We must make rural health care a high priority

Health Progress, Sep/Oct 2001 by Place, Michael D

In early August I had the privilege of visiting two rural Michigan hospitals, Mercy Health Services North-Cadillac and Mercy Health Services North-Cadillac and Mercy Health Services North-- Grayling, both part of Trinity Health, Nov, MI. Mercy Cadillac has served its community for 93 years; Mercy Grayling has done the same for 90 years. These visits are part of my effort to learn more about the rural Catholic health care ministry. I had previously spent time with the North Dakota Catholic Association, Bismarck, ND; the Southern Region of the Illinois Hospital & HealthSystems Association, Carbondale, IL; and the board of Avera Health, Yankton, SD, all of which are deeply involved in rural health care. In the few next months, I hope to experience other dimensions of this important aspect of Catholic health care in the United States. And it is important: According to our latest figures, about 28 percent of Catholic hospitals are located in rural areas.

In preparation for my recent visits, I reviewed some of the information presented at a recent conference, "Rural Health Care: Current Issues and Future Directions," cosponsored by Southern Illinois Healthcare, a health care system, and the Southern Illinois University School of Law, both based in Carbondale, IL. In this article, I will share some important information about rural health care from that conference and several other sources.

Some readers may ask, "Why should a city boy like Fr. Mike Place be interested in rural health care?" My answer is based on our church's preferential concern for the poor and vulnerable-and for those who serve them. In recent years, I have come to appreciate (as I did not before) the fact that rural Catholic health care provides an invaluable service to an often overlooked segment of our population, a segment that suffers significant socioeconomic poverty and is quite vulnerable when it comes to health status. I have also learned that the rural health care ministry is itself often economically disadvantaged and that its very future is at risk.

I therefore offer this column as a beginner's introduction to an important part of our U.S. health care ministry. In the future, I hope that more knowledgeable writers will-perhaps in a special issue of Health Progress-provide us with insight into the success and challenges of the rural health care ministry.

RURAL CHALLENGES

Rural America faces a variety of socioeconomic challenges. For one thing, agriculture no longer supports the rural economy; today only 1.78 percent of the rural population is engaged in farming as a primary occupation.1 More than 20 percent of total personal income in rural areas is derived from federal transfers. As the federal government continues to reduce such payments, rural communities will have to develop income substitutes. If they fail to do so, they will not remain viable, let alone grow.

In general, the rural economy has strengthened over the past decade, but the economic status of rural Americans has not. Rural employment continues to be dominated by industries in which both wages and health benefits are low. Jobs in rural areas are often seasonal, weather-dependent, and hitched to the economic vagaries of but one or two industries.

Employment among rural Americans has increased somewhat, but wages have not. To increase family income, a worker must often hold more than one job. What is more, rural families are more likely than urban families to be poor despite employment. Rural families find it difficult to qualify for Medicaid because, even if they do meet the program's income limits, they do not meet its categorical requirements.

Although rural America's general economy has improved, it continues to have persistent pockets of intractable poverty. In general, poverty rates are higher in rural areas than in urban areas (15.7 percent vs. 12.6 percent, according to 1997 figures.) Child poverty is also higher in rural areas (22.7 percent, as opposed to 19.2 percent in urban areas). According to the federal government, 23 percent of the nation's 600 "persistent poverty counties" (those in which, from 1960 to 1990, 20 percent or more of the population was impoverished) are rural, being found in the South, Appalachia, the lower Rio Grande Valley, and on Indian reservations.

Along with continuing poverty, rural America is dealing with important demographic changes. Between 1990 and 1999, for example, 61 percent of rural counties experienced a population increase. Nearly 88 percent of that increase was the result of migration from metropolitan areas. When city people move into a rural community, they tend to change its ethnic and racial composition, which, in turn, puts new pressure on the community's traditionally limited governmental infrastructure and small schools.

Rural America's dilemma is complicated by the fact that, despite relative population increases, the historical trend is in the other direction. The United States, once a nation of farmers, changed radically in the 20th century. According to the 2000 census, the population is today 60 percent suburban, 20 percent urban, and 20 percent rural. In 1996 only 76 of 435 congressional districts were in predominantly rural areas. In only 13 states is a majority of the population rural. Those 13 rural states have a total of 59 electoral votes-five more than the number held by California alone.