The Struggle for Healthcare Access in Rural America

Only 14% of Americans, almost 46 million people, live in rural areas. But these communities represent nearly two-thirds of primary care health professional shortage areas, according to data from the Health Resources and Services Administration (HRSA).

The Kaiser Family Foundation estimates that an additional 14,858 healthcare providers are needed to eliminate this shortage across the country. A 2021 survey found that the turnover rate at hospitals (the aggregate rate of employee turnover for a hospital) increased to 19.5% in 2020. In their projections for 2020, 16% fewer hospitals expected an increase in their labor force compared to 2019.

Ensuring that the supply of healthcare providers outpaces the turnover rate — and that the supply is distributed to areas with shortages rather than to areas with provider surpluses — is critical to supporting the health of rural communities.

Although living in rural America offers positives such as more space, fewer people, scenic landscapes, and a sense of community, there are challenges to staying healthy.

While we all experience ups and downs throughout our lives, we can generally adapt – thanks to resilience. Times of difficulty or stress won’t go away. We will always face them. But according to the Mayo Clinic, having resilience can give you the ability to see past challenges, find enjoyment in life, and better handle stress.

Resilience in the workplace

These challenges result from the fact that many residents in rural areas don’t have access to healthcare. Barriers to healthcare cause increases in unmet needs, a lack of preventive and screening services, and inadequate treatment of illnesses.

According to the Rural Health Information Hub (RHIH), barriers to access include:

Distance and Transportation

Rural populations are more likely to have to travel long distances to access healthcare, particularly subspecialist services. This can be a significant burden in terms of travel time, cost, and time away from the workplace. In addition, the lack of reliable transportation is a barrier to care. While public transit is generally an option for patients in urban areas, it is often lacking in rural areas. Likewise, rural communities often have more elderly residents with chronic conditions that require multiple visits to medical appointments. This can be a big challenge when public or private transportation availability is not there.

Workforce Shortages

While both urban and rural healthcare workforce shortages are a massive issue across the country, the most significant impact is felt in rural communities. A regular source of care requires an adequate workforce. Some health services researchers argue that evaluating healthcare access by measuring provider availability is inadequate to fully understand the issue. Measures of nonuse, such as counting rural residents who could not find an appropriate care provider, can help provide a fuller picture of whether a sufficient healthcare workforce is available to rural residents.

A shortage of healthcare professionals in rural areas of the U.S. can restrict access to healthcare by limiting the supply of available services. As of September 2022, 65.6% of Primary Care Health Professional Shortage Areas were located in rural areas.

Health Insurance Coverage

Individuals without health insurance have less access to healthcare services. According to Geographic Variation in Health Insurance Coverage: United States, 2021, rural children and adults under 65 were more likely than their urban peers to be uninsured.

The June 2016 issue brief from the Office of the Assistant Secretary for Planning and Evaluation, Impact of the Affordable Care Act Coverage Expansion on Rural and Urban Populations, found that 43.4% of uninsured rural residents reported not having a usual source of care, which was less than the 52.6% of uninsured urban residents reporting not having a usual source of care. However, the brief also reports that 26.5% of uninsured rural residents delayed receiving healthcare in the past year due to cost. The Affordable Care Act and Insurance Coverage in Rural Areas, a 2014 Kaiser Family Foundation issue brief, points out that uninsured rural residents face greater difficulty accessing care due to the limited supply of rural healthcare providers who offer low-cost or charity healthcare, when compared to their urban counterparts.

Health insurance affordability is a concern for rural areas. A RUPRI Center for Rural Health Policy Analysis policy brief, Health Insurance Marketplaces: Issuer Participation and Premium Trends in Rural Places, 2018, evaluated changes in average health insurance marketplace (HIM) plan premiums from 2014 to 2018. Average premiums were higher in rural counties than in urban counties. In addition, rural counties were more likely to have only one insurance issuer participating in the HIM. Medicare Advantage plan copays and deductibles are also higher in rural areas. Likewise, no-cost benefits like health clubs and transportation are less frequently offered in rural areas.

Broadband Access

While telehealth services were already becoming more popular and widespread at the beginning of 2020, measures implemented in response to the COVID-19 pandemic accelerated this growth. Unfortunately, many areas still lack access to broadband internet and experience slow internet speeds, both of which are barriers to utilizing these services. Rural individuals are nearly two times more likely to lack broadband access than their urban counterparts. A Peterson Center on Healthcare and Kaiser Family Foundation report, How Might Internet Connectivity Affect Healthcare Access?, found that 7% of people in metropolitan areas did not have internet connections at home in 2019, while 13% of people in nonmetropolitan areas lacked it.

Lack of Understanding

Health literacy can also be a barrier to accessing healthcare. Health literacy impacts a patient’s ability to understand information and instructions from their healthcare providers. This can be especially concerning in rural communities, where lower educational levels and higher incidences of poverty often impact residents. Low health literacy can make residents reluctant to seek care due to fear or frustration about communicating with a healthcare professional. Additionally, navigating the healthcare system can be frustrating to begin with, but it can be made easier by acquiring health literacy skills.

Social Stigma and Privacy Issues

In rural areas, because there is little anonymity, social stigma, and privacy concerns are more likely to act as barriers to healthcare access. Rural residents can have unease stemming from privacy concerns about seeking care for mental health, substance use, sexual health, pregnancy, or even common chronic illnesses. Additionally, patients may worry about utilizing services for health conditions that are typically not openly discussed, such as counseling or HIV testing services. They may experience fears of a neighbor or co-worker seeing them. Co-location or integrating behavioral health services with primary care healthcare services in the same building can help ease some patient concerns.

Financial Barriers to Practice

Some of the most significant barriers to rural healthcare are the financial challenges that physicians encounter when establishing rural healthcare practices.

Because of the high cost of medical school, the number of students who can apply and attend is limited. In turn, high levels of student loan debt can lead physicians to pursue high salaries, which are typically found in urban rather than rural settings.

According to a report from the Center for American Progress, two policy-related things can be done that would encourage providers to work in rural areas after medical school: loan repayment and loan issuance and assistance.

The report also found that medical malpractice reform presents another barrier for those who are choosing to practice in rural areas. Malpractice insurance is vital for doctors due to the possibility of being responsible for a large payment in the event of a medical error, but it is costly. Suggestions include implementing a state-run program to help reduce the cost of medical malpractice insurance for providers and allowing states to directly subsidize the cost of medical malpractice insurance premiums to help promote rural healthcare practices.

Either option would go a long way toward helping providers in rural areas.A 2004 Journal of the American Medical Association study of rural physicians in Florida found that “difficulty finding or paying for PLI [medical malpractice insurance] was listed as an important factor by those reducing or eliminating services and by those planning to leave the community within the next 2 years.”

Hospitals Face Their Own Challenges

Hospitals are cornerstones of their communities, serving as principal access points for those who live in rural areas and need care. They maintain timely access to services through local, on-site care and connect patients to more distant providers via telehealth or care networks. In addition, hospitals are often the leading employers in rural areas, bringing good jobs and critical financial support to the communities they serve to help promote community growth and development.

The American Hospital Association (AHA) realizes that challenges persist for rural hospitals, especially in the wake of the pandemic. They include low patient volume, a heavy reliance on government payers, and an older population with more chronic conditions, among others. They reflect changes in the healthcare field and policy environment, such as shifts from inpatient to outpatient care delivery, growing behavioral health needs, continued regulatory burdens and markedly higher drug costs. According to the AHA, other emergent challenges include those events and circumstances, such as natural disasters, violence and epidemics, which occur with little warning but require immediate attention.

What Can Be Done to Help?

The RHIH lists a few strategies being used to improve access in rural areas. They include:

Use of Community Paramedicine

This is a model of care that allows paramedics and emergency medical technicians to operate in expanded roles to assist with healthcare services for those in need without duplicating available services that already exist within the community.

Community Health Workers

They can help facilitate healthcare access by acting as liaisons between healthcare providers and rural residents to ensure their needs are met. Care coordination and team-based care models, such as Accountable Care Organizations and Patient-Centered Medical Homes, can also extend access to primary care services in rural communities.

Affiliation with Larger Systems or Networks

Local rural healthcare facilities may choose to join healthcare networks or affiliate themselves with larger healthcare systems as a strategic move to maintain or improve healthcare access in their communities. These affiliations or joining of healthcare networks may improve the financial viability of rural facilities, provide additional resources and infrastructure, and allow rural healthcare facilities to offer new or expanded services they could not otherwise provide.

Strengthening the Workforce

Strategies might include allowing healthcare professionals to work at the top of their license, using new types of providers, working in interprofessional teams, and creative scheduling to offer clinic time outside of regular work hours.