HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 1

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1 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 1 Health Care Disparities and Health Care Policy Affecting the Rural Community Cheryl Shapiro Ferris State University

2 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 2 Abstract This paper discusses the health care disparities, social determinants and health care policies of rural America. Statistically, rural populations show a pattern of risky behaviors and increased morbidity and mortality as compared with urban populations (NRHA, 2013). Compared to urban communities there are less doctors and dentists per person and emergency response is significantly slower (NRHA, 2013). Rural communities are being recognized as vulnerable with policies and programs in place to attempt to achieve health equity.

3 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 3 Health Care Disparities and Health Care Policy Affecting the Rural Community Populations of rural America suffer from substantial health care disparities compared to those living in urban areas. Between risky health behaviors and geographic barriers to quality medical care, they have a higher morbidly and mortality rate (NRHA, 2013). Certainly, there are economic factors, cultural differences and educational shortcomings that play a role here (The White House Council of Economic Advisors, 2013). Several policies and programs are in place to study and help everyone receive equitable health care. However, it is hard to determine concrete factors for some of the disparities. Culture might be the answer, but culture is inherently hard to define. Population and Health Care Disparity Over 59 million people live in rural areas (United States Census Bureau, 2010). The government has numerical ways to define rural for their reports, but the common definition will suffice. The population and houses are sparsely located compared with urban living. Therefore the distance it takes to travel to anywhere will be further. The amount of unpaved roads is greater. This adds up to a different way of thinking and living. For example, an elderly person living in a rural area might not receive as many visits from family, so their health declines before someone notices. The road is icy and full of snow so they may put off going to the doctor until the weather is better. In addition, emergency care will simply take longer to receive. There is a cultural and environmental difference. Healthy People 2020 (2010) define health disparity as: A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their... socioeconomic status... geographic location; or other

4 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 4 characteristics historically linked to discrimination or exclusion. (Healthy People 2020, 2010, para. 6). Rural residents are more likely to have risky behaviors such as smoking, exercising less, having less nutritional diets, and they are more likely to be obese than suburban residents (Hartley, 2004). Not surprisingly then, rural Americans are more likely to suffer from cerebrovascular disease and hypertension. (National Rural Health Association, NRHA, 2013) These disparities start in youth. Rural teenagers have a higher rate of abusing alcohol and smokeless tobacco (NRHA, 2013). Forty percent of high school seniors reported drinking and driving compared to 25% of urban seniors (NRHA, 2013). Eighth graders in rural areas are more than twice as likely to smoke cigarettes (NRHA, 2013). People in rural America are more likely to die from automobile accidents. While onethird of all motor vehicle accidents take place in rural areas, two-thirds of the deaths happen on rural roads (NRHA, 2013). Not including traffic accidents, rural residents are nearly twice as likely to die from unintentional injuries as are urban people (NRHA, 2013). They are at higher risk to die by gunshot wounds as well (NRHA, 2013). All in all this population has a disadvantage with health care. This has resulted in a significant contrast with those in an urban setting in regards to morbidity and mortality rates. Social Determinants and their connection to rural health disparities The social determinants of health are the circumstances in which people are born; grow up, live, work and age, and the systems put in place to deal with illness (WHO, 2013, para. 6). Those who are born or have chosen to live in rural areas have circumstances that shape the amount of money and resources they have to work with. First, incomes are lower and poverty rates are higher in rural areas than they are in urban areas. Second, a lower proportion of the rural population is of

5 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 5 working age (20-64), which presents challenges for future job creation, and the share of the U.S. population living in rural counties has steadily declined over time. Third, a higher portion of rural residents are on disability and therefore unable to participate in the rural workforce. Fourth, educational attainment lags behind that of urban areas for the working-age population (The White House Council of Economic Advisors, 2013) Those that live in rural settings have geographical barriers in accessing health care specialties like hemodialysis centers that mainly exist in more populated areas. In addition, the extra cost may make this impossible for some. Even public transportation that specializes in transporting the elderly and disabled is likely to only operate near cities. Rural families have less access to general health care services. For instance, rural areas tend to have fewer physicians and specialists per person than metropolitan areas (NRHA, 2013). This creates difficulty in accessing care and makes early detection of disease like hypertension less likely. About 20% of Americans live in rural areas but only around 10% of physicians practice in these communities (NRHA, 2013). In addition, fewer dentists practice in rural areas (NRHA, 2013). Patients with acute myocardial infarction (AMI) who were treated in rural hospitals had significantly higher adjusted 30-day post AMI death rates from all causes than those in urban hospitals (NRHA, 2013). Access to emergency care is a major problem. 90% of emergency responders are volunteers (NRHA, 2013). That plus distance means a longer response time. In fact, it is eight lifesaving minutes longer that in urban areas (NRHA, 2013). This can be especially problematic in the case of heart attacks, strokes and traumas where quick treatment saves lives. Arriving to a small local hospital is another problem. They do not have the staff and skill needed for difficult

6 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 6 traumas. Statistically this adds up to the death toll being twice as high on rural as opposed to urban roads (Gamm, L., Hutchison, L., Dabney, B., and Dorsey, A., 2003). Health Care Policy Several policies are in place to improve the health care of rural populations. This starts with quantifying the problem in order to find the causes of health disparities. The Department of Health and Human Services, Centers for Disease Control and Prevention National Center for Health Statistics, has compiled the 25 th United States, 2001 Urban and Rural Health Chartbook (2001). This 189 page book is available free in print or electronic copy. These are the statistics that are used to know who, what, when, where and why we have health disparities and how to improve them. A second program that has much potential is Telehealth which was created by the Health Resources and Services Administration, HRSA (n.d.). Its purpose is the use of electronic information and telecommunications technologies to support long-distance clinical health care, education, and health administration (HRSA, n.d.). Hopefully this will grow with electronic health records to provide video conferencing for emergency referrals. As well as untold education for the public and health care professions for communities that would ever be able to afford quality products. Medicare and Medicaid have programs to address transportation needs for poor people. For those that qualify, Medicaid does provide for personal care services (Centers for Medicare & Medicaid Services.CMMS, n.d.). Transportation services, essentially driving and escorting the client, were allowed in at least 65 percent of the States for the attendant... However, escorting was more frequently allowed than driving because it alleviates some concerns about accident liability (LeBlanc, Tonner, and Harrington, 2001, p. 166). In other words, they had to be able to afford their own car. So what about the people who almost qualify but their income was too high? They would be eligible after spending this excessive income on medical expenses first in

7 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 7 the month (CMMS n.d.) However, if someone is poor enough to almost qualify for Medicaid there is a good chance that this will still be too much. For example, a dialysis patient needs treatments 12 times per month, every month. Contributing Factors to Disparities Culture There are two groups to question about the contributions to the health care disparities. Of the rural residents, we have to ask why they are not doing more to attain a healthy life style. Why are they more obese? The answer does not have to do with how many physicians are in a given area. It may have to do with the independence of the American people. We are free do to as we please, and often it pleases us to sit on the couch and smoke and drink. We could ask the urban residents if they are perhaps responding to a type of peer pressure. How do their fellow citizens dress and look. Do we see them smoking or out for a bike ride? Values held by those in power In is not uncommon for anyone in political or financial power to make decisions based on numbers. Statistics are used to show where there is the greatest need and to show improvement. When the population needs of a rural area are compared to urban, the smaller population is likely to lose. The number of people helped would not be as many. Honestly, physicians who specialize will always be closer to a city hospital as well. Health care workers also have a type of power. Many have some uncharitable attitudes that are not encouraging. In a free, mobile society, there are those who would have the attitude that things will level out eventually and if needs are not being met, those who have that unmet need should move to where they can have their needs met. In a way, it is a byproduct of a society that is economically based on supply and demand. Finally, let us not forget the well meaning but unkind attitude that everyone should pull themselves up by their own boot straps.

8 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 8 References Centers for Medicare & Medicaid Services.CMMS. (n.d.). Medicaid. Retrieved from: Department of Health and Human Services, Centers for Disease Control and Prevention National Center for Health Statistics. (2001). Health, United States, 2001 urban and rural health chartbook. Retrieved from: Gamm, L., Hutchison, L., Dabney, B., and Dorsey, A. (2003). Rural Healthy People 2010: A companion document to healthy people Volume 1. Retrieved from: Hartley, D. (2004). Rural health disparities, population health, and rural culture. American Journal of Public Health, 94(10), Retrieved from: Health Resources and Services Administration, HRSA. (n.d.). Telehealth. Retrieved from: Healthy People (2010). Disparities. Retrieved from: LeBlanc, A., Tonner, C., and Harrington, C. (2001). State Medicaid programs offering personal care services. Health Care Financing Review, 22(4), National Rural Health Association (NRHA). (2013). Retrieved from: The White House Council of Economic Advisors. (2013). The labor force in rural America strengthening the rural economy - The current state of rural America. Retrieved from:

9 HEALTH CARE DISPARITIES AND HEALTH CARE POLICY 9 United State census Bureau. (2010). Frequently asked questions. Retrieved from: World Health Organization. (2013). Key concepts. Retrieved from: