Health-care reform—specifically, the Patient Protection and Affordable Care Act (PPACA)—mandated sweeping changes to the US health-care system. Some of the more controversial of these, such as the individual mandate to purchase health insurance, are being contested in court, but Jon Bailey, JD, director of the Rural Research and Analysis Program at the Center for Rural Affairs, Lyons, Nebraska, notes that among the law’s less publicized effects are some important changes for rural health care.
“There’s a lot of emphasis on prevention and public health,” he says. “This is a major change to our public policy. We liken it to Social Security and Medicare, which continue to evolve; perfection from the start is unrealistic, but there are a lot of possibilities here.”
In 2009, Bailey wrote a paper on behalf of the Center for Rural Affairs that outlined key rural issues that health-care reform could potentially address. The paper, “ The Top 10 Rural Issues for Health Care Reform,” highlights areas of particular vulnerability for rural, underserved areas, including an aging health-care workforce, lack of access to preventive services, financially stressed health-care facilities, and lack of infrastructure.
What’s more, Bailey says, many of these issues interconnect, ensuring that there will be no easy fix for rural health care’s woes. “There’s been a lot of emphasis, in recent years, on health-care IT and electronic medical records, and that emphasis represents a lot of challenges to rural hospitals, clinics, and provider offices,” he says. “The broadband-technology infrastructure is not always the greatest in rural areas, and the workforce tends to be older, so workers may not be as familiar or comfortable with that technology.”
Access to specialists (including radiologists) has long been a challenge in outlying areas, meaning that many smaller hospitals have turned to telemedicine to provide them with specialty expertise. “We’re not seeing many radiologists and other specialists coming into rural communities,” Bailey says. “If we can devise systems that allow people to have access to them where they’re practicing, that provides a great alternative for rural patients.”
Unfortunately, the weak broadband infrastructure in many of these areas still presents an obstacle: “It’s a big cost investment up front,” he notes. “Over the long term, however, it becomes cost effective when people don’t have to travel from their home communities.”
These issues are even thornier to address because of the razor-thin margins at which many rural hospitals and clinics operate. “Rural hospitals really have a tough time with nonpaying, uninsured, or underinsured patients, and they wind up eating a lot of the cost of their care—which really eats into their resources,” Bailey says. “They’re not swimming in money. They have to make decisions based on immediate patient-care needs, rather than long-term goals.”
Add to these factors a workforce that is aging, with many caregivers on the verge of retirement, and you have a perfect storm of challenges, Bailey says. “A lot of rural areas are struggling with their health-care workforce as people retire, and it’s increasingly difficult to recruit newer and younger health-care professionals to rural areas,” he says. “Because of the cost of the education they undergo, the lack of potential patients, and other problems, in most cases, it’s just not financially feasible to establish a rural practice.”
This goes double for specialists. He adds, “The issue of specialists in rural areas is probably a bigger problem than that of primary-care providers. As people get their training in specialties, there’s less inclination to practice in rural areas.”
Solutions and Ongoing Challenges
The PPACA contains a multitude of provisions that aim to (or have the potential to) create solutions for rural health care, Bailey says. “It’s understated,” he notes. “Most people don’t even know it’s in there. Many of the provisions and programs already existed, and the PPACA expanded them or provided more resources for them. In the long term, the law could be very helpful for health care in rural communities.”
One of the law’s most debated mandates, which would require all US residents to have some form of health insurance, stands to benefit rural providers enormously—once it takes effect. “The law tries to address some of the financial challenges faced by hospitals and other health-care institutions