resources Administration of the US Department of Health and Human Services, rural areas of the United States demonstrate a visible and disproportionate lack of services in medically underserved areas, including a paucity of primary care physicians, i.e. family doctors, pediatricians, and internists, as shown in Fig. 1. Rural residents have different health-seeking behaviors compared to their urban counterparts; and this, coupled with different approaches to patient care among physicians, exacerbates the disparity in expectations and delivery of care.¹⁶ Although there was great hope that information technology solutions would help to bridge communication gaps and extend the availability of telemedicine, resulting improvements in utilization, in service delivery and in patient outcome have not been consistent; instead, evidence of a digital divide across the USA has emerged.¹⁷ Disparities in health care are exacerbated by a commensurate gap in both access to and availability of technology, especially, the Internet. As Tom Wheeler, FCC chairman, observes, ‘Americans living in urban areas are three times more likely to have access to Next Generation broadband than Americans in rural areas.’18, 19

The demand for better access to health care in rural America is, therefore, increasingly clear. The National Rural Health care Association (NRHA) states the health needs in the following terms:

The obstacles faced by healthcare providers and patients in rural areas are vastly different than those in urban areas. Rural Americans face a unique combination of factors that create disparities in health care not found in urban areas. Economic factors, cultural and social differences, educational shortcomings, lack of recognition by legislators and the sheer isolation of living in remote rural areas all conspire to impede rural Americans in their struggle to lead a normal, healthy life.²⁰

Rural residents have the same right to quality health care as their urban counterparts. According to the World Health Organization, ‘[U]niversal access to skilled, motivated and supported health workers, especially in remote and rural communities, is a necessary condition for realizing the human right to health, a matter of social justice.’²¹ This problem is pervasive, affecting both specialist and primary care, and services delivered directly by physicians, nurses and pharmacists alike. As we show in this paper, the literature demonstrates that disparities affect all rural patient groups, irrespective of age, race, gender or sexual orientation; vulnerable populations, however, remain the worst affected. Thus, a reexamination of the evidence for barriers in seeking health care and in access to health care for rural populations across the United States of America is both timely and important. We describe these barriers, emphasizing the differences in health-seeking behaviors between rural and urban populations; identifying critical areas for improvement and adding our voice to the call for urgent action to address inequalities in rural health.