Health Affairs’ Rural Health Issue Has Special Relevance to California

Stories that caught our attention

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Photo: Vincent James

Where you live shouldn’t determine your access to health care or the quality of that care. But because one in five Americans lives in a rural area, many millions of people face significant barriers to care and in almost every state are burdened with higher mortality rates than people in urban areas, according to the new issue of Health Affairs.Essential Coverage

Rural residents are confronted by many obstacles, including a shortage of physicians and other providers, hospital closures, higher maternal morbidity and mortality rates, and limited access to treatment for opioid use disorder. Here are highlights of research published in the Health Affairs December theme issue on rural health.

Rural Doctor Shortage

The uneven distribution of physicians has long been a challenge for rural residents, especially for rural residents of color, who may encounter difficulty finding a provider that shares their racial/ethnic background, which is important for culturally and linguistically competent care.

Only 11% of US physicians (PDF) practice in rural areas, and the proportion of medical students from rural backgrounds decreased 28% between 2002 and 2017, according to research from Scott A. Shipman, MD, MPH, director of clinical innovations at the Association of American Medical Colleges and colleagues at the association and Michigan State University.

This finding is concerning because studies show that medical students from underserved areas are more likely to practice in those areas. Additionally, “physicians from racial/ethnic minority groups that are traditionally underrepresented in medicine are more likely to practice in underserved communities and provide care to minority populations,” Shipman and colleagues wrote. However, in 2017, only 1 in 200 first-year medical students had a rural background.

To reverse that trend, the researchers recommended prioritizing policies and education programs to help young students in rural areas identify a pathway into medicine. This could include college readiness programs, education about available financial aid, and opportunities to shadow established physicians. The researchers also encouraged medical schools to recognize and value applicant diversity, including those applicants from rural and underserved areas, in the admission process.

Some communities in California have already implemented programs in rural areas to boost their physician workforce. In the Inland Empire, which is the region most affected by California’s physician shortage, the University of California, Riverside, medical school specifically trains doctors to practice locally, Elizabeth Aguilera reported for CalMatters. The UC Riverside medical school opened in 2013 and “offers scholarships to students who promise to return after residency to practice in the area.” It also partners with the Riverside University Health System residency program to prioritize applicants who are from or who have a connection to the area.

Pressure for Rural Hospitals to Join Systems

Although rural hospitals play a crucial role in their communities, many facilities struggle to maintain financial stability. Since 2005, 161 rural hospitals across the country have closed. Some rural hospitals have tried to mitigate financial losses by joining a multihospital system. A RAND Corporation study published in the journal examined the relationship between health system affiliation and hospital performance.

Claire E. O’Hanlon, PhD, MPP, adjunct policy researcher at RAND, and colleagues compared changes in performance between 2008 and 2017 for a nationwide sample of rural hospitals that became affiliated with health systems to changes among those that remained unaffiliated. They found that while health system affiliation was associated with improved financial margins for rural hospitals, it was also related to significant reductions in access to on-site imaging, obstetric, primary care, and nonemergency outpatient services. They did not observe improvements in health care quality following affiliations.

A CHCF study of the impact of system membership on rural hospitals in California provided a similarly mixed picture. Among the six rural hospitals in the state that joined a system over the last 20 years, no clear financial patterns emerged. Only one of the hospitals reported substantially improved financial status after joining a multihospital system. Hospital system membership also did not appear to be linked to more clinically integrated care, the researchers concluded.

Rural Maternity Care

The US lags behind other developed nations in decreasing its maternal morbidity and mortality rates. In rural communities, many of which are losing obstetric units at an alarming rate, the challenges are particularly severe for patients trying to access quality maternity care.

Katy B. Kozhimannil, PhD, MPA, associate professor at the University of Minnesota School of Public Health, and colleagues compared maternal morbidity and mortality trends in rural and urban areas between 2007 and 2015. Their study found that rural residents had a 9% greater probability of severe maternal morbidity and mortality than urban residents with the same sociodemographic and clinical characteristics. For both rural and urban residents, some women of color (non-Hispanic Black, American Indian / Alaska Native, and Hispanic) and women who had Medicaid or no health insurance were at greater risk of severe maternal morbidity and mortality.

To reduce severe maternal morbidity and mortality, the researchers encouraged policymakers to include rural residents on decisionmaking bodies, including maternal morbidity and mortality review committees. They also highlighted the need for consistent data collection to drive hospital quality improvement (the CMQCC Maternal Data Center could be a model).

Finally, they stressed the importance of Medicaid, which funds nearly half of all births in the US. Reimbursement rates for births in Medicaid are much lower than in private health plans, which can make it difficult for rural providers to maintain obstetrics units. Increasing reimbursement rates and extending pregnancy-related Medicaid eligibility beyond 60 days postpartum could disproportionately benefit rural residents. California recently extended Medi-Cal benefits from 60 days to one year for people who are pregnant and diagnosed with a maternal mental health condition.

Rural Recovery Residences

While California has had more success curbing the opioid epidemic than other states, rural communities in Northern California still struggle to recover. Lack of access to treatment options and support services are a major problem, journalist Brian Rinker wrote in Health Affairs.

In the town of Klamath, which sits in California’s rural northwest corner, the Yurok Tribe is building its own recovery residences that incorporate traditional Native American healing practices to help community members break the cycle of addiction. Recovery residences, also known as sober-living facilities or halfway homes, are abstinence-based living environments.

Residents of Klamath currently do not have local treatment options, and Yurok Tribe members must travel more than 300 miles to seek help at a Native American residential treatment center in San Francisco. “We have a lot of substance use disorder here,” Andrew Forscht, the Yurok Tribal Court’s re-entry case manager, told Rinker. “It’s generational — a vicious cycle.”

Last year, the tribe opened a recovery residence for men and plans to add one for women soon. Though recovery residences do not offer medical treatment, they provide residents with stable housing and social support, and hold them accountable for staying sober. Because recovery residences are unregulated, there can be a lot of variation — some houses are run entirely by peers, while others offer clinical services from physicians, nurses, or clinical social workers. The peer model is especially suitable for rural areas, where access to behavioral health workers is often limited.

A key limitation for some recovery residences is the prohibition of medication-assisted treatment (MAT), the gold standard for treating opioid use disorder. Because MAT uses opioid treatment, many abstinence-based recovery residences won’t admit people who are on MAT. However, Rinker reported that as the toll of the opioid epidemic grows, more recovery residences are accepting MAT.

Read These Journal Articles

CHCF has arranged free access to the four journal articles mentioned above. The Health Affairs rural health issue is supported by CHCF, the Robert Wood Johnson Foundation, the Colorado Health Foundation, the Episcopal Health Foundation, the Kate B. Reynolds Charitable Trust, Con Alma Health Foundation, Empire Health Foundation, the John A. Hartford Foundation, and St. David’s Foundation.

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