Physical location affects how and how much healthcare access individuals can get. The study of these location-based, geographic barriers, in our contemporary healthcare system reveals immensely important underlying structural challenges that hinder adequate care access. North Carolina has the second largest rural population in the country and less than half of residents are earning below a “family-sustaining wage” (My Future NC). The compounding effects of income-gap at inception in the context of geographic barriers have led to a cycle of diminished healthcare access. The challenges observed specifically include limited care availability and a shortage of primary-care physicians in rural areas. According to the American Hospital Association, estimates suggest that “each year 3.6 million people in the United States do not obtain medical care due to transportation issues.” According to a study on rural healthcare challenges, “The federal government projects a shortage of over 20,000 primary care physicians in rural areas by 2025” (Neilsen et al. 2017). Geographic barriers present a major block to health access and equity and the challenges faced comment on their deeply ingrained character within our care framework. The Stories to Save Lives project by the Southern Oral History Program includes many interview records discussing how North Carolina residents have been harmed by this barrier. In conjunction with qualitative research, we can learn a great deal about how geographical barriers present a major structural barrier to healthcare.
First and foremost, we can analyze the availability of healthcare in rural vs. urban areas. In his oral history interview, Chris Vann describes how he not only experienced reduced access to the healthcare he needed but also the contrasting atmospheres of rural vs. more urban care. He says,
“Kaiser had a huge medical practice in Raleigh, so for us to get care,
we had to drive to Raleigh. Fortunately, we had transportation… it was an HMO, and an HMO’s in the business of regulating costs of care, and it was a very different environment… Compared to the rural health clinic, which was very warm, very inviting,
the HMO offices were very sterile and very businesslike… “Yes, you’re coming in with a cold,” or, “You’re coming in with an ear infection,” whatever it may be, “and we’re going to treat that. But that’s all we’re going to do,” you know.”
With an emphasis on geographic barriers, we conclude that essential healthcare first necessitated long journeys to urban centers and second that the care provided contributed to an emotionally burdensome healthcare environment.
Transportation is a large challenge for individuals living in rural communities to access proper care (Wolfe et al. 2020). It is regarded as “a basic but necessary step for ongoing health care and medication access, particularly for those with chronic diseases” (Syed et al. 2014). The geographical dispersion of essential healthcare facilities exacerbates this challenge, resulting in delayed interventions and the accumulation of avoidable complications. In fact, in their study, Syed et al. analyzed other peer-reviewed literature and found strong evidence that lower-income individuals, minorities, and those residing in rural areas are especially harmed by limited public transportation and distance of major health facilities.
It is also important to maintain strong patient satisfaction to accomplish long-term health goals. As seen in Vann’s interview, the disconnect between the patient and provider he observed can overall exacerbate dissatisfaction, deterring individuals from traveling long distances and seeking necessary care. Furthermore studies focusing on public healthcare have found that “there may not be a financial interest in performing these studies since they are not particularly interested in profit” (Ferreira et al. 2023). This highlights an important need to not only provide literal services but also necessary care that aims to strengthen patient satisfaction.
Looking at the two issues challenging the availability of healthcare in rural vs. urban areas we can draw an important distinction between available and usable healthcare which especially challenges individuals living in rural communities. To provide more usable healthcare we must consider transportation challenges and effectiveness as measured by patient satisfaction. By taking an approach that considers logistical challenges, protects the provider-patient relationship, and addresses social determinants of health, the larger health system can work towards achieving equitable healthcare access for all individuals, regardless of the challenging geographic barriers.
Secondly, we can also analyze the shortage of physicians and resources in rural areas. In her oral history interview, Lori Hinga describes the physician shortage she experienced and the consequences of models of payment for healthcare in rural areas. She says,
“…we have a shortage of primary care doctors… in every state, probably, almost. So we’re directing healthcare by payment… if we’re gonna go to pay for performance, I’m all about that… I’m all about value-based payment. I’m a quality person… The part we forgot in that was affordable healthcare for everybody… So even though there’s subsidies, people, they either have to eat or they gotta pay a healthcare premium, and they’re gonna eat. You know what I mean? So we haven’t solved that problem yet.”
Rural populations heavily depend on primary care physicians for care and “although fourteen percent of the U.S. population lives in rural areas, only ten percent of primary care physicians practice medicine there” (Kulka et al. 2019). From Hinga’s interview, we can learn that there are importantly two components of the physician shortage we observe. The first factor stems from the literal shortage of physicians in rural areas. The second factor stems from how healthcare services are priced. If we choose to model payment by service then individuals in rural communities with lower incomes or limited insurance coverage will not be able to afford care for complex and necessary procedures. Likewise, if we choose to model this by patient satisfaction (value) then physicians will not be able to see as many patients as before. The same amount of physicians will now need to spend more time with existing patients once again causing a shortage of physicians. What this does is effectively perpetuate the problem for individuals in rural areas to not have affordable and quality care access. Addressing the shortage of physicians in rural areas therefore requires a multifaceted approach that not only increases the literal quantity of physicians that practice near rural areas but also usable physician availability.
The availability of healthcare and the physician shortage in rural areas represent geographic barriers because these regions lack the necessary resources resulting in limited access to essential medical services for residents. These challenges also broadly represent structural barriers because they are deeply rooted in systemic issues such as the building of clinics, provider-patient relationships, and funding models. It is evident that to address these challenges, change needs to be made to address the structural barriers behind these geographic barriers. With regard to the actual availability of care, transportation, and strong patient-provider relationship is important. Without addressing these challenges, the amount of actual healthcare members of rural communities can access becomes limited. With regards to addressing the physician shortage, it is important to consider the availability of physicians in rural communities through policies affecting student loan forgiveness, subsidies, etc., and also proper pricing models. If we choose to implement an ineffective model then we risk further reducing physician availability. To address these broader issues, it is important to continue to consider first-hand evidence of these experiences through projects such as the Stories to Save Lives Project. These stories and examples matter because medicine is fundamentally a human practice.
References
Vann, Chris. Interview with Ramirez Joanna. 28 June 2018 (Y-0058). Southern Oral History Program Collection (#4007), Wilson Library, University of North Carolina at Chapel Hill.
Hinga, Lori. Interview with Maddy Kameny. 26 June 2018 (Y-0032). Southern Oral History Program Collection (#4007), Wilson Library, University of North Carolina at Chapel Hill.
Ferreira, Diogo Cunha, et al. “Patient Satisfaction with Healthcare Services and the Techniques Used for Its Assessment: A Systematic Literature Review and a Bibliometric Analysis.” Healthcare (Basel, Switzerland), U.S. National Library of Medicine, 21 Feb. 2023, www.ncbi.nlm.nih.gov/pmc/articles/PMC10001171/.
Kulka, Amrita, and Dennis McWeeny. “Rural Physician Shortages and Policy Intervention.” SSRN, 14 Nov. 2019, papers.ssrn.com/sol3/papers.cfm?abstract_id=3481777.
Nielsen, Marci, et al. “Addressing Rural Health Challenges Head On.” Missouri Medicine, U.S. National Library of Medicine, 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC6140198/.
“North Carolina Family-Sustaining Wage.” MyFutureNC, dashboard.myfuturenc.org/workforce-alignment/family-sustaining-wage/. Accessed 28 Apr. 2024.
“Social Determinants of Health Series: Transportation and the Role of Hospitals: AHA.” American Hospital Association, www.aha.org/ahahret-guides/2017-11-15-social-determinants-health-series-transportation-and-role-hospitals. Accessed 28 Apr. 2024.
Syed, Samina T, et al. “Traveling towards Disease: Transportation Barriers to Health Care Access.” Journal of Community Health, U.S. National Library of Medicine, Oct. 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/.
Wolfe, Mary K, et al. “Transportation Barriers to Health Care in the United States: Findings from the National Health Interview Survey, 1997-2017.” American Journal of Public Health, U.S. National Library of Medicine, June 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7204444/.