Full Citation

Title: Improving Health among Rural Residents in the US

Citation Type: Miscellaneous

Publication Year: 2021

ISBN:

ISSN: 15383598

DOI: 10.1001/jama.2020.26372

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Abstract: Nearly 20% of US residents, an estimated 65 million people, live in small towns and sparsely populated areas that the Census Bureau designates as rural; this proportion of rural residents has increased slightly since 2016. Whilethetiredadagethatruralresidentsare"older,poorer, and sicker" has been true for decades and remains so, it masks the wide range of rural US people and places. Rural residents are diverse along numerous dimensions: sex, age, family structure, sexual orientation, socioeconomic status, and occupation. One in 5 rural residents is Black, Indigenous, or a Person of Color, and that proportion is increasing. Improving rural health requires policy solutions to work for the US/Mexico border region, frontier Alaska,theGreatPlains,thesouthernBlackBelt,themoun-tainous Appalachian range, and many other places. The COVID-19 pandemic has highlighted deep and enduring inadequacies of health care services and policy decisions in rural communities. As of December 5, 2020, the COVID-19-related death rate was 7.8 per 100 000 people in nonmetropolitan counties, compared with 3.5 per 100 000 people in metropolitan counties. 1 Some of the highest COVID-19 infection and death rates in the US are among rural residents. COVID-19 is not creating these inequities but has revealed the depths of long-standing failures to ensure equitable opportunities for health, regardless of geography , socioeconomic status, or demographics. As the US emerges from the COVID-19 pandemic, there is opportunity for broad, bold, bipartisan policies to improvethelivesofruralresidents.Manyruralhealthpolicy efforts focus on bolstering the health care delivery system , and for good reason. The number of rural hospitals is declining; 135 rural hospitals (6.5% of a total of 2083) have closed since 2010, 19 in 2020 alone. 2 The number of ruralhospitalclosureshasincreasednearlyeveryyearsince 2010,and453remainingruralhospitalsareconsideredvul-nerable to closure, as determined by financial and operational data. 3 Rural hospitals in states that did not expand Medicaid under the Affordable Care Act are at particular risk, with 52% of rural hospitals in those states operating with a negative profit margin (vs 44% in Medicaid expansion states). 3 Currently, metropolitan and nonmetropoli-tan counties have similar numbers of hospital beds per capita(approximately 24/100 000), but hospitals in nonmetropolitan counties have less access to specialty services, including fewer intensive care units and declining access to obstetric services. 4,5 Additionally, work-forceshortagesareapersistentchallenge.AsofSeptember 30, 2020, 62% of the 7203 Medical Health Professional Shortage Areas across the US were in rural communities. 6 In short, rural residents do not have adequate access to health care and have worse health status. Rural residents experience systematic disadvantages because of structural urbanism. 7 That is, most policies are based on the needs of the urban majority, rather than the distinct needs of rural residents. Sustainable policy must be grounded in rural reality, which involve the unique assets and challenges in rural places, well-known to rural people. Evidence indicates that policies to improve rural healthmustbeproportionatelyfocusedonsocialandstruc-tural factors outside of the hospital or clinic. For example, a recent analysis found that geographic differences in infant mortality were not explained by individual maternal behaviorsorhealthsystemsfactorsbutratherbysocioeco-nomic disadvantage and poor community health. 8 Additionally , suicide rates in rural areas are 25% higher than those in urban areas (with rates of 17.6 in large metropolitan areas vs 22.1 in rural counties, per 100 000), and highest risks occur in rural counties with more gun shops, lower social capital, and lower rates of health insurance. 9 These factorsareamenabletopolicyintervention. 9 TheBidenad-ministrationandCongressshouldprioritize policies that reflect the needs of rural residents to halt the pernicious effects of structural urbanism. Two major policy strategies-one administrative and one legislative-may represent crucial initial steps toward improving rural health: The new presidential administration should seek rural representation on regulations and in policy implementation, and Congress should pursue evidence based policy options to improve rural community infrastructure, starting with broadband internet. To improve rural health, the executive branch must ensure rural representation in the establishment of regulations and implementation of programs and policies. Achieving rural representation means that people who live and work in rural areas should be included in key decision making roles and on advisory panels and bodies. This could be implemented by requiring reporting on the demographics of decision-makers, including whether they are residents of rural areas. The Biden administration has embraced a focus on sex and racial/ethnic diversity among its leadership in assembling a Cabinet and is well-positioned to adopt a clear stance on rural representation. Rather than creating post hoc rural-focused fixes (eg, the Critical Access Hospital Program) to reme-diate problems created by urban-focused decisions on health care access, financing, and quality, rural perspectives should be included in all policy efforts from the start. The presence of rural representation is essential for One in 5 rural residents is Black, Indigenous, or a Person of Color, and that proportion is increasing.

Url: www.shepscenter.unc.edu/programs-projects/

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Authors: Kozhimannil, Katy B.; Henning-Smith, Carrie

Publisher: American Medical Association

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