To highlight the health care issues facing rural people and places, we present The Top 10 Rural Issues for Health Care Reform, the second report in our series examining health care issues in rural America. Rural people and communities face many of the same health care concerns confronting the rest of the nation – exploding heath care costs, large numbers of uninsured and underinsured, and an overextended health care infrastructure. However, we also face many unique challenges.

○ An Economy Based on Self-Employment and Small Business
Owner-operated farms, ranches and small businesses dominate the rural economy. As a result, rural areas have lower rates of employer-sponsored health insurance and higher rates of uninsurance and underinsurance. Any health care reform provision that relies exclusively on maintaining the current employer-sponsored health insurance system will not be as relevant for rural areas for these reasons. Health care reform must include options – including a public health insurance plan option – to small businesses and the self-employed for comprehensive, affordable and continuous coverage comparable to larger group coverage.

○ Public Health Insurance Plans: Dependence and Need
Nearly a third more rural people are covered by public health insurance plans compared to urban residents. Public plans in health care reform are important to rural people for two reasons – strengthening the current plans for those already a part of them and providing a public health insurance plan option for those who do not qualify for current programs and who are unable to obtain affordable, comprehensive and continuous health insurance through their work or through the private market. Private and public health insurance plans is not an either-or proposition. Rather, both are necessary and compatible for a high-functioning, cost-effective system.

○ A Stressed Health Care Delivery System
The health care infrastructure in much of rural America is a web of small hospitals, clinics and nursing homes (often attached to the hospitals) often experiencing significant financial stress. Reform must provide these facilities with resources to update their technology, provide care to the unserved and underserved, and must address the current funding model that places many rural facilities at a disadvantage.

○ Health Care Provider and Workforce Shortage
Rural areas have critical shortages of all health care providers and professionals, particularly the primary care professionals that are so important in rural communities. Reform must offer new approaches and incentives for rural health professionals. New methods of financing health care must also not exacerbate the rural health care shortage by providing even more economic disincentives to rural, primary-care medical professionals.

○ An Aging Population
Many rural areas are experiencing an aging population, and with it an increase in chronic diseases, disability, and pressure on an already burdened health care system. Reform must provide the services and facilities to enable aging rural people to stay in their homes and communities.

○ A Sicker, More At-Risk Population
Rural people have higher rates of nearly all chronic diseases and conditions and higher rates of disability. The ultimate health status of rural people has much to do with health insurance coverage and the type of health insurance coverage. These differentials between rural and non-rural people also place rural people more at risk of higher premiums or being denied coverage when pre-existing conditions exist. These factors all lead to poorer health outcomes for many rural people. To address these disparities, health care reform legislation should act to both enhance and promote health and remove barriers to affordable health insurance coverage.

○ Need for Preventive Care, Health and Wellness Resources
Rather than treating just sickness, our health care system must focus on wellness and prevention. This is particularly true for rural areas that suffer higher rates of obesity and other preventable problems. Reform must do more to enhance and promote health and wellness.

○ Lack of Mental Health Services
Over half the counties in the United States have no mental health professionals. As a result, the stressed primary care delivery system in rural areas ends up treating mental health issues for which they are ill-equipped. Reform must create incentives to provide resources for a specialty rural mental health marketplace similar to what exists for rural medical clinics.

○ Increasing Dependence on Technology
Technology is increasingly used to improve patient safety, quality of care, and efficiency. However, adoption of health information and telehealth technology remains low in rural areas in many respects. Reform must include resources for health technology, and efforts to close the rural broadband gap.

○ Effective Emergency Medical Services
Emergency medical services (EMS) are first-line health care providers in rural areas. Rural EMS providers are underfunded, face growing demand, and workforce and volunteer shortages. Reform legislation must provide resources to make these vital EMS services sustainable.

The Top 10 Rural Issues for Health Care Reform report is available here. Contact Jon Bailey, jonb@cfra.org for information.