Population Health in Rural America in 2020 Proceedings of a Workshop (2021) / Chapter Skim
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2 Rural America in Context
2 Rural America in Context
Pages 5-20
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From page 5... ...
The session was moderated by Lars Peterson from the Rural & Underserved Health Research Center at the University of Kentucky. RURAL DEMOGRAPHICS AND SOCIAL DETERMINANTS OF HEALTH Alana Knudson from the Walsh Center for Rural Health Analysis at NORC at the University of Chicago highlighted relevant demographic features of rural communities in the United States.
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From page 6... ...
Additionally, many rural counties have had persistent population loss over the past 40 years attributable to younger people migrating from rural communities to urban areas in search of jobs. In geographical terms, the distribution of rural elderly populations is somewhat different than in metropolitan (metro)
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Department of Agriculture using data from the U.S. Census Bureau Population Estimates program.
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. Knudson noted that over the past 20 years, the greatest growth in racial and ethnic representation in rural communities has occurred among the Hispanic, American Indian, and Alaska Native populations.
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Specifically, the SDOH are the neighborhood and built environment, health and health care, the social and community context, education, and economic stability.6 To explore the effect of economic stability on the health and well-being of people in rural areas, she noted that "wealth equals health." Earning a livable wage with compensation that enables access to affordable health care and health insurance is a foundational component of good health and well-being. 6 Categories of SDOH as defined by the Office of Disease Prevention and Health Promotion are available at https://www.healthypeople.gov/2020/topics-objectives/topic/socialdeterminants-of-health (accessed July 21, 2020)
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From page 10... ...
In 2018, the poverty rate for nonmetro residents was 16.1 percent compared to 12.6 percent for metro residents. Poverty rates vary in different rural areas across the country, with greater percentages of rural communities living in poverty concentrated in Appalachia, along the Mississippi Delta, in some areas of border states, in areas in the West predominantly populated by American Indian tribal communities, and in Alaska Native communities.9 Rural communities are also disproportionately affected by persistent poverty, which has long-lasting implications for health and well-being, she added.
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From page 11... ...
Similarly, central and western rural regions feature some of the least affordable housing options based on the ratio of housing prices to income.14 The Walsh Center for Rural Health Analysis at NORC at the University of Chicago looked at the ability of Missouri residents to maintain housing and found that although housing prices were affordable, the cost of electricity was not. This is one example of the multiple factors that determine whether rural residents are able to maintain safe and affordable housing.
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Probst explained how structural urbanism and current funding mechanisms systematically disadvantage rural populations and negatively affect their health outcomes. Effect of Structural Urbanism on Direct Health Care Services Probst said that structural urbanism underlies the health issues facing rural areas.
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From page 13... ...
Because of the requirements for a minimum number of funded participants and the focus on attaining national goals, rural communities are often excluded from public health programs, she explained. Probst noted that some resources contend that a physician's office in a private-pay health care system requires an estimated 1,900–2,500 patients to operate successfully.16 Small populations generally cannot provide this number of patients to a single office, which discourages practitioners from opening offices in rural areas.
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Multiple compositional factors influence health outcomes for the rural population; this results in a higher risk of death for people with diabetes who live in rural areas. These causative factors include lower levels of education and lower health insurance rates in rural America.
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For instance, national goals set by large agencies, such as the Healthy People 2020 agenda, often feature national averages without the analysis of subgroup data that is needed to accurately assess the success of public health initiatives. To illustrate, Probst noted that the Healthy People 2020 national targets for child mortality had been met for four out of five age groups by 2017 (Khan et al., 2018)
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From page 16... ...
Probst warned that without substantial changes to the ways that rural health care is delivered and funded, the COVID-19 pandemic could potentially decimate rural America's entire health infrastructure. Health Care as Infrastructure: Framework for Change As a framework for change to address the barriers posed by structural urbanism, Probst suggested framing health care as essential infrastructure within a community.
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From page 17... ...
For instance, the Tennessee Valley Authority covers parts of seven states, while the Delta Valley Authority includes eight states within the Mississippi Delta.21 Despite the challenges involved in driving change, "the consequences of failure to strengthen the faltering rural health care infrastructure would be much worse," said Probst. She then added that the United States will not be internationally competitive without a strong rural base for extractive and small manufacturing industries.
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Knudson suggested shifting from a deficit-focused view of older Americans to an asset-focused view that acknowledges the contributions older populations make to the fabric of their communities. Telehealth Services Peterson asked about the potential interplay between the lack of diabetes patient education programs described by Probst and the increase in telecommuting work that Knudson mentioned.
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From page 19... ...
Probst expressed similar concern about defining counties with less than 500,000 people as rural, because solving the problems of structural urbanism will require assessing the needs of rural communities with finer granularity. She noted that mechanisms such as the Health Professional Shortage Areas do consider multiple factors such as population, population health, and the availability of health providers,22 but even those definitions can be contentious.
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From page 20... ...
Knudson added that rural residents have historically had lower rates of health insurance coverage. She surmised that perhaps because of how closely knit some communities are, people may prefer not to owe money to anyone in their community, so the decision to forgo health care may be as much a financial preference as it is a cultural preference.
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