Medicalization of Rural Poverty: Challenges for Access

Abstract

This article provides a broad survey of issues facing rural communities and suggests that medicalization of poverty concepts and interventions need to be tailored to those populations. Rural poverty may be both broader and deeper than in urban areas. Those challenges seem to produce a constellation of health conditions, as rural residents struggle with unemployment and lack of opportunities. Relatedly, rural communities struggle to maintain financially viable hospitals and specialty providers. The article closes by offering a snapshot of rural-specific strategies to address these issues.

Get full access to this article

View all access options for this article.

References

See, e.g., “About RUPRI,” RUPRI, available at <http://www.rupri.org/about-rupri/> (last visited July 11, 2018).

Domm

, “Goldman Says This May Become the Longest Economic Expansion in History,” CNBC, May 8, 2017, available at <https://www.cnbc.com/2017/05/08/goldman-says-u-s-economy-may-be-slowly-growing-into-the-longest-expansion-in-history.html> (last visited July 11, 2018).

K. D.

Kochanek ,

Arias , and

R. N.

Anderson , “Leading Causes of Death Contributing to Decrease in Life Expectancy Gap Between Black and White Populations: United States, 1999-2013,” NCHS Data Brief, no. 218 (2015): 1-7, at 1, available at <https://www.cdc.gov/nchs/data/databriefs/db218.pdf> (last visited July 11, 2018).

Brasch

, “Is the Economic Recovery Leaving Rural America Behind?,” Modern Farmer, December 5, 2013, available at <https://modernfarmer.com/2013/12/economic-recovery-leaving-rural-america-behind/> (last visited July 11, 2018).

G. K.

Singh and

Siahpush , “Widening Rural-Urban Disparities in Life Expectancy, U.S., 1969-2009,” American Journal of Preventative Medicine 29, no. 2 (2014): e19-e29, available at <http://www.ajpmonline.org/article/S0749-3797(13)00590-4/pdf> (last visited July 11, 2018).

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (March 23, 2010); Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (March 30, 2010).

See, e.g., Rural Policy Research Institute, “About RUPRI,” RUPRI, available at <http://www.rupri.org/about-rupri/> (last visited July 11, 2018); see also

Williams Jr. and

Holmes , “Rural Health Care Costs: Are They Higher and Why Might They Differ from Urban Health Care Costs?,” North Carolina Medical Journal 79, no. 1 (2018): 51-55, available at <http://www.ncmedicaljournal.com/content/79/1/51.full.pdf+html> (last visited July 11, 2018); “6 Charts that Illustrate the Divide Between Rural and Urban America,” PBS News Hour, March 17, 2016, available at <https://www.pbs.org/newshour/nation/six-charts-illustrate-divide-rural-urban-america> (last visited July 11, 2018).

See id.

U.S. Department of Agriculture, Economic Research Service, “Rural Poverty & Well-being,” available at <https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/> (last visited July 11, 2018).

10.

See id.

11.

See id.

12.

See generally

A. R.

Tickamyer ,

Sherman , and

Warlick , eds., Rural Poverty in the United States (New York: Colombia University Press, 2017).

13.

Dudenhefer

, Poverty in the Rural United States, Persistent Poverty in Rural America (Boulder: Westview Press 1993): 37-46, available at <https://www.irp.wisc.edu/publications/focus/pdfs/foc151c.pdf> (last visited February 12, 2018);

Thiede ,

Greiman ,

Weiler ,

Beda , and

Conroy , “6 Charts That Illustrate the Divide Between Rural and Urban America,” PBS, March 17, 2017, available at <https://www.pbs.org/newshour/nation/six-charts-illustrate-divide-rural-urban-america> (last visited July 11, 2018).

14.

L. K.

Gurley

, “Why the Left Isn't Talking About Rural American Poverty,” In These Times, October 22, 2015, available at <http://inthesetimes.com/rural-america/entry/18526/whythe-left-isnt-talking-about-rural-american-poverty> (last visited July 11, 2018).

15.

See id.

16.

Misra

, “A Complex Portrait of Rural America,” City-Lab, December 8, 2016, available at <https://www.citylab.com/equity/2016/12/a-complex-portrait-of-rural-america/509828/> (last visited July 11, 2018).

17.

Gurley, supra note 14.

18.

MacGillis

, “The Original Underclass,” The Atlantic, September 2016, available at <https://www.theatlantic.com/magazine/archive/2016/09/the-original-underclass/492731/> (last visited July 11, 2018)(“The barely veiled implication…is that the people undergoing these travails deserve relatively little sympathy — that they maybe, kinda had this reckoning coming. Either they are layabouts drenched in self-pity or they are sad cases consumed with racial status anxiety and animus toward the nonwhites passing them on the ladder.”).

19.

See Gurley, supra note 14.

20.

See

K. B.

Kozhimannil and

Henning-Smith , “Racism and Health in Rural America,” Journal for the Health Care of the Poor and Underserved 29, no. 1 (November 22, 2017): 35-43, available at <https://preprint.press.jhu.edu/sites/default/files/KozhimannilFinalCE%20preprint.pdf> (last visited July 11, 2018).

21.

Frederique and

Moore , “Opioids Became a Crisis Because They Kill So Many White Americans,” The Hill, November 13, 2017, available at <http://thehill.com/opinion/healthcare/360162-opioids-became-a-crisis-because-they-kill-so-many-white-americans> (last visited July 11, 2018).

22.

Mortality and Life Expectancy in Rural America: Connecting the Health and Human Service Safety Nets to Improve Health Outcomes Over the Life Course, National Advisory Committee on Rural Health and Human Services Policy Brief (October 2015): 1-10, at 1, available at <https://www.hrsa.gov/advisory-committees/rural/publications/mortality.pdf> (last visited July 11, 2018).

23.

See id. at 2.

24.

See id. at 7-8,9.

25.

“Rural Americans at Higher Risk of Death From Five Leading Causes,”

CDC, January 12, 2017, available at <https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html> (last visited January 25, 2018).

26.

See id.

27.

See id. at 1545-1546.

28.

See id. at 1545-1546.

29.

See id. at 1545.

30.

Case and

Deaton , “Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century,” PNAS 112, no. 49 (2015): 15078-15083.

31.

See id. at 15081.

32.

See, e.g.,

Friedsam

, “Does the Rural-Urban Frame Help Explain Health Status?” Health Affairs Blog, April 30, 2018, available at <https://www.healthaffairs.org/do/10.1377/hblog20180426.201480/full/> (last visited July 11, 2018).

33.

See, e.g.,

Auerbach and

Gelman , “Age-Aggregation Bias in Mortality Trends,” PNAS 113, no. 7 (2016): E816-E817, available at <https://doi.org/10.1073/pnas.1523465113> (last visited July 11, 2018);

Auerbach and

Gelman , “Stop Saying White Mortality Is Rising,” Slate, March 28, 2017, available at <http://www.slate.com/articles/health_and_science/science/2017/03/is_white_mortality_rising_not_really.html> (last visited June 22, 2018);

Guo

, “‘How dare you work on whites': Professors under fire for research on white mortality,” The Washington Post, April 6, 2017, available at <https://www.washingtonpost.com/news/wonk/wp/2017/04/06/how-dare-you-work-on-whites-professors-under-fire-for-research-on-white-mortality/?noredirect=on&utm_term=.7d7323e3a4ba> (last visited July 11, 2018);

Semuels

, “Is Economic Despair What's Killing Middle-Aged White Americans?” The Atlantic, March 23, 2017, available at <https://www.theatlantic.com/business/archive/2017/03/economic-despair/520473/> (last visited June 22, 2018).

34.

See

C. V.

James

et al ., “Racial/Ethnic Health Disparities Among Rural Adults — United States, 2012–2015,” Centers for Disease Control & Prevention, Morbidity and Mortality Weekly Report 66, no. 3 (2017), available at <https://www.cdc.gov/mmwr/volumes/66/ss/ss6623a1.htm> (last visited July 11, 2018) (noting that although rural populations are less diverse, rural racial/ethnic minority populations suffer substantial health, access to care, and lifestyle challenges that should not be overlooked).

35.

Johnson and

Wagner , “Trump Declares the Opioid Crisis a Public Health Emergency,” The Washington Post, October 26, 2017, available at <https://www.washingtonpost.com/news/post-politics/wp/2017/10/26/trump-plans-to-declare-the-opioid-crisis-a-public-health-emergency/?utm_term=.a48bcea0297e>(last July 11, 2018).

36.

Runyon

, “Why is the Opioid Epidemic Hitting Rural America Especially Hard?” NPR, January, 4, 2017, available at <http://nprillinois.org/post/why-opioid-epidemic-hitting-rural-america-especially-hard#stream/0> (last visited January 25, 2018).

37.

Substance Abuse Research Alliance, “Prescription Opioids and Heroin Epidemic in Georgia-A White Paper,” (2017):1-60, available at <http://www.senate.ga.gov/sro/Documents/StudyCommRpts/OpioidsAppendix.pdf> (last visited July 11, 2018).

38.

C. A.

Cunningham

, “The Opiate Crisis in Rural America,” National Association of State EMS Officials, available at <https://www.nasemso.org/Advocacy/PositionsResolutions/documents/The-Opiate-Crisis-in-Rural-America.pdf> (last visited January 25, 2018).

39.

DiJulio ,

Kirzinger ,

Wu , and

Brodie , “Data Note: Americans' Challenges with Health Care Costs,” The Henry J. Kaiser Family Foundation, March 2, 2017, available at <https://www.kff.org/health-costs/poll-finding/data-note-americans-challenges-with-health-care-costs/> (last visited July 11, 2018).

40.

A. R.

Barker

et al ., Health Insurance Marketplaces: Premium Trends in Rural Areas, RUPRI Center for Rural Health Policy Analysis Rural Policy Brief, May 2016, available at <https://www.public-health.uiowa.edu/rupri/publications/policy-briefs/2016/HIMs%20rural%20premium%20trends.pdf> (last visited July 11, 2018); Williams and Holmes, supra note 7, at 53-54.

41.

Khazan

, “Why are ther so Few Doctors in Rural America,” The Atlantic, August 28, 2018, 2014, available at <https://www.theatlantic.com/health/archive/2014/08/why-wont-doctors-move-to-rural-america/379291/> (last visited September 14, 2018).

42.

“Meeting the Primary Care Needs of Rural America: Examining the Role of Non-Physician Providers,”

National Conference of State Legislatures, available at <http://www.ncsl.org/research/health/meeting-the-primary-care-needs-of-rural-america.aspx> (last visited September 14, 2018).

43.

“About Rural Health Care,”

National Rural Health Association, available at <https://www.ruralhealthweb.org/about-nrha/about-rural-health-care> (last visited January 25, 2018); see Substance Abuse Research Alliance, supra note 37, at 5 (discussing shortage of substance abuse and medication-assisted treatment in rural areas).

44.

“83 Rural Hospital Closures: January 2010-Present,” UNC: The Cecil G. Sheps Center for Health Services Research, available at <http://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/> (last visited January 25, 2018).

45.

See id.

46.

“Rural Hospital Closures Since 2010,”

Stroudwater, July 7, 2017, available at <http://www.stroudwater.com/?resources=analyses-rural-hospital-closures-since-2010> (last visited July 11, 2018).

47.

“CMS Proposes $43B in Cuts to Disproportionate Share Hospital Payments,”

Advisory Board, July 31, 2017, available at <https://www.advisory.com/daily-briefing/2017/07/31/dsh-cuts> (last visited July 11, 2018).

48.

Wishner ,

Solleveld ,

Rudowitz ,

Paradise , and

Antonisse , “A Look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies,” The Henry J. Kaiser Family Foundation, July 7, 2016, available at <https://www.kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/> (last visited July 11, 2018).

49.

See

Percy

, “Georgia's Hospitals: Rural Hospitals In Crisis,” Georgia Trend, December 2016, available at <http://www.georgiatrend.com/December-2016/GEORGIAs-HOSPITALS-Rural-Hospitals-In-Crisis/> (last visited July 11 2018).

50.

U.S. Internal Revenue Service, “New Requirements for 501(c) (3) Hospitals Under the Affordable Care Act,” available at <https://www.irs.gov/charities-non-profits/charitable-organizations/new-requirements-for-501c3-hospitals-under-theaffordable-care-act> (last visited July 11, 2018);

Daly

, “IRS Makes First Revocation of Hospital Not-for-Profit Exemption Under 501®,” HFMA, August 15, 2017, available at <https://www.hfma.org/Content.aspx?id=55271> (last visited July 11, 2018).

51.

See Percy, supra note 49.

52.

National Federation of Independent Business v. Sebelius, 567 U.S. 519, 587-88 (2012).

53.

Luthra

, “Lack of Medicaid Expansion Hurts Rural Hospitals More Than Urban Facilities,” Kaiser Health News, September 7, 2016, available at <https://khn.org/news/lack-of-medicaid-expansion-hurts-rural-hospitals-more-than-urban-facilities/> (last visited July 11, 2018).

54.

R. C.

Lindrooth ,

M. C.

Perraillon ,

R. Y.

Hardy , and

G. J.

Tung , “Understanding The Relationship Between Medical Expansions and Hospital Closures,” Health Affairs 37, no. 1 (2018): 111-120, at 117-119.

55.

A. R.

Barker ,

L. M.

Kemper ,

T. D.

McBride , and

K. J.

Mueller , Rural Policy Brief: Health Insurance Marketplaces: Premium Trends in Rural Areas, RUPRI Center for Rural Health Policy Analysis, available at <https://cph.uiowa.edu/rupri/publications/policybriefs/2016/HIMs%20rural%20premium%20trends.pdf> (last visited July 11, 2018).

56.

See id.

57.

See id.; see also

Semanskee

et al ., “Insurer Participation on ACA Marketplaces, 2014-2018,” Henry J. Kaiser Family Foundation, Health Reform, November 10, 2017, available at <https://www.kff.org/health-reform/issue-brief/insurer-participation-on-aca-marketplaces/> (last visited July 11, 2018).

58.

Gelburd

, “Federal Open Enrollment Now Even Shorter Than It Was Before,” The Hill, October 6, 2017, available at <http://thehill.com/opinion/healthcare/354229-federal-open-enrollment-period-is-now-shorter-than-it-was-before> (last visited July 11, 2018).

59.

Mangan

, “Trump Administration Health Reps Told Not to Participate in Obamacare Outreach Nationwide, as Advocates Claim ‘sabotage,’” CNBC, September 27, 2017, available at <https://www.cnbc.com/2017/09/27/federal-health-reps-told-not-to-participate-in-obamacare-outreach.html> (last visited July 11, 2018).

60.

Eilperin ,

Goldstein , and

C. Y.

Johnson , “White House's Decision to Stop ACA Cost-Sharing Subsidies Triggers Strong Opposition,” The Washington Post, October 13, 2017, available at <https://www.washingtonpost.com/politics/white-house-tells-court-it-is-immediately-stopping-aca-cost-sharing-subsidies/2017/10/13/4c404234-b01d-11e7-be94-fabb0f1e9ffb_story.html?utm_term=.bd396e2c5818> (last visited July 11, 2018).

61.

Jost

, “The Tax Bill and the Individual Mandate: What Happened, and What Does It Mean?” Health Affairs, December 20, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20171220.323429/full/> (last visited February 12, 2018).

62.

See

Gorenstein and

Kasperkevic , “Health Care Premiums for 2018 Set to Go up by as Much as 50 Percent,” Marketplace, October 5, 2017, available at <https://www.marketplace.org/2017/10/05/health-care/uncertainty-healthcare-premiums-increase-2018-50-percent> (last visited July 11, 2018).

63.

See 42 C.F.R. § 1001.952(n) (8).

64.

See, e.g.,

A. G.

Sheinin

, “’Broadband Deserts’ Hinder Growth in Rural Georgia,” The Atlanta Journal-Constitution, June 11, 2017, available at <http://politics.myajc.com/news/state--regional-govt--politics/broadband-deserts-hinder-growth-rural-georgia/Fx3iwMdptBtTfMpdz0CgtJ/> (last visited July 11, 2018).

65.

J.T.

Ripton and

C. S.

Winkler , “How Telemedicine is Transforming Treatment in Rural Communities,” Becker's Healthcare, April 8, 2016, available at <https://www.beckershospitalre-view.com/healthcare-information-technology/how-telemedicine-is-transforming-treatment-in-rural-communities.html> (last visited July 11, 2018).

66.

See Lindrooth, supra note 54, at 111.

67.

See id.

68.

See O.C.G.A. § 31-7-72.

69.

Weldon Freeman, Press Release No. 0151.17: “USDA Invests More Than $1 Billion to Improve Health Care in Rural Areas,” USDA, November 17, 2017, available at <https://www.usda.gov/media/press-releases/2017/11/17/usda-invests-more-1-billion-improve-health-care-rural-areas> (last visited July 11, 2018).

70.

Herman

, “When the Tiny Hospital Can't Survive: Free-standing EDs With Primary Care Seen as New Rural Model,” Modern Healthcare, September 27, 2014, available at <http://www.modernhealthcare.com/article/20140927/MAGAZINE/309279952> (last visited July 11, 2018).

71.

Nolin

, “Rural Hospital Measure Clears Path for ‘micro’ Hospitals,” Tifton Gazette, February 7, 2018, available at <http://www.tiftongazette.com/news/rural-hospital-measure-clears-path-for-micro-hospitals/article_97115402-0c33-11e8-861e-0b6ca029e873.html> (last visited July 11, 2018).

72.

See Rural Health Information Hub, “Rural Care Coordination Toolkit,” available at <https://www.ruralhealthinfo.org/tool-kits/care-coordination> (last visited July 11, 2018).

73.

“Frontier Community Health Integration Project (FCHIP),”

Rural Health Information Hub, available at <https://www.ruralhealthinfo.org/new-approaches/frontier-community-health-integration-program> (last visited July 11, 2018).

74.

“Health Extension Rural Offices (HEROs),”

Rural Health Information Hub, October 11, 2017, available at <https://www.ruralhealthinfo.org/community-health/project-examples/981> (last visited July 11, 2018).