Bridging the Divide of Health and Economic Disparities between Rural and Urban America Timothy McBride, PhD Professor, Brown School, Washington University in St. Louis Co-Director, Center for Health Economics and Policy
Outline • Challenges Facing Rural Health in MO and the US • Why so many challenges facing rural health? • State, federal responses to rural health challenges • Bridging the Divide
Concerns • Concerns about equity and access to care in rural Missouri, rural America • Rural hospital closures • Challenges accessing affordable care • Provider shortages • Rising concerns about impacts on health, well being in rural areas • Rising mortality and morbidity among some groups • Infant and maternal mortality • Substance use disorders • Question: why is this happening? What are the underlying causes?
Financial distress • Rural Hospital Closures • Affordability and Costs • Rising costs of insurance • Public sector costs • Out of pocket costs • Access • Provider shortages • Public health challenges • Substance use disorders • Infant and maternal mortality • Chronic disease, aging
Rural Hospital Closures (since 2010)(113 rural hospital closures) Source: UNC, Sheps Center.
Missouri Rural Hospital Closures (since 2010) • Six Hospital Closures • I-70 Community Hospital, Sweet Springs (15 beds) • Southeast Health Center of Ripley County, Doniphan (21 beds) • Twin Rivers Regional Medical Center, Kennett, MO (100 beds) • SoutheastHEALTH Center of Reynolds County, Ellington MO (21 beds) • Parkland Health Center, Farmington MO (98 beds) • Sac-Osage Hospital, Osceola MO (47 beds) Source: UNC, Sheps Center.
Financial distress and rural hospital closures • Causes of financial distress and closure are multi-faceted and complex • Long-term unprofitability is a major cause • Many factors go into contributing to long-term unprofitability • Low volumes • Market structure • Population served (older, sicker, lower incomes) • Service mix • Workforce issues • Technology challenges • Policy challenges: lack of Medicaid expansion, low payment, Medicare payment changes • The South has the greatest number of rural hospitals at high risk of financial distress
Losing Jobs in Rural America Source USDA, Economic Research Service
Losing Population in Rural America Source USDA, Economic Research Service
Though poverty rates fell significantly until the early 1970s, nonmetro poverty rates have always been higher than metro poverty rates.
Some rural areas in the U.S. have significantly higher poverty rates; mostly in the rural South and Southwest, Appalachia.
Median age: Rural 43, Urban 36 % of population age 65+: Rural 17.2%, Urban 12.8% Aged population will double from 2000 to 2030! Implications for Medicare&Medicaid Map shows two reasons for this: migration to retirement/recreation counties, but also loss of population elsewhere.
A lower proportion (28%<41%) have college education in rural America. Implication for opportunities for skilled labor positions.
Diversity in Rural America Although it is true that rural America is less diverse than urban America overall (rural: 78% white, non-Hispanic; US: 64% white, non-Hispanic)… Many areas of rural America are majority-minority
Health Insurance Marketplaces • As the marketplaces developed: • premiums offered in rural areas (dashed lines) exceeded premiums offered in urban areas. • Growth rate higher in rural than in urban. • Premiums lower in Medicaid expansion states. Health Insurance Marketplaces: Issuer Participation and Premium Trends in Rural Places, 2018 Abigail R. Barker, PhD; Lindsey Nienstedt, BA; Leah M. Kemper, MPH; Timothy D. McBride, PhD; Keith J. Mueller, PhD August 2018
Change in Uninsured due to ACA? • Uninsured rate LOWER in rural areas before ACA implemented; Uninsured rate now higher. • Why? • Higher proportion of rural people live in states that did not implement Medicaid expansion • As shown, marketplace plans less available and more expansive in rural areas • Also … less outreach and more skepticism about ACA?
Medicare Advantage Enrollment Growth Continued steady growth in Medicare Advantage enrollment in rural and urban areas. But rural enrollment has always lagged behind urban by about 10 percentage points. Implications for rural provider payment.
Medicaid Enrollment Growth • Medicaid and CHIP enrollment growth • 38% growth in Medicaid Expansion States • 12% growth in non-expansion states • 29% growth overall in all states Source: CMS, January 2018.
More than 63% of rural hospital inpatient days paid by Medicare and Medicaid; 49% for urban hospitals. SOURCE: Healthcare Management Partners, LLC, June 2017.
“Deaths of Despair” Deaths of despair from alcohol, substance abuse, guns, suicide.. Also obesity. Leading to first declines we have seen in mortality in years, decades. Much of it in the south, East South Central region, and rural areas in specific. Cumulative disadvantage: low education, poverty.
Key takeaways • Causes of financial distress and closure are complex and the number of hospitals at risk of financial distress is growing • Rural America has endured major shocks in the last few decades to its economy • Like the rest of America, rural America is aging, but a faster rate • Educational attainment levels are lower • Payer mix • Uninsured rates lower since 2013, but drop smaller in rural • Medicaid coverage growing, Medicare Advantage growing (and Medicare) • Lack of Medicaid expansion adding to financial stress in some states • Marketplace enrollment lower in rural • Overall: rural has higher proportion of funding covered by public funding
State and Federal Policy • Missouri: • Gov. Parson has identified rural health as one of his major focus areas • Transformation of the Missouri Medicaid program • Federal policy: • Rural health not a major focus of recent policy initiatives Price transparency, prices of prescription drugs, “Surprise billing” • Presidential campaign? • Clashes over ACA, Medicare for all • Rural health and rural America • A concern: • Will the critical needs of rural areas be pitted against the needs of urban areas? • Will this be seen as a “zero sum game” • To help rural America, we need to take from urban America?
Disparities and Equity • Concerns about equity and access to care in rural Missouri, rural America • Rural hospital closures • Challenges accessing affordable care • Provider shortages • Rising concerns about impacts on health, well being in rural areas • Rising mortality and morbidity among some groups • Infant and maternal mortality • Substance use disorders • Question: why is this happening? What are the underlying causes?
Bridging the Divide • Parallel concerns in urban Missouri, urban America • Challenges accessing affordable care • Provider shortages • Transportation issues • Social determinants of health • Concerns about health in urban America • Mortality and morbidity higher among some groups • Infant and maternal mortality • Substance use disorders
Bridging the Divide • Some of the challenges we face in rural America mirror those faced in urban America • At least parts of urban America – central cities – but usually not the “suburbs” • We need to recognize this and design policies that address these challenges, regardless of place • But recognize where the challenges are uniquely “rural”, or uniquely “urban”
Rural America • What characterizes Rural America today? • Slow economic growth • Depopulation • Lack of access to health care; few health providers; rural hospital closures • Poor health • Despair, morbidity, higher mortality • How different is this from Urban America, central cities?
Moving forward If we concentrate on what connects us, and not what divides us… there is so much we can achieve.