October 16, 2009
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Hot Topic: Rural Health

Approximately 17 percent of the US population is spread out over 80 percent of the country’s land mass.1 Such geographic dispersion, and often isolation, has resulted in unique health care challenges. Of those living in rural areas, 15 percent live below the poverty level, compared to 12 percent of those in urban areas.2  Priority public health issues in these areas are not sanitation and communicable disease prevention, as in urban America, but unintentional injury, environmental health hazards, substance abuse, an insufficient health care workforce, and limited access to health care services.

Disparities
Health disparities are particularly relevant in rural America. Some specific population subgroups living in rural America are particularly influenced by these disparities, including American Indians, Alaska Natives, and agriculture workers. A complex web of factors contribute to these differences, including poverty, educational attainment, access to health services and health insurance, personal behaviors, cultural influences, and environmental conditions.

Forty percent of American Indians and Alaska Natives live in rural areas.3 More than one-quarter of them are smokers; one in five have two or more chronic health conditions; and one-third live in families with incomes below the federal poverty level.4 HCFO grantee Kathryn Langwell, of Sundance Research Institute and formerly of Sanford Research/University of South Dakota, examined health care access and quality of care for those in this population who receive care through the Indian Health Services (IHS). In particular, she analyzed the resources available for health care for this population and the service priorities and mechanisms for explicit and implicit rationing of care. Langwell and her research team concluded that IHS per patient funding is less than half of national per capita health spending. Further, they deduced that under-funding of the IHS system has led to explicit rationing of services to American Indian and Alaska Native patients, with many specialized services provided only for “life or limb threatening” conditions. While most prefer to receive care through the IHS, its patients report experiencing access barriers. In addition, they rate the quality of care process substantially lower than do Medicaid beneficiaries. A recent HCFO findings brief describes Langwell’s findings in more detail.

Not all rural residents face the same barriers to health. For example, agricultural workers face the particular challenges of tooth decay and tuberculosis. Migrant workers specifically suffer from excessively high disease and mortality rates. This group, which is estimated at 3 million seasonal and farm workers in the United States, is plagued by lack of insurance, inadequate health information, illiteracy, language barriers, and negative attitudes toward traditional medicine.5

A HCFO project, funded under the special topic solicitation in public health systems research (PHSR), aims to uncover strategies for addressing the public health needs of culturally and linguistically diverse populations. For this project, led by Claudia Schur, Ph.D. at Social and Scientific Systems Inc., researchers are developing detailed community multicultural profiles describing the cultural and linguistic diversity of populations served by local health departments (LHDs). They will use these profiles to understand specific strategies that LHDs engage in to meet the needs of diverse populations and what strategies appear to be most successful. Also, they will explore the obstacles that appear to be most difficult to overcome in serving different types of population subgroups and which types of services are most difficult to deliver.

Access
The rural health infrastructure is comprised of a fragmented and under-resourced public health system as well as a fragile safety net. Access to care is a primary concern; almost one out of every five uninsured Americans are located in rural areas.6

In addition to high rates of poverty and uninsurance, rural residents are more likely to be elderly and to have children in the household, making these groups more reliant on Medicaid. In fact, 14.7 percent of rural residents were enrolled in Medicaid in 2002, as compared to 11.2 percent of urban residents; one-third of all births were paid for by Medicaid; and nearly 20 percent of rural physician revenue was accounted for by Medicaid.7

In a previous HCFO funded study, William Pittard, Ph.D. at the Medical University of South Carolina found that there was a striking difference in Early and Periodic Screening Diagnosis and Treatment (EPSDT) utilization among infants enrolled in different South Carolina Medicaid health care systems.  Rural infants had a significant difference in evaluations in the first year of life. Since the primary goal of EPSDT services is to prevent and detect disease early, so that more serious health problems and more costly health care services can be avoided, variation in EPSDT utilization could have adverse effects on both health outcome and cost for low-income infants.

Resources
A well documented challenge for rural communities is the lack of a reliable and well educated health workforce. However, other resource challenges exist. Two HCFO grants, funded under the special topic solicitation in PHSR, explore ‘regionalization’ as a strategy for resource sharing. Michael Stoto, Ph.D., from Georgetown University, investigated regionalization in the context of increasing emergency preparedness capacity and coordination of response. He found that this strategy allows for more efficient use of resources. He also found that regionalization can lead to better planning and coordination, the development of professional networks, and enhancements to preparedness training and exercises. In the other grant funded under the PHSR solicitation to investigate regionalization, Li-Wu Chen, Ph.D., at the University of Nebraska Medical Center, is evaluating Nebraska’s change from a single-county health department to multi-county public health systems. He expects that a regional approach could have advantages for states like Nebraska, due to its relatively small population base and large geographic area. The objective of this project is to inform federal and state policymakers about the lessons learned through Nebraska’s ‘natural experiment’ with a regional public health agency model, so that performance of public health practice can be improved.

Public Health System Structure
Because of the scarcity of resources in rural communities, Douglas Wholey, Ph.D. from the University of Minnesota researched the structure and process of integrating public and private resources in rural areas. He investigated how system organization, specifically, the centrality of local health departments, impacts public health system performance. His results illuminate the relationship between local public health departments and the systems in which they reside, suggesting that rural communities tap into unused system partners, such as faith-based groups and senior volunteers.8

In a related project, Susan Zahner, Ph.D. at the University of Washington examined the factors that influence the performance of small local public health systems in Wisconsin. The challenges she identified for these systems include small labor pools and out-migration of younger workers; limited information capacities, including lack of small area data, limited IT systems, and lack of integration of electronic data systems; inadequate physical resources; and lack of physical proximity to important system partners, hindering collaboration, especially when technological capacity is lacking.

Funding
The research findings noted above suggest that increased funding for rural health has the potential to improve the health status of rural residents and influence the disparities that abound. However, as Langwell notes in her brief, options to increase funding would impose higher costs on federal and state budgets and are unlikely to be feasible in the current economic environment.

In a project examining local funding for health services in nine rural states, Mary Zimmerman, Ph.D. from the University of Kansas Medical Center Research Institute found that counties in largely rural states often spend a sizable portion of their tax monies to support health care services. In comparing rural to metro counties, she found that rural counties spent statistically significant more public monies for health care than metro counties in six of the nine states (Georgia, Kansas, Montana, Nebraska, New Mexico, Utah). A key factor explaining when counties are likely to spend more public funds for health care was low population density (i.e. greater rurality). In most states, the major share of county-level health care expenditures went to ambulatory care/public health and hospitals. 

These unique challenges posed by rural America will intensify, particularly as its demographics change—the population is aging and the greatest population growth is among Native Americans, African Americans, Hispanics, and migrant populations.9 Addressing the special needs of rural America, especially in today’s difficult economic climate, will require an understanding of its distinct challenges.

HCFO Sponsored Work on Rural Health

The HCFO program currently has several studies underway which will help to shed light on the unique policy needs of rural communities.

Title: Financing American Indian Health Care: Impacts and Options for Improving Access and Quality of Care
Institution: Sanford Research/University of South Dakota
Principal Investigator: Kathryn Langwell
Grant Period: September 2007 - September 2008

The researchers examined health care access and quality of care for American Indians who receive care through the Indian Health Service (IHS). In particular, they: 1) determined the resources (national and regional per capita spending) available for health care for this population from 2000 to 2005; 2) assessed service priorities and the mechanisms for explicit and implicit rationing of care; 3) analyzed the impact of priorities and rationing mechanisms on access to care, availability of services, quality, and outcomes; and 4) developed options for improving access and quality for American Indian heath care and analyze the feasibility and costs of these options. The objective of the project was to contribute to the understanding of the impact of current financing and organization of the Indian Health Service on access and quality and the contribution of these factors to the health disparities experienced by this population.

Title: Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations
Institution: Social and Scientific Systems, Inc.
Principal Investigator: Claudia Schur, Ph.D.
Grant Period: May 2008 - December 2009

The researchers will examine the public health needs of culturally and linguistically diverse populations. Specifically, they will develop detailed community multicultural profiles describing the cultural and linguistic diversity of populations served by local health departments (LHDs). They will then use these profiles to analyze the relationships between population characteristics and existing public health capacity and to identify and survey select communities for more in-depth information about serving these populations. They will seek answers to the following research questions: 1) How do jurisdictions with LHDs compare in terms of the composition of the population served? To what extent do communities include substantial numbers of racial/ethnic minorities, immigrants, and/or persons who speak a language other than English? 2) Does the structure and capacities of LHDs vary with respect to the multicultural profile of the populations they serve? How do LHD resources and activities correspond to local community characteristics? 3) What are the specific strategies that LHDs engage in to meet the needs of diverse populations? What types of strategies appear to be most successful? Are community partnerships used either for training purposes or for the delivery of culturally appropriate services? 4) What obstacles appear to be most difficult to overcome in serving different types of population subgroups? Which types of services are most difficult to deliver? What characteristics or combinations of characteristics of communities and LHDs create the most substantial obstacles? The objective of this project is to develop policy recommendations for implementation of promising strategies to better serve diverse populations.

Title: A Systematic Study of Nebraska’s Regional Public Health Agency Model
Institution: Board of Regents of the University of Nebraska (University of Nebraska Medical Center)
Principal Investigator: Li-Wu Chen, Ph.D.
Grant Period: January, 2008 - December, 2009

The researchers will evaluate Nebraska’s change from single-county health departments to multi-county or regional public health systems. The researchers posit that a regional approach could have advantages for states like Nebraska due to the state’s relatively small population base and large geographic area. They will examine the regional public health agency model based on variation and/or effectiveness of the following factors: 1) macro context, i.e., political, social, and economic environment; 2) structural capacity, i.e., human, organizational, fiscal, and informational resources); 3) processes, i.e., community partnerships, resource allocation; and 4) outcomes, i.e., practice and performance of public health services. The objective of this project is to inform federal and state policymakers about the lessons learned through Nebraska’s experience with a regional public health agency model, so that performance of public health practice can be improved.

Title: Public Health System Organization and Performance in Rural Communities
Institution: University of Minnesota
Principal Investigator: Douglas R. Wholey, Ph.D.
Grant Period: January 2007 - June 2009

The researchers will examine public health system organization and public health performance in eight rural communities through a comparative case study. Their focus is particularly on rural communities, since the scarcity of resources there increases the importance of integrating public and private resources optimally. In particular, they will: 1) describe the organization of key essential services networks within each rural community; 2) describe the structures and processes that integrate activities across the essential services networks; and 3) compare public health system performance. The objective of this project is to illuminate the relationship between local public health systems and public health outcomes.

Title: Structural Capacities, Processes and Performance of Essential Public Health Services by Small Local Public Health Systems
Institution: University of Wisconsin
Principal Investigator: Susan Zahner, Ph.D.
Grant Period: February, 2006 - July, 2009

What factors influence the performance of small local public health agencies (LPHA) in Wisconsin? The researchers will identify key factors by determining the contributions of specific structural capacities and processes in providing three public health services: 1) monitoring health status, 2) mobilizing community partnerships, and 3) developing policies and plans. The objective of the study is to gain insight into specific factors that can improve the quality of small local public health systems in order to assist policymakers and administrators with targeting resources and technical assistance.

Title: Local Funding for Health Services in Rural Counties
Institution: University of Kansas Medical Center Research Institute, Inc.
Principal Investigator: Mary Zimmerman, Ph.D.
Grant Period: April 2003 - March 2004

What is the role of local public funding for rural health care? Building on prior work studying this funding stream in the state of Kansas, the researchers replicated their analysis in nine rural states. They tested their hypothesis that local public funding is more extensive than previously recognized by examining (1) the extent to which county tax expenditures are being used to fund local health care services in rural areas of the United States; (2) the factors that explain the extent to which counties will tax themselves to finance local health care services; and (3) which categories of services most commonly receive local public funding and under what conditions. This study informs policymakers about the role of public funding for rural health care systems and its impact on health delivery for vulnerable populations, especially the rural elderly.

Title: Quality Assessment of South Carolina Medicaid Managed Care
Institution: Medical University of South Carolina
Principal Investigator: William B. Pittard, M.D.
Grant Period: March 2002 - February 2003

What amount of preventive care is provided to urban and rural South Carolina preschool Medicaid children in two voluntary primary case management (PCCM) managed care programs? The hypothesis tested was that there are significant differences between the proportion of one year old Medicaid children who receive the American Academy of Pediatrics recommended number of Early and Periodic Screening Diagnosis and Treatment (EPSDT) evaluations enrolled in the state's two PCCM programs and that these differences vary based on rural versus urban residence. The objective of this work was to produce results that will suggest future alterations in public health-care financing to facilitate further improvement in cost, access and quality of care for children.

Title: Racial and Socioeconomic Disparities in Health Care Among the Insured
Institution:  University of Rochester
Principal Investigator: Kevin Fiscella, M.D.
Grant Period: January 2000 - December 2000

What is the effect of managed care market penetration on socioeconomic and racial/ethnic disparities in health care? Researchers at the University of Rochester hypothesized that, given managed care’s assumption of responsibility for the health care of populations (rather than specific individuals), managed care penetration may help alleviate disparities in health care access and quality between different socioeconomic and racial/ethnic populations. Among their hypotheses was that enrollment in an HMO will result in lower access, utilization and satisfaction, but higher overall disease prevention compliance. In addition to the CTS Household Survey, the researchers used market data from the Area Resource File in their analyses. The study had three specific objectives: 1) to examine racial/ethnic and socioeconomic disparities in health care access, utilization, preventative care, and satisfaction among insured populations; 2) to compare disparities in health care by socioeconomic and racial/ethnic status among persons enrolled in HMOs with similar individuals covered through indemnity insurance; and 3) to examine disparities in health care access, quality, and satisfaction among HMO enrollees of different racial/ethnic groups based on HMO market penetration, patient choice, and duration of enrollment.

1 Brand, M. and T. Morris. “More Efforts Needed to Better Understand Rural Public Health,” Journal of Public Health Management and Practice, Vol. 15, No. 3, May/June 2009, pp. 181-92.
2 DeNavas-Walt, C. et al. "Current Population Reports: Income, Poverty, and Health Insurance Coverage in the United States: 2007," U.S. Census Bureau, U.S. Government Printing Office, 2008.
3 U.S. Department of Health and Human Services Office of Minority Health; www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=52
4 James, C. et al. "A Profile of American Indians and Alaska Natives and Their Health Coverage," The Henry J. Kaiser Family Foundation, September 2009. www.kff.org/minorityhealth/7977.cfm
5 Larson, A. and L. Plascencia. "Migrant Enumeration Study," U.S. Office of Minority Health, 1993.
6 Seshamani, M. et al. "Hard Times in the Heartland: Health Care in Rural America," U.S. Department of Health and Human Services. www.healthreform.gov/reports/hardtimes/
7 "Medicaid and Its Importance to Rural Health," Issue Brief, Rural Policy Research Institute, May 2006. www.rupri.org/Forms/IssueBrief.pdf
8 Wholey, D. et al. “Public Health Systems: A Social Network Perspective,” Health Services Research, Vol. 44, No. 5, Part II, October 2009, p. 1855.
9 Meit, M. and A. Knudson. “Why is Rural Public Health Important?,” Journal of Public Health Management and Practice, Vol. 15, No. 3, May/June 2009, pp. 185-90.
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