The Rural Conundrum Requires Action

Rural communities are approaching a perfect storm. Chronic instability in prices paid to farmers, similar to that in the 1980s, is underway, 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 healthcare available, are fighting for their very survival. Other health and behavioral health services urban residents take for granted are usually nonexistent. It is 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 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, young 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 either lack entirely or have inadequate behavioral health services.

What are some strategies that can be employed to address this conundrum that is becoming critical?

Medicaid expansion. 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 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.

Advocacy. 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.

Leverage federal programs. Third, we need to begin devising 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, at least 1743 counties have public health programs. How could the Centers for Disease Control and Prevention (CDC) modify that program to improve health and behavioral health services in rural counties?

Tech investment. 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 telehealth delivery, but also for facilitating communication for all rural residents, particularly those who are seniors and who are socially isolated.

Immediate and urgent action is needed by our state and federal legislative leaders if our rural communities are to survive. One rural resident’s 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 equally clear for our rural communities.

Ron Manderscheid, PhD, is the former president and CEO of NACBHDD and NARMH, as well as an adjunct professor at the Johns Hopkins Bloomberg School of Public Health and the USC School of Social Work.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.