Moonshot, Upshot, Hot Spot, Bullshot
By Daniel Derksen, in ARIZONA PHYSICIAN, Maricopa County Medical Society | Summer Issue 2021
One in five Americans lives in a rural area. Yet it’s been 25 years since the U.S. invested in its rural health infrastructure through Hill Burton funding (1947-1997) based on community need. While 18-20% of the nation’s population lives in a rural area, just 10% of primary care physicians and 7% of specialist physicians reside there.
The Great Society Programs of the 1960s intended to address the 25% of Americans living below the Federal Poverty Level, and even higher (33% below FPL) in rural areas, and included creating a Job Corps, Head Start, Medicare, Medicaid, and other programs to expand affordable health care, education, and housing. Over that decade rural poverty dropped to 17.9%.
Investments in individual health insurance coverage started with amendments to the Social Security Act that created Medicare and Medicaid in 1965, added the Children’s Health Insurance Program in 1997, and in 2014 expanded Medicaid and subsidized private health insurance for 20 million Americans via the Affordable Care Act. These investments helped stabilize finances in rural hospitals and clinics. However, many community clinics, rural and critical access hospitals operate on thin margins without reserves to weather economic downturns.
In 2021, intractable rural versus urban socioeconomic and health disparities persist.
Rural counties are often defined simply as having a population of less than 50,000. There are more precise designations such as federal-state determinations for Health Professional Shortage Areas, Rural Urban Commuting Areas (RUCAs), and other sub classifications.
Rural America is demographically and economically diverse, suggesting that while some commonalities exist (rural populations tend to be older, have lower incomes, and higher rates of certain chronic diseases), policy and programmatic interventions should be customized to meet diverse rural community needs. While rural age adjusted death rates per 100,000 are improving for cancer, coronary heart disease and stroke – they are not improving as much as in metro areas. Rural death rates are worsening for COPD, diabetes, unintentional injury and suicide.
Of the 69 million Americans living in rural areas, 13 million are people of color, and 2 million are immigrants. Rural residents who are Black, Latinx/Hispanic and American Indian have social determinants that contribute to poorer health outcomes including higher rates of poverty, lower educational attainment, and less access to affordable housing and health insurance coverage and services.
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