Introduction
Heart disease is the leading cause of death of people in the United States. Rural American communities are especially susceptible and more likely to die from heart disease or related complications than their urban counterparts. This is the reality of over 46 million rural Americans for whom the nearest hospital might be hours away, the local clinic struggles to keep its doors open, and the impact of high-level policy decisions unfolds daily [1]. The interplay of factors such as socioeconomic status and access to services such as medicare, medicaid, and health insurance and concurrent disparities in availability of the aforementioned often leaves rural populations at a significant disadvantage. As healthcare continues to evolve, the decisions made in distant legislatures and corporate boardrooms ripple through these communities, manifesting in ways that can mean life or death. Understanding these connections is not just critical for improving health outcomes in rural areas but essential for ensuring equitable healthcare across the nation. This paper explores how socioeconomic factors, health policies, and systems impact rural health stakeholders.
Rural versus Urban Health Landscape
Healthcare disparities between rural and urban populations are stark and multifaceted. In rural areas, lower socioeconomic status and lower insurance rates are prevalent, serving as significant impacts on healthcare access. This is a significant source of anxiety for stakeholders in rural communities, as evidenced by Margot Barnhardt’s testimony [2]: “I think our healthcare is in a terrible state for this wealthy country…so many people can’t afford health insurance, and they aren’t covered.” An issue brief by the Kaiser Commission on Medicaid and the Uninsured Approximately further expands on Barnhardt’s testimony by providing an analytical characterization of the issues faced by rural health stakeholders. Approximately one-quarter of the non-elderly population in rural areas live below the federal poverty level, a reality that positions them at a disadvantage compared to their urban counterparts [3]. This economic disparity restricts access to health care as financial constraints make health insurance unaffordable for many. Moreover, rural residents are less likely to have access to employer-sponsored insurance (ESI), which is a primary source of health coverage for many Americans. The lower incidence of ESI is compounded by the fact that rural workers often engage in “Low ESI industries,” characterized by lower wages and fewer benefits. This situation sets a foundational challenge in rural healthcare access, where economic factors limit both the availability and affordability of necessary services. However, some systems, such as the Affordable Care Act (ACA) and Medicaid expansion, have been enforced to remedy these challenges, along with the discontent of community members such as Margot Barnhardt. However, even with such policy measures, uninsurance rates have continued to climb in the past decade as the disparity between rural and urban communities expands [4]. Rural health research outlined in this paper will endeavor to explore the reasons for this disconnect.
The Impact of Medicaid Expansion
The implementation of the ACA aimed to mitigate some of these challenges by expanding Medicaid and providing premium tax credits to lower-income families, thereby broadening access to affordable healthcare. However, as explored in a findings brief by the NC Rural Health Research Program, the optional nature of Medicaid expansion across states has created a patchwork of coverage, where nearly two-thirds of uninsured rural residents live in states that have not adopted the expansion [5]. This lack of uniformity has resulted in a significant “coverage gap,” particularly affecting rural areas, wherein people are uninsured or underinsured. The decision against Medicaid expansion in states like Georgia and Maine has left a sizable segment of the rural population in a precarious position, caught in the coverage gap—earning too much to qualify for Medicaid yet too little to afford private insurance. This scenario has disproportionately affected rural areas, where incomes tend to be lower, and employer-sponsored health insurance is less common. Lori Hinga’s oral history vividly illustrates these points [6]. Working with the uninsured for eight years, Hinga highlighted the dichotomy within the ACA: while it intends to provide healthcare for all, the actual affordability of care remains elusive for many. Her narrative underscores the plight of rural residents who, despite the availability of subsidies, still find healthcare premiums prohibitively expensive and are often forced to choose between basic necessities and maintaining health coverage. “People either gotta eat or pay a healthcare premium, and they’re gonna eat,” she notes, capturing the desperate choices some rural residents face. Though a nationwide expansion of Medicaid would shorten the gap between rural and urban healthcare stakeholders due to the allowance of patchwork expansion, inherent disparities are allowed to persist, exacerbating issues of affordability and access to insured healthcare.
Community Health and Provider Outlooks
Another fundamental feature of rural healthcare lies in the reliance of rural stakeholders on community-based health care that accept uninsured or underinsured patients, primarily operating under reimbursements under medicaid policy. Because low socioeconomic status and uninsured populations are disproportionately represented in regions served by these community centers, they are faced with a higher burden. Barbara Brayboy highlights her experience visiting a struggling community health center in her rural community, describing it as far devolved from how tight-knit community providers used to operate in her childhood [7]. She says: “Growing up, when my mom went to the doctor, they sat down and told us…here’s what’s going on, here’s how we’re gonna fix you…now they are in a rush…they look at the computer and type and don’t talk to you.” In Brystana Kaufman’s policy brief, she details how the expansion of Medicaid should theoretically offer a lifeline for rural healthcare facilities that traditionally face high rates of uncompensated care [8]. Medicaid expansions aimed to lower the number of uninsured individuals by providing Medicaid coverage to adults earning up to 138% of the federal poverty level (FPL). In expansion states, rural community health centers saw an increasing number of insured patients, which in turn improved the financial viability of these centers. Health centers in Medicaid expansion states have reported not only a surge in insured patients but also an enhancement in their capacity to provide comprehensive services, including oral and behavioral health care [9]. This improvement is directly linked to the influx of federal funding and higher Medicaid reimbursements that followed the ACA’s implementation.
However, the benefits brought by the ACA and expanded Medicaid have not uniformly reached all rural areas, particularly those in states that chose not to expand Medicaid. In these regions, community health centers face significant challenges due to a higher proportion of uninsured patients and inadequate funding streams. These centers often struggle with financial instability due to uncompensated care while also grappling with the high deductibles and copays that keep healthcare out of reach for many insured patients. Additionally, as a result of centers struggling to stay afloat, they lack the infrastructure to educate rural health stakeholders on their options for healthcare. Lori Hinga’s oral history underscores this reality, revealing the struggles of community health centers and the convoluted processes for rural stakeholders to receive care. As someone who worked at a community health center, Hinga details, “We’ve got so many requirements…meaningful use, joint commission, CMS, HRSA… in order to meet those requirements you have to train and educate people including providers.” [10] When community health centers must serve such a heavy burden as a result of being underfunded in rural areas, they are not able to provide outreach efforts and careful care to communities being disproportionately impacted by low socioeconomic status, physical and sociocultural barriers to healthcare. Hinga’s testimony encapsulates how measures are in place to provide care to rural communities and ensure support for community health systems but are disproportionately disbursed due to patchwork policy. The disconnect between policy intentions and real-world effects in these areas illuminates the critical need for comprehensive policy solutions that consider the unique challenges of rural healthcare systems. These solutions should aim to reduce disparities by ensuring more consistent coverage across states and improving funding mechanisms for rural health centers.
Implications
As policymakers look forward, it is crucial to consider divergent outcomes in Medicaid expansion versus non-expansion states and to ensure consideration of characteristic physical and socio cultural features of rural communities to ensure proper education and reception of policy implementation. Overwhelming evidence suggests that expanding Medicaid not only bridges the gap in healthcare coverage but also supports rural healthcare systems financially and operationally, thereby addressing both access and sustainability. To mitigate the systemic barriers inherent in rural healthcare, prioritization of expansion of Medicaid to populations that need it most is necessary. Furthermore, the experiences and voices from the ground, such as those documented in the oral histories of Hinga, Barnhardt, and Brayboy, should inform ongoing debates and adjustments to healthcare policies to better meet the unique challenges faced by rural communities.
References
“About Rural Health.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 28 Nov. 2023, www.cdc.gov/ruralhealth/about.html.
Barnhardt, Margot. “Y-0007 Interview with Margot Barnhardt.” By Chadwick Dunefsky, 2018-06-26. Southern Oral History Program, https://dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28381/rec/5 Accessed 24 April 2024.
Vann Newkirk and Anthony Damico “The Affordable Care Act and Insurance Coverage in Rural Areas.” KFF, 30 May 2014, www.kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in-rural-areas/.
Long, Alexander S et al. “Socioeconomic variables explain rural disparities in US mortality rates: Implications for rural health research and policy.” SSM – population health vol. 6 72-74. 31 Aug. 2018, doi:10.1016/j.ssmph.2018.08.009
Kaufman, Brystana. “Findings Brief – Sheps Center.” The Cecil G. Sheps Center for Health Services Reserach , www.shepscenter.unc.edu/wp-content/uploads/2014/07/MedicaidCoverageJuly2014.pdf. Accessed 27 Apr. 2024.
Hinga, Lori. “Y-0032 Interview with Lori Hinga.” By Maddy Kameny, 2018-06-26. Southern Oral History Program, https://dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/27965/rec/1 Accessed 24 April 2024.
Brayboy, Barbara “Y-0011 Interview with Barbara Brayboy” By Darius Scott, 2018-07-11. Southern Oral History Program, https://dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/27918/rec/6 Accessed 24 April 2024.
Rosenbaum, Sara. “Community Health Centers: Recent Growth and the Role Of …” The Henry J. Kaiser Family Foundation, files.kff.org/attachment/Issue-Brief-Community-Health-Centers-Recent-Growth-and-the-Role-of-the-ACA. Accessed 27 Apr. 2024.