“Should I call a midwife or try and make it to the hospital?” “Can I afford to make it to my ultrasound appointment?” “Should I buy my prenatals or groceries this week?” These were among the many questions bouncing around the head of the mother of Martha Mac Harris as she was pregnant with her. Far greater concerns lie between the many thoughts about baby names, crib sizes, and paint colors.
In rural communities, accessing essential healthcare remains an uphill battle. The reality is filled with harsh battles between medical bills and electric bills. In rural communities across the United States, health disparities are often exacerbated by the limited access to medical facilities that provide preventative and necessary care. Untangling this intricate web, however, requires both the perspectives of experts and the perspectives of rural Americans who can provide insight into the nuances of accessing care. Low financial resources and geographical barriers have proven to be two of the largest issues concerning access. By examining these disparities, we can gain knowledge to target intervention and increase healthcare access to all citizens, especially those like Martha’s mom.
What research often misses are the personal narratives of each statistic they record. After sifting through the Southern Oral History archives here at UNC Chapel Hill, one interview struck a chord. Sue Villnave, a healthcare worker from North Carolina, shared her experience regarding her time working in the industry. She says, “There’s a lot of low income, and I think there’s a lot of individuals that just don’t get the healthcare that they need because they can’t afford it, and they fall in that”.[1] This sentiment certainly rings true. In a poll conducted by Harvard University, 40% of rural Americans struggle with routine medical bills, food, and housing, while 49% said they could not afford to pay an unexpected $1000 expense of any type.[2] With financial insecurity comes a cascade of challenges that widen disparities and hinder access to essential healthcare services. This insecurity often forces individuals to make difficult decisions between seeking medical treatment and meeting other basic needs such as food and housing. Americans are most likely to skip needed care because of costs, compared to comparably developed nations like Australia, Switzerland, New Zealand, Canada, Germany, France, Sweden, Norway, and the United Kingdom.[3] This is likely because of America’s enormously high costs of healthcare. Ten percent of rural Americans are uninsured or underinsured.[4] Without insurance, this makes a simple checkup alone between $300 and $600, not including any other tests your doctor may run.[5]
Accessibility also manifests itself in plain geography. As found in the study, patients in rural areas tend to travel two to three times farther to see medical and surgical specialists than those in urban areas. [6]This is consistent in the interview of Martha Mac-Harris as she reflects on her mother’s experience with childbirth. “It was called Charlotte Memorial Hospital,” she says, “ and that’s where people had to go to have their babies. If you lived in Montgomery County, that was pretty much your only choice unless you wanted to have a home birth with a midwife or find a room in the Health Department building, a spare bed.”[7] When asked about the distance to CMC Hospital she says, “It was an hour at the best. With not bad traffic, it was an hour minimum to get there from Troy.” With this low access to care, it is understandable why pregnancy-related mortality rates are highest in rural populations. These distances are partially from the isolated nature of rural communities, but also because of the lack of resources rural hospitals often have, leading to understaffing, inadequate supplies, and even shutdowns.
Sure, financial and geographical barriers strain rural accessibility to healthcare but to what extent? America has been seeing a wider gap in the mortality rates between urban and rural individuals. Between 1999 and 2019, death rates in urban areas declined from 865.1 per 100,000 to 634.4, whereas rates in rural areas initially declined from 1999 (923.8) through 2019 (837.6) and then stabilized through 2019 (834).[8] This means that mortality rates are declining for urban Americans, much faster than they are for rural Americans.
Heart disease and cancer are the leading causes of death in the United States. These causes, however, disproportionately affect rural Americans. This is most likely because of preventative care and early diagnosis. Heart disease and cancer can certainly be preventable or at least managed when caught in their early stages. Because rural Americans are less likely to access yearly checkups and doctors in general when they are not feeling well, they aren’t afforded the same opportunities urban Americans are when it comes to access.
So what can we do to support people like Martha and Sue? Well first, we start. We start thinking about perspectives beyond our own. We continue to read, research, and listen to these perspectives. After consulting these sources, there seems to be a lot of hope in the power of Telehealth. As we further ourselves into this technological age, electronics are becoming more popular and accessible among households. Through the world’s joint experience with Covid-19, we’ve become more familiar and more confident in technology. Maybe with technology, Martha’s mother wouldn’t have to figure out transportation to every appointment but instead could attend checkups via telehealth and seek in-person care when necessary. While this isn’t as ideal as going in person, it is certainly better than no care at all.
On top of this, we can consider the expansion of Medicaid. Many people, especially in rural communities, fall right below the poverty line. This makes them too wealthy for Medicaid, but unfortunate enough to not have enough money for insurance, or to be underinsured. The expansion of Medicaid could provide Sue’s friends and clients with enough to afford both groceries and medical bills, detect illnesses early, and equip them with the medical knowledge necessary for managing their conditions.
As we continue to navigate the accessibility to rural healthcare we must remember that behind it all are narratives of loss, pain, and resilience. Within each of these stories lies a solution and it is our job to keep searching for it. Hopefully, this solution creates an impact where healthcare is no longer a luxury but rather a right.
References
[1] Villnave, Sue, “Y-0134”, Southern Oral History Program, 23 June 2018.
[2] Harvard T. H. Chan School of Public Health. “Poll: Financial Insecurity and Limited Access to Health Care Plague Many Rural Americans.” Harvard T.H. Chan School of Public Health, 7 June 2019
[3] Gunja, Munira Z. “U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes.” U.S. Health Care from a Global Perspective, 2022 | Commonwealth Fund, 31 Jan. 2023.
[4] Gunja, Munira Z. “U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes.” U.S. Health Care from a Global Perspective, 2022 | Commonwealth Fund, 31 Jan. 2023.
[5] Slobin, Jacqueline. “How Much Is a Doctor’s Visit Cost with and without Insurance?” Mira Health, 14 Apr. 2024.
[6] Chan, L. “Geographic Access to Health Care for Rural Medicare Beneficiaries.” The Journal of Rural Health : Official Journal of the American Rural Health Association and the National Rural Health Care Association, U.S. National Library of Medicine. Accessed 29 Apr. 2024.
[7] Harris, Martha-Mac, “Y-0029”, Southern Oral History Program, 14 June 2018
[8] Curtin, Sally. “Products – Data Briefs – Number 417 – September 2021.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 29 July 2021.