In comparison to their urban neighbors, rural residents of the U.S. have a greater need for, but reduced access to healthcare, especially behavioral health services. By behavioral health services I mean counseling, prescription of psychotropic medications, addictions treatments and any other professional services aimed at helping people deal with emotional turmoil.
In an article in the American Journal of Public Health (June 2006 issue, pages 954-955), Dr. Ramin Mojtabai analyzed the annual National Health Interview Survey data for the years 1997-2002. He found that the prevalence of significant psychological distress was higher in nonmetropolitan areas than in metropolitan areas. This finding varied from earlier research, which reported few differences between urban and rural rates of psychological distress.
Even though their need for professional services was higher, Mojtabai reported that rural survey participants were less likely than their urban counterparts to seek mental health care. Rural residents also were less able to afford medications and professional behavioral health services.
Lack of professional behavioral healthcare providers contributes to the problem of limited access for rural residents. Data (available at www.raconline.org and the National Organization of State Offices of Rural Health) used to calculate health professional shortage areas indicate the number of psychiatrists and psychologists per 100,000 residents in rural areas is half that of these same providers in urban and suburban areas.
Recent surveys, such as the annual National Health Interview Survey, consistently indicate rural residents also tend to be older, poorer, lesser educated and to have more transportation difficulties than their urban counterparts.
Rural residents are more likely to lack health insurance. Writing for the Daily Yonder (www.dailyyonder.com/uninsured-rural-america/2012/10/22/4597), Bill Bishop reported rural and exurban counties (regions lying beyond the suburbs of a city) had higher percentages of residents under age 65 without health insurance than counties with cities or suburbs.
The counties with the most uninsured were in the intermountain region of the West and in the South. Thirty-two of the fifty rural and exurban counties with the largest percentages of uninsured persons were in Texas.
In 2003 I collected information about insurance costs for farm people, as a subsection of rural residents. Farm and ranch owners were more likely to have health insurance than workers on farms. The deductible amounts and the premiums paid by the owners were higher than for people not engaged in agriculture.
Are there solutions? The recently passed Affordable Care Act (ACA) addresses the lack of healthcare insurance. As written currently, it is estimated the ACA will reduce the number of uninsured people by half.
The ACA creates a “medical home” team of care providers which includes a nurse care manager and a primary care provider (physician, nurse practitioner or physician assistant) who follow the patient’s overall health and manage most medications, and psychiatrists, psychologists and other specialists who are available as consultants either in-person or through telecommunications.
The ACA penalizes hospitals, clinics and insurers with too high administrative costs. Current administrative costs by the Medicare system on a “per case” basis are well below those of private facilities and insurers; Medicare provides a model for administrative cost-saving.
The ACA also offers tax credits to small businesses, such as most farm operations, to make insurance more affordable for their employees.
Unless the ACA is significantly “tweaked,” the Congressional Budget Office estimates 30 million residents will still lack healthcare insurance a decade after its full implementation. Besides extending insurance coverage, the “tweaking” that needs to be done should include reducing excessive costs for drugs and certain procedures, limiting malpractice awards, and establishing a single claims processor, among other things, in order to approach “budget neutral.”
There is also a need to address the persistent stigma that seeking behavioral healthcare assistance is a sign of weakness. Farm and rural people especially tend to be self reliant and avoid seeking behavioral health services even when needed. Improving education about behavioral health in rural areas is essential. We should look at our behavior as something we can manage. Even using the term “behavioral health” is more acceptable to most people than “mental health.”
Training currently available primary physicians in rural areas to respond better to the behavioral healthcare needs of their patients and training more psychologists and behavioral health nurse practitioners to prescribe psychotropic medications are also partial solutions. Current estimates by most primary care providers are that about 25-50 percent of their services involve treating behavioral health problems.
Together with full implementation of a “tweaked” ACA, better training to diagnose and treat rural and agricultural patients’ behavioral health would vastly improve the overall quality of healthcare in rural America.
By Mike Rosmann, Ph.D.
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