Have you ever given any thought to the idea that where you live may have a direct impact on your health outcomes? Probably not, because I don’t think many people think about their health and where they are living until they have significant health concerns or are retiring. People choose where they live based on a variety of issues: family, employment, economic factors, opportunities, education, etc. This article will examine the impact living in a rural area has on your health outcomes and some of the influencing factors.
The geography of where you live is generally classified into three categories: urban, suburban and rural. Each of these three categories have different ecosystems impacting life, whether it be education, economic, healthcare, religion, etc. Most mature adults have lived in at least two of these categories.
- Urban can be described as big cities, compact housing, densely populated, with lots of available services like hospitals, medical providers and resources.
- Suburban is described as areas surrounding urban areas. Frequently densely populated, lots of housing, some resources, sometimes described as “bedroom” communities. People may live in a suburban area but work in an urban area.
- Rural is a bit more challenging to describe. Most people think of rural as “country,” farms and primarily agricultural and natural resources, open space, not a lot of resources, sparse population.
Our federal government actually has seven statutory definitions of rural depending on a specific program, but all of the definitions have census as a major element in the definition. Other considerations in defining rural include economic concepts and land-use concepts. The definitions of the U.S. Department of Agriculture, the U.S. Census Bureau and the Office of Management and Budget are the ones most widely used. Some describe rural as any non-metropolitan urban area. A rural town usually is defined as having fewer than 5,000 people and fewer than 2,000 housing units. A rural land area has fewer than 1,000 people per square mile.
Urban areas make up about 3% of the entire land area of the United States but more than 80% of the population. Meanwhile, 97% of the United States land is rural, but only 19.3% of the population lives there (reference 1). That translates to about 63 million people.
Some information about rural areas in the United States:
- Most rural counties have a declining population (reference 2).
- Rural households have a lower household income than urban households (reference 3).
- Rural median home values are lower (reference 3).
- More housing units are owned “free and clear” in rural areas as compared to urban households (reference 3).
What impact does living rural have on health? Let’s look at the evidence:
- The suicide rate for rural Americans aged 10-24 was almost double the rate among urban Americans of the same age (reference 4).
- The per capita rate of primary care physicians is lower in rural areas as compared to urban and suburban areas (reference 5).
- Rural residents have higher rates of mortality from heart disease, respiratory disease, cancer, stroke and unintentional injury, which are the five leading causes of death in the United States (reference 6).
- Rural Americans experience higher maternal and infant mortality (reference 7).
- Rural populations are older and sicker than those in urban areas (reference 7).
- Rural Americans have a lower life expectancy than those living in an urban area (reference 8).
- Smoking has stayed the same or increased in rural areas compared to the rest of the United States, leading to a higher burden of lung cancer (reference 9).
- Rural older adults have a higher prevalence of chronic diseases compared to urban older adults (reference 10).
- Rural areas have fewer healthcare resources than urban areas.
There are several factors that contribute to the health disparities experienced in rural areas. It is important to remember that each rural area is unique, although they may have similarities. When individuals don’t receive healthcare when needed, then individuals present with disease much further advanced.
One of the leading determinants to healthcare in rural areas is the availability of services at hospitals, imaging centers, laboratories, and healthcare providers, etc. Geographic isolation plays a factor in healthcare disparities because health services often are scarce. There is a growing shortage of primary care physicians in the United States, but the shortage is acute in rural areas. Because of the availability of providers, people see their provider when they are sicker and utilize more resources because of this delay. Another variable is the distance to a healthcare provider. In some cases, it may be a few hours with lack of emergency transportation. Typically, there is no public transportation in rural areas. Because many living in rural America are self-employed, they must take time off, which means their day work does not get done and then impacts their income. Because internet access is not available in many rural areas, many individuals living in rural American cannot take advantage of telemedicine.
Rural hospitals are part of the healthcare system and make contributions to their community but struggle in providing services across the continuum of care from acute care to long-term care.
Compounding all the above factors, rural America is diverse. Areas which are racially and ethnically varied will have unique health disparities which must be addressed. Rural diversity has been increasing, which presents increasing demand and challenges.
Rural hospitals struggle financially because of low reimbursement rates, increased regulation, reduced patient volumes, uncompensated care and myriad staffing issues. Forty-seven percent of rural hospitals have 25 or fewer staffed beds. Many rural hospitals are nonprofit owned, followed by state and local government and a very small percentage investor owned. Between 2015 and 2019, 59% of the decline in community hospitals were rural hospitals (reference 11). The recent trend in healthcare delivery has been the clustering of services into systems and networks, but this has been a challenge for rural healthcare delivery.
All the health disparities of people in rural America present unique challenges for the case manager. Whether you are working with a patient who received care in a rural setting or with a patient who received care at an urban center and is going back home in rural America, case managers must create the systems, build the networks and create resources to meet the patient’s needs and many times in very creative ways.
Although rural health disparities are rooted in economic, social, racial, ethical, geographic and workforce factors, living rural can be a healthcare risk based upon the evidence. Change can happen. Innovative and sustained approaches are needed to address all of the challenges whether they be structural, social or policy issues in addressing the health disparities in rural America.
REFERENCES
, RN, CCM, FCM is the editor-in-chief of CareManagement. A past president of CMSA as well as a CMSA Chapter leader, Gary has significant leadership experience in managed care organizations. Currently, Gary’s focus is on improving professional case management practice through education.
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