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The rural conundrum turns critical
Rural communities are approaching a perfect storm. A major farm crisis, similar to that in the 1980s, is looming on the horizon, particularly in the Midwest. Rural communities are becoming older, with upwards of one-fifth of their populations now being seniors. Community hospitals, often the only health care available, are fighting for their very survival. Other health and behavioral health services urban residents take for granted are sparse or nonexistent. Not a very positive overall picture.
These economic and social realities are reflected every day in the behavioral problems that rural communities face. Care for persons with serious mental illness is now being made more difficult because many of these same people now have drug problems, particularly opioid dependence. County and local jail inmates consist predominantly of persons with behavioral health conditions, and a new group, persons with intellectual and developmental disabilities (I/DD), is growing in these settings. Opioid and other drug problems continue to escalate, and many rural communities face frequent and tragic overdose deaths.
In a growing number of rural counties, what behavioral health and I/DD services do exist are being regionalized. Although well intentioned and sometimes effective, many of these regional entities lack the resources and personnel to deliver needed services across multiple counties. At the same time, the distance between provider and client has been multiplied. The oft stated statistic remains true that 85% of rural counties lack entirely or have inadequate behavioral health services.
What are some strategies that can be employed to address this conundrum that is turning critical?
First, it is essential that health insurance be available to those who live in rural counties. Because many rural residents will qualify, this means that the Affordable Care Act (ACA) Medicaid expansion or an appropriate alternative must be made available in states that have yet to adopt it. Part of the irony in the failure of these states to take action is that most have large rural populations who are being punished by stubborn political inaction.
Second, we need to engage in vigorous national advocacy to protect community hospitals and to extend federally qualified health centers and rural health centers into more rural counties. We also need to support the expansion of the certified community behavioral health clinic program to additional states and communities.
Third, we need to begin thinking outside the proverbial box about new strategies for delivering health and behavioral services in rural counties. Several possibilities come immediately to mind. Virtually all rural counties have a USDA Agricultural Extension Service Office. How could that program be modified to incorporate nurse practitioners, physician assistants, and peers on a county level, with more senior personnel at a regional level? Similarly, 1,743 counties have public health programs. How could the Centers for Disease Control and Prevention modify that program to improve health and behavioral health services in rural counties?
Fourth, we need to invest in communication technology so that all rural counties have the same online capacities as their urban counterparts. Not only will these tools be vital for telecare delivery, but also for facilitating communication for all rural residents, particularly those who are seniors and who are socially isolated.
On April 5, I had the opportunity to attend the 3rd Annual Rural Health Conference held at the University of Georgia in Athens. Throughout the day, discussion by hospital, county, and state leaders highlighted the life-and-death nature of the issues described above.
I left the meeting with the overwhelming impression that immediate and urgent action is needed by our state and federal legislative leaders if our rural communities are to survive. One comment seemed to sum this up: “To have a town, you need a hospital, a school, and a grocery store. If you lose any of the three, you no longer have a town.” The implications seem very clear.
Our hats are off to Bill Boling and to Mason Reid, of Boling Associates in Atlanta, the pair that organized the conference. We thank them and their Georgia colleagues for bringing the issue of rural survival to a broader audience for immediate action.
