HealthVoices Health and Healthcare in Rural Georgia Issue 3, Publication #100, February 2017 Samantha Bourque Tucker, MPH; Hilton Mozee, BA; Gary Nelson, PhD The perspective of rural Georgians Rural Georgia communities are losing their capacity to deliver the right care, at the right time, and at the right place. Increasingly, many rural Georgians now reside in medical deserts, where access to affordable, quality healthcare is severely compromised. Hospital closures, healthcare workforce shortages, and limited access to preventive services are among a host of factors that contribute to the health penalty for living in rural Georgia. Among Georgia s 159 counties, of which 108 are defined as rural, 34 rural counties report the worst health outcomes (University of Wisconsin Population Health Institute, County Health Rankings and Roadmaps, ). For rural Georgians, their place of residence or zip code has now become a powerful predictor of their health status. More rural Georgians reported personally experiencing barriers in accessing healthcare services. Because health disparities have become a substantially place-based issue, Healthcare Georgia Foundation is committed to taking the pulse and temperature of rural Georgians with the fundamental belief that in the midst of difficulty lies opportunity for greater health equity. In, the Foundation supported a statewide public opinion survey designed to capture the perspective of rural Georgians with respect to the structure, delivery, and financing of their healthcare. The results are reported in this issue of HealthVoices.
2 HealthVoices: Health and Healthcare in Rural Georgia About this Survey During the summer of, Healthcare Georgia Foundation provided support to Opinion Savvy to conduct a second public opinion survey among rural Georgians (see HealthVoices: Rural Health and Healthcare: Georgia Poll Results). THE survey provided an opportunity to support the Foundation s interest in continuously monitoring health and healthcare as important issues among the 1.8 million residents calling rural Georgia their home. The survey also sought to reveal rural Georgians personal experience with healthcare, unique local healthcare issues, and perceptions regarding responsibility for rural healthcare. More than 1,900 rural Georgians were asked in this statewide survey to consider the importance of better health and healthcare as an issue where they live; how they personally experience access to affordable, quality healthcare; and what it means to access care. Additional questions were added in this survey to obtain rural Georgians perceptions on recent state legislation regarding hospital tax credits; methods for expanding healthcare coverage; and perceived changes in personal healthcare access, quality, and cost. Personal Experience with Healthcare in Rural Georgia FIGURE 1 Opinion on Pursuing Methods for Expanding Health Coverage without Expanding Medicaid? TABLE 1 Issues Experienced with Personal Healthcare? Cost of Care Lack of Doctors/Providers Lack of Insurance Transportation/Distance to Care Insurance Not Accepted 46.3% approve 24.8% undecided 53.1% 32.6% 41.9% 18.0% 28.2% 53.0% 46.0% 49.5% 33.2% 48.7% 28.9% disapprove In, Rural Georgians more frequently reported experiencing a number of issues with respect to personal healthcare, access, and coverage (Table 1). In contrast to results, survey respondents increasingly experienced personal issues with lack of doctors/providers (46%), lack of insurance (49.5%), acceptance of health insurance (48.7%), and physically accessing healthcare transportation/ distance to care (33.2%). Young adults, African Americans, females, and low-income populations were most likely to self-report experiencing issues related to healthcare access and coverage. Nearly half of respondents indicated an experience that included a lack of health insurance. In addition, more than 46% of respondents in approved the state pursuing methods of expanding healthcare coverage for uninsured Georgians without expanding Medicaid (Figure 1).
Issue 3, Publication #100, February 2017 3 68.8% 61.2% Perceived Rural Healthcare Issues and their Impact on Communities What do rural Georgians perceive as the biggest problem in local healthcare? In contrast to results, access to care has become more important relative to cost of care. In, 61.2% of respondents cited cost as the biggest problem, followed by quality (24.4%) and access to care (14.4%) (Figure 2). Minority respondents were more likely to self-report problems accessing healthcare locally. In addition, younger African-American and female respondents were least likely to cite cost of care as a problem. Access to care has become more important relative to cost of care 6.4% 14.4% Access to Care Quality of Care FIGURE 2 Biggest Problem in Local Healthcare? 24.8% 24.4% Cost of Care FIGURE 3 Changes in Personal Experiences with Healthcare? 39.7% about the same QUALITY OF CARE ACCESS TO CARE 40.9% about the same 20.8% better 38.3% worse 24.1% about the same 33.5% 26.8% worse better 15.8% better COST OF CARE 60.1% worse Rural Georgians were asked to evaluate changes they experienced with healthcare access, quality, and cost. The results suggest a potentially complex interaction between perceptions of access and cost, noting the changes from. Sixty percent of respondents cited perceived cost of healthcare as worse over the past year, while access (40.9%) and quality of care (39.7%) remained about the same (Figure 3). Further, the survey results indicate that affordability of insurance is the greatest issue related to payment for healthcare services (48.4%). 49.6% 48.8% Consistently, in both and surveys, rural Georgians identified a clinic as the most important healthcare need in their community (49.6% and 48.8% respectively), while 18.2% of respondents cited hospital services as most important (Figure 4). In addition, younger, white, and female respondents were most likely to cite local emergency or urgent care as an important need in their community. While better nonemergency transportation was not cited as a concern as frequently as others, all demographics cited non-emergency transportation concerns at levels higher than. Clinic 19% 23% Local Emergency/ Urgent Care 13.3% 10.1% 18% 18.2% Hospital Non- Services Emergency Transportation FIGURE 4 Most Important Healthcare Need In Your Community?
4 HealthVoices: Health and Healthcare in Rural Georgia Perceived Rural Healthcare Issues and their Impact on Communities (continued from page 3) Asked to describe the shortage of medical care providers in their community, 26.8% of respondents indicated there was no shortage, 35.8% a moderate shortage, and 37.4% a severe/ extreme shortage (Figure 5). There was an increase from to in the percent of respondents reporting severe to extreme shortages in medical care providers in their communities. 49.5% 35.8% 22.8% 26.8% 23.6% 16.6% 13.8% 11.1% 66% 57.6% None Moderate Severe Extreme 24% 20% 16.6% FIGURE 5 Shortages of Medical Care Providers in Your Community? Family Practitioner Specialist 5.8% 3% Dentist 6.9% Mental Health Professional FIGURE 6 Type of Provider Having the Greatest Impact On Health of Community? With respect to types of healthcare providers, family practitioners (57.6%) maintained their role of being perceived as having the greatest impact on the health of their community, followed by specialists (20.0%), mental health professionals (16.6%), and dentists (5.8%) (Figure 6). Further, there was a 9.7% increase from to in number of respondents citing mental health professionals as having the greatest impact on the health of the community. In and, rural Georgians were asked to identify how the lack of healthcare access impacted their community, of which the two most frequently cited answers were quality of life concerns (77.2% and 80.6% respectively) and the community s economic health (66.6% and 71.2% respectively) (Table 2). Younger respondents were more likely than older respondents to identify job and population loss as a result of lacking healthcare access. TABLE 2 Community Impact Due to Lack of Healthcare Access? Loss of Jobs Loss of Population Community s Economic Health Quality of Life 64.7% 34.2% 66.6% 77.2% 69.9% 38.5% 71.2% 80.6% Less Healthy Population Accessing Mental Health Services Accessing Dental Care 61.9% 62.7% 62.5% 63.9% 75.7% 65.4%
Issue 3, Publication #100, February 2017 5 Most Important Healthcare Initiatives and Issues Facing the Rural Community Rural respondents were asked to identify important healthcare initiatives and issues facing the rural community. Most strategies addressing healthcare access and cost cited in Table 3 were assessed as more important in. In, the Georgia legislature passed Senate Bill 258, which allowed individuals and corporations to receive tax credits for donations to eligible rural hospitals. Nearly two-thirds (62.3%) of rural respondents indicated their approval of this legislation and the rural hospital tax credit (Figure 7). TABLE 3 Most Important Healthcare Initiatives in Your Community? Expand free/reduced cost clinics Provide case management services Attract more doctors & healthcare providers Provide better transportation to medical care 61.6% 72.9% 80.2% 57.5% 79.4% 80.1% 88.8% 68.9% Provide more health education 71.2% 81.2% FIGURE 7 Opinion on Legislation that Allows Individuals/ Corporations to Receive Tax Credit for Donating to Rural Hospitals? 62.3% approve Improve access to emergency care Ensure access to mental health services Ensure access to dental services 78.8% 77.0% 80.7% 78.4% 85.5% 81.9% 17.7% disapprove 20% undecided TABLE 4 Responsibility For Ensuring Local Access to Quality Care? Local Government State Government Federal Government Private Sector Community at Large 19.6% 20.1% 13.1% 27.3% 19.9% 13.1% 27.9% 26.4% 17.8% 14.8% Where Does the Responsibility for Rural Healthcare Rest? Survey respondents were asked to identify where the responsibility lies for ensuring local community access to quality care. In, respondents most frequently cited state government (27.9%) and the federal government (26.4%) as having the greatest responsibility, a change (or shift) from, where the private sector (27.5%) was held as the most responsible (Table 4). Rural Georgians were asked to identify the most important role for city/county government with respect to healthcare and the health of the community. In, the most frequently cited roles included funding (37.5%) and policy (29.7%) the reverse of (Figure 8, page 6). More than twice as many respondents in (39.5%) than in (18.3%) agreed that taxpayers should be responsible for local hospital/essential health services (Figure 9, page 6). Compared to, taxpayer responsibility for care has support among higher earner, younger respondent, and African-American populations.
6 HealthVoices: Health and Healthcare in Rural Georgia Where Does the Responsibility for Rural Healthcare Rest? (continued from page 5) 37.5% 35.7% 27.8% 29.7% 21.4% 19.5% 13.4% 15.1% 18.3% Funding Oversight Policies Services 39.5% FIGURE 8 Most Important Role for City/County Government in Providing Healthcare Services in Rural Areas? FIGURE 9 Taxpayers Should be Responsible for Local Hospital/Essential Health Services? The Survey Results: Reflections by the Foundation Where rural Georgians live should not determine whether they have access to quality healthcare services. This statewide public opinion survey addresses multiple dimensions of healthcare access broadly defined in terms of the Five Dimension Framework: affordability, accessibility, availability, accommodation, and acceptability (Figure 10). FROM the Foundation s perspective, there is significant variability in how rural consumers experience healthcare. In some communities the presence of a facility or service does not exist. A health service or a healthcare provider may not be available whenever or wherever needed. Timely access may not be possible. In addition, there may be significant shortages in types of healthcare providers. If a provider is available, he/she may not be a cultural fit with the population seeking care. The affordability of services further limit access, especially when limitations are imposed on consumers with respect to methods of procuring services. Finally, the ability to receive the right healthcare services, at the right time, in the right place is not simply determined by the healthcare system, but also includes social and environmental factors, as well as personal attributes of health consumers, ie. literacy, poverty, transportation.
Issue 3, Publication #100, February 2017 7 FIGURE 10 Five Dimension Framework Prices of services meet client s income and ability to pay Affordability Location of supply aligns with location of clients or demand Site or volume of the supply meets client s needs Delivery of healthcare accomodates client s needs Accessibility Availability Accommodation ACCESS Healthcare providers accept all clients regardless of their characteristics Acceptability Although the results of the survey do not address in-depth all dimensions of healthcare access, the findings have important implications for: 1) defining where and under what conditions healthcare access is inadequate and where it is working well; 2) improving access where it is inadequate; and 3) preserving and promoting access where it may exist. The following findings have important implications for programs and policies seeking to address health equity and decrease health disparities for rural Georgians: Cost of care, coverage, and and can t afford care were common themes among all demographics throughout the survey: nearly two thirds of respondents cited cost of care as the biggest problem in local healthcare, where affordability of insurance was the greatest issue related to payment of healthcare services. From a policy perspective, this suggests that the current system might impact rural communities disproportionately. Survey respondents reported that urgent care, transportation and access to doctors were the most desired basic services. Accessing mental health services and ensuring access within the community has become increasingly important among rural Georgians over the past year. Almost 89% of respondents indicated that attracting more doctors and healthcare providers was an important healthcare initiative in their community. From a policy perspective, this is an opportunity to expand access to primary care and coverage for low-cost clinics. Among all respondents, 27.9% believe it is the state government s responsibility to ensure local access to quality care. More than twice as many respondents in reported that taxpayers should be responsible for local hospital/essential health services than in.
About the Survey CONDUCTED BY OPINION SAVVY Target Population Rural Georgia registered voters Sampling Method The survey uses a blended sample, mixed mode: IVR: Registered voters were selected randomly from rural Georgia counties (as defined by the USDA ERS) and surveyed on the evenings of July 18th-27th, using an interactive voice response system. Mobile: Registered voters not otherwise reachable by landline telephone were surveyed July 18th August 1st, on their mobile devices. Weighting The survey was weighted for age, race, and gender where weighting benchmarks were determined using a combination of voter registration data and census data. Total Number of Respondents 1972 (weighted) Margins of Error For questions with n respondents where n = 897 n = 782 n = 983 n = 1972 Margin of error (95% confidence) ± 3.3% ± 3.5% ± 3.1% ± 2.2% Recommended Citation HealthVoices: Rural Health and Healthcare: Georgia Survey Results, Conducted by Matthew Towery, Opinion Savvy LLC, and Reported by Healthcare Georgia Foundation, Issue 3, Publication #100, February 2017 About The Two Georgias Initiative: The Initiative is Healthcare Georgia Foundation s blueprint for better health and healthcare for rural Georgians. Scheduled for implementation in 2017, this grantmaking program represents an investment in selected rural communities seeking to eliminate disparities in health. Healthcare Georgia Foundation is a catalyst for better health and healthcare in Georgia. Through strategic grantmaking, Healthcare Georgia Foundation supports organizations that drive positive change; promotes programs that improve health and healthcare among underserved individuals and communities; and connects people, partners and resources across Georgia. HealthVoices is published periodically by Healthcare Georgia Foundation as an educational service to Georgians interested in health policy. HealthVoices is available online at www.healthcaregeorgia.org. For further information, please contact Andrea Berry, Communications Manager, at 404-653-0990 or aberry@healthcaregeorgia.org.