Health care in rural America—sacrificing to survive

Driving two hours for routine health care check-ups may seem absurd to most people, but for those living in small, rural communities throughout the U.S., this is their reality. With the nearest hospital potentially hundreds of miles away, those in rural communities do not receive equal access to quality medical treatment.

Recently, Jordan Rasmussen, assistant policy director for the Center for Rural Affairs, joined hosts Josh McCormack and Rosalie Aguilar on the podcast Salud Talks to discuss the challenges rural communities face when trying to access health care.

Painting a picture of health care in rural America

There are a number of health disparities in small communities. In general, the population is older in age, rural Americans are more likely to be uninsured, and they may have lower incomes.

These people also struggle with barriers to transportation, and small communities often suffer staffing shortages in the medical field. Latino community members may face even more challenges.

“Latino populations, at least in the state of Nebraska, fall in that category of our lower-income folks, and are more likely to be uninsured because the nature of rural businesses where insurance is not always a benefit that is afforded through employment,” Jordan said.

Many rural Americans make sacrifices to acquire the health care they need.

“It’s very disheartening to hear people from across the state aren't able to access basic pieces of care,” said Jordan. “Often, people [in Nebraska] have to take off an entire day of work to be able to see a specialist in Omaha. That’s an unfortunate challenge, not only your day off work, but the cost of making that travel.”

Who falls into the coverage gap?

There are 90,000 Nebraskans who fall into the insurance coverage gap—earning too little to qualify for subsidies to purchase coverage from the insurance marketplace and too much to qualify for traditional Medicaid—and a third of them live in rural communities.

Often, it’s difficult for people to share the circumstances that landed them in the coverage gap, due to being affected by personal injury or loss.

“We actually have a colleague whose brother has fallen in the gap,” said Jordan. “He was injured on the job a number of years ago and has been unable to get insurance even though he has a disability as a result of that work injury. It’s prohibited his ability to work and secure the resources he needs to be able to live his best life and be able to work and take care of his family the way he would like to.”

Center staff also encounter farm families facing challenges finding affordable coverage.

“We’re finding with falling incomes, those who cannot afford to purchase insurance from the marketplace would qualify for Medicaid expansion,” said Jordan. “But, because we have not implemented Medicaid, they continue to fall into the gap. We want people to be able to go to the doctor when they have a cold, but also if an injury occurs, they need to be able to take care of that quickly and not be worried about if they can afford it, or if it will bankrupt their family because they don't have the insurance coverage they need.”

And, when people aren’t able to receive the care they need, the problems often intensify over time.

“When that cold turns into pneumonia, more aggressive, costly treatments are needed,” Jordan said. "And, because they don’t have the insurance resources to be able to go to that doctor, it’s problematic for both that patient and their family."

This predicament also causes issues for rural hospitals, and potentially the communities they serve.

“Our rural hospitals are teetering on the edge of financial viability already, so there can be instances where this uncompensated care will not result in reimbursement from Medicaid or Medicare, which can also be costly,” said Jordan. “Then, those hospitals are pushed even closer to the brink of closure, which is so traumatic for the entire community. It’s not just a loss of that health care resource, it’s a social loss, an employment loss—it’s radiating.”

Moving the issue forward

Nebraskans voted to expand Medicaid in 2018.

“But, we are now unfortunately in a long, protracted delay of that implementation,” said Jordan. “We are anticipating that people will not be able to access coverage until October 2020. So, we have folks that continue to fall in that insurance coverage gap who aren’t able to access the care they need.”

When Nebraskans rose to the occasion and supported their neighbors by voting to implement Medicaid expansion, it was in large part due to the countless stories being shared by those in the coverage gap.

“I think there’s a disconnect in belief that if you need Medicaid it’s because you’re not working, and that’s very rarely the case,” Jordan said. “People are working multiple jobs, trying to make ends meet. There are just not enough dollars at the end of the day to make that happen and be able to afford the health care that they need to be healthy and productive on top of going to work and school and taking care of their families the way they want to.”

The Center has also advocated for policy to bring in additional providers in the behavioral health space, a challenge that staff continue to see and hear about in rural communities.

“Times are tough on the farm right now, and it extends beyond our farmers and into their communities,” said Jordan. “We don’t have enough doctors to be able to fill those needed positions. Or, the doctors are only there for a short period of time because they can make higher salaries in a larger city, or be a specialist in a larger community.”

However, some progress is being made. Provided through the University of Nebraska-Lincoln, a rural health opportunities program, which the Center has worked closely with, ensures graduating rural students are given the opportunity to come back to rural communities as doctors, mental health practitioners, nurses, etc.

“We need to encourage more of our rural students to come back and fill in those gaps in our rural medical professions,” said Jordan. “We also need to make sure we have health care providers who have cultural sensitivity and an awareness of different health behaviors. If patients don’t have somebody they feel comfortable with, they may not be able to articulate what they’re feeling.”

Tell your story

When Center staff go before legislators, often times the representatives have no idea there isn’t a basic access to care or that there are so many uninsured residents in their communities. But, there’s a way to change that.

“Being willing to share your story can sometimes require you to be very brave and open yourself up in a way that you may not have before, but that’s how policy is really moved,” said Jordan. “We hear time and time again from senators that’s what makes it real for them—when they’re able to look you in the eye and see that because you did not have health care, these other radiating impacts occurred. Sharing your story is so important, and it increases awareness that there is this disparity in our rural communities and that health care is not uniform—the access to care, or the quality of care as well.”

Jordan also emphasizes that spreading these stories gives a voice to rural America that the rest of the country may not have heard before.

“Rural America is not a monolith—we’re not all the white farmers that have been raised up in the recent media,” she said. “We have a very diverse population. The reason Nebraska has grown is because of our immigrant population. That additional diversity of our communities is molding the future and allowing us to continue being a viable state, as well as the businesses on our main streets and people in our schools. Sharing those stories makes sure we’re not continuing those assumed narratives.”