By Olivia Cassidy
Traveling an hour away on under serviced roads is not an ideal trip to the doctor, but it is the disappointing reality for many rural North Carolinians desperately attempting to access healthcare. According to the US Census Bureau, North Carolina has the second-largest rural population in the country and 80 of the state’s 100 counties are classified as rural (NCDOT). One of the biggest challenges facing rural residents is finding accessible and affordable transportation to seek providers. Without transportation, rural individuals are unable to travel to regular primary care appointments or life-saving treatments. This problem has become compounded in recent years by limited rural health centers, extreme distances to care, and a lack of investment in public transportation systems. Addressing the physical barriers of transportation issues is the first step necessary to improving rural residents’ access to quality healthcare.
In rural areas of the state, there are fewer physicians, hospitals, and specialists per capita than in urban or suburban areas. This problem has been exacerbated in North Carolina where “there are 66 counties, or parts thereof, that are considered primary care shortage areas, which means that there are too few primary care physicians to meet population needs” (NCIOM). This disparity in the number of providers is troublesome because research has shown that having fewer physicians leads to worse health outcomes. Regular visits to primary care providers are necessary interventions involved in promoting health. When these physical limitations exist, however, regular visits become unavailable causing a greater percentage of rural residents to be admitted to hospitals with preventable diseases and have a higher mortality rate (Johnston). Recent data “analyses showed that access-to-care factors explained 89 percent of the difference in the probability of preventable hospitalizations” (Johnston). Furthermore, it is not just primary care providers that impact outcomes; limited numbers of specialists play a major role in determinants of health. Contact with specialists is “associated with substantially lower preventable hospitalizations and mortality rates among all beneficiaries” (Johnston). Norma Armwood, a Wayne County resident, experienced the impact of the lack of specialty treatment during her mother’s diagnosis of ovarian cancer. Her mother was unable to see a provider nearby and delayed her diagnosis. After the diagnosis, Norma recalls, “We had to travel two hours for her to go and seek treatment, even for chemo. Five days a week for five weeks, we had to drive two hours a day for her to get the treatment that she needed. So that was one of the disadvantages” [0:38:42-0:39:00]. Norma’s experience with having to travel far distances to get specialty treatment is a sentiment familiar with many rural families due to limited providers and physical barriers.
Not only are there fewer physicians in rural areas, but as seen in Armwood’s experience, they are also located farther away which leads to more challenges accessing them. In the US, on average, rural residents live twice as far from hospitals as urban or suburban residents (Lam, Onyi, et al.). Farther distances equate to longer driving times and more money spent on gas. The trips also take more time out of individuals’ already busy schedules affecting their ability to go to work or to school. The snowballing of these factors are negative deterrents for rural individuals because they increase the cost and stress of visits to a physician. Individuals, in turn, become less likely to frequently visit the physician, a phenomenon known as distance decay. When the distance between two locations increases, the interaction between them decreases (Mattson). While this effect was originally studied in consumer behavior, its application to health care has found the same trend (Mattson). Rural individuals find it harder to travel far distances for non-emergent care and often remain at home until conditions gravely worsen.
Besides the mileage patients must travel, another negative factor causing many to stay home is the lack of public transportation in rural areas. According to the NC Department of Transportation, “Long distances and sparser populations can make rural transit costly and difficult to provide, leading to limited service in some areas” (NCDOT). This leaves rural populations neglected from government funding because of the expense of implementing better services. Residents have no access to public buses, car services, or shuttles. Former OB-GYN in Warren County, George Cosmos witnessed the toll of this on his patients’ lives. Cosmos says, “A big challenge that I saw, the fact that a lot of people could not come to the doctor because they did not have transportation and there is no public transportation” (0:52:00-10). In his interview, he further discusses how patients would wait for neighbors who had transportation to come home and then go to the emergency room to seek care. Besides public transportation, there are very few private transportation options either. Stefanie Atkinson, a nurse at CommWell Health in Dunn, notes that “Well, the fact that we’re rural and that there—if you don’t have a car, there’s no Uber or Lyft or cabs, really. I’m not 100 percent certain, but I don’t think there are any cab services left in Clinton, and when I was growing up, there was only one or two when I was younger, and now I don’t think anybody does that anymore” (0:26:09-36). Even if residents are able to get an Uber to an appointment there is no guarantee there will be another driver in the area who is able to get them back. They are left with two options: remain at home with unresolved illnesses or be stranded at the physician’s office. Structural change must be implemented to mitigate these two extremes.
Access to healthcare depends on a patient’s ability to travel to a health facility. With limited numbers of facilities, the costs associated with lengthy drives, and insufficient public transportation the health of rural communities falls behind its urban or suburban counterparts. North Carolina Health infrastructure should focus on increasing the number of rural health centers, providing funding for transportation services, and modernizing transportation services covered through insurance. The oral histories included in this research help better understand the lived experience of those suffering and unable to receive care. These narratives are impactful because North Carolina has one of the largest rural populations in the country and the health of rural citizens is an impactful contributor to overall population health. With rural health statistics lagging, it is imperative that health providers and legislators address these issues while further working to ensure health equity across the state.
Armwood, Norma. Interview with Maddy Katz. 15 July 2019 (Y-0073). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Atkinson, Stefanie. Interview with Maddy Kameny. 25 June 2018 (Y-003). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Cosmos, George. Interview with Darius Scott. 26 June 2018 (Y-0015). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Johnston, Kenton J., Hefei Wen, and Karen E. J. Maddox. “Lack of Access to Specialists Associated with Mortality and Preventable Hospitalizations of Rural Medicare Beneficiaries.” Health Affairs, vol. 38, no. 12, 2019, pp. 1993-2002. https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00838.
Lam, Onyi, et al. “How Far Americans Live from the Closest Hospital Differs by Community Type.” Pew Research Center, Pew Research Center, 27 July 2020, www.pewresearch.org/fact-tank/2018/12/12/how-far-americans-live-from-the-closest-hospital-differs-by-community-type/.
Mattson, Jeremy. “Transportation, Distance, and Health Care Utilization for Older Adults in Rural and Small Urban Areas.” Transportation Research Record, vol. 2265, no. 1, Jan. 2011, pp. 192–199, doi:10.3141/2265-22. https://journals.sagepub.com/doi/10.3141/2265-22
NC DOT. “Rural Transportation Issues in North Carolina.” NC First Commission, Issue brief, Edition 4, Nov. 2019. https://www.ncdot.gov/about-us/how-we-operate/finance-budget/nc-first/Documents/nc-first-brief-edition-4.pdf
North Carolina Institute of Medicine. “North Carolina Rural Health Action Plan: A Report of the NCIOM Task Force on Rural Health.” Morrisville, NC: North Carolina Institute of Medicine; 2014. https://nciom.org/wp-content/uploads/2017/07/RuralHealthActionPlan_report_FINAL.pdf