Helping rural counties keep abreast of urban counterparts

Rural counties are characterized by aging populations, low incomes, and social isolation. Many young people have departed in search of urban jobs; poverty lurks in many hollows; and the local social fabric has many holes. Despite these obvious urgent needs, an old adage still rings true: Urban counties have difficulty coping with all the latest changes; rural counties still wait for these changes to arrive.

The problem of keeping rural counties abreast of their urban counterparts is especially pronounced in the behavioral health and in the intellectual development/developmental disability (ID/DD) fields. Today, most providers in these fields are located in our urban centers. Many rural counties have no providers at all. As a very pointed example, about 85% of US counties have either inadequate or no mental health services at all. The vast majority of these counties are rural.

What can be done to begin to redress these unacceptable imbalances?

First, as a matter of routine practice, federal and  state agencies must make a deliberate and planned effort to balance grant and contract awards between urban and rural counties. Today, this is not always done. There are many reasons why this occurs: urban counties frequently write better proposals; federal and state agencies prefer to administer a smaller number of larger grants or contracts, etc. As a result, rural counties often are left out. Such biases need to be recognized and addressed. One potentially promising way to address this issue is to require urban counties to mentor their rural cousins.

Second, federal and state agencies must develop specific programs for rural counties. Rural counties are likely to have both infrastructure and program deficits not experienced by urban counties. Further, these rural counties may need additional technical assistance in order to take advantage of federal and state programs. Such TA should be planned as part of federal and state program development targeted toward rural counties. This will require grant and contract announcements directed specifically toward rural counties.

Third, federal and state agencies must work closely together to train and incentivize behavioral health and ID/DD providers to work in rural counties. Although some excellent programs exist today, such as the HRSA National Health Service Corps, much, much more needs to be done. Workforce shortages now are at crisis levels.

Fourth, federal and state agencies must work together to implement tele-health outreach for rural counties. This will require development of infrastructure and changes in state-to-state legal restrictions on clinical practice.

Each of these recommended actions actually should be much easier to undertake today compared with a decade ago. The 2008 Mental Health Parity and Addiction Equity Act requires parity between behavioral health and general medical insurance benefits and their management not only in urban counties, but also in rural counties. Parity requirements can provide a very strong rationale for federal and state action in rural counties to improve behavioral health and ID/DD services.

At the same time, the 2010 Affordable Care Act already has provided both insurance and care subsidies for many rural residents with smaller incomes who previously lacked health insurance. Similarly, the ACA also has provided financial resources for Medicaid coverage for rural residents with the lowest incomes, but only in those states that have undertaken the Medicaid Expansion. Thus, additional financial resources already are available in many rural counties to multiply the effectiveness of other federal and state programs targeted there.    

Finally, some stellar federal efforts already exist. President Obama’s White House staff has undertaken outreach to rural counties to improve decarceration efforts for persons with behavioral health and ID/DD conditions. This outreach focuses on improving information technology and improving best practices. The USDA, under the outstanding leadership of Secretary Tom Vilsack, has begun significant outreach to rural counties to address the rural opioid crisis.

Bottom line: The current environment is an excellent one for federal and state programs to target specific initiatives on needy rural counties. Please advocate strongly with the federal agencies and your state agencies so that this essential work can begin.