Healthcare Access in Rural Communities
Access to healthcare services is critical for rural residents. Ideally, residents should be able to conveniently and confidently use services such as primary care, dental, behavioral health, emergency, and public health services. According to Healthy People 2020, access to healthcare is important for:
- Overall physical, social, and mental health status
- Prevention of disease
- Detection and treatment of illnesses
- Quality of life
- Preventable death
- Life expectancy
Rural residents often experience barriers to healthcare that limit their ability to get the care they need. In order for rural residents to have sufficient healthcare access, necessary and appropriate services must be available which can be accessed in a timely manner. In addition to having an adequate supply of healthcare services in the community, there are other factors which play a significant role in healthcare access. For instance, to have good healthcare access, a rural resident must also have:
- Financial means to pay for services, such as health insurance coverage that is accepted by the provider.
- Means to reach and use services, such as transportation to services which may be located at a distance, and the ability to take paid time off of work
- Confidence in their ability to communicate with healthcare providers, particularly if the patient is not fluent in English or has poor health literacy.
- Confidence in their ability to use services without compromising privacy.
- Confidence in the quality of the care that they will receive.
This guide provides an overview of challenges to healthcare access in rural America and ways communities and policymakers can address these community needs. The guide includes information on barriers to care such as workforce shortages, health insurance status, distance and transportation, poor health literacy, and the stigma of certain conditions such as mental health or substance abuse issues.
Frequently Asked Questions
- What are barriers to healthcare access in rural areas?
- How many rural Americans are without health insurance?
- What types of healthcare services are frequently difficult to access in rural areas?
- How does the lack of healthcare access affect population health and patient well-being in a community?
- How do rural healthcare workforce shortages affect access to care?
- How do closures of healthcare facilities and services impact access to care for rural citizens?
- What happens when your nearest hospital is not in your network of providers?
- What are some strategies that have been used to improve access to care in rural communities?
- What are some challenges that Veterans face in their access to healthcare?
- What are some challenges that Native Americans face in their access to healthcare?
- What organizations work to improve rural healthcare access?
What are barriers to healthcare access in rural areas?
A lack of healthcare professionals can inhibit access to services by limiting the supply of available services. This is particularly a factor in rural areas. As of August 2014, 60% of Primary Medical Health Professional Shortage Areas were located in non-metropolitan areas, according to information pulled from the HRSA Data Warehouse.
RHIhub’s Rural Healthcare Workforce topic guide has more information on ways that rural areas can address these workforce shortages, such as partnering with other healthcare facilities and increasing staff’s pay and flexibility to improve recruitment and retention of healthcare providers and using telehealth services.
Health Insurance Status
Individuals who do not have health insurance have reduced access to healthcare services. According to a 2008 report, Health Disparities: A Rural-Urban Chartbook, there is a larger percentage of rural residents who do not have health insurance compared to urban residents. The most remote rural residents are the least likely to have health insurance coverage.
Health Care Access and Use Among the Rural Uninsured, identifies some key facts on the rural uninsured:
- Uninsured people face barriers to care compared to people with health insurance coverage.
- Rural uninsured are more likely to delay or forgo medical care because of the cost of care compared to those with insurance.
According to the 2014 report, The Affordable Care Act and Insurance Coverage in Rural Areas, rural populations have a larger proportion of low-income residents who could potentially benefit from the Affordable Care Act to receive health insurance coverage. However, nearly two-thirds of uninsured rural individuals live in a state which has not expanded Medicaid, which means that these rural individuals have fewer affordable health insurance choices.
Distance and Transportation
People in rural areas are more likely to have to travel long distances to access healthcare services, particularly specialist services. This can be a significant burden in terms of both time and money. In addition, the lack of reliable transportation is a barrier to care. In urban areas, there is often public transit for patients to get to medical appointments; however, these transportation services are often lacking in rural areas. Rural communities have more elderly residents who have chronic conditions, which may require multiple visits to outpatient healthcare facilities which requires a reliable source of transportation. RHIhub’s Transportation to Support Rural Healthcare topic guide has more resources and models and innovations for rural communities.
Social Stigma and Privacy Issues
In rural areas, where there is little anonymity, social stigma and privacy concerns are more likely to act as barriers to healthcare access. Residents may be concerned about seeking care for issues related to mental health, substance abuse, sexual health, pregnancy, or even common chronic illnesses due to unease or privacy concerns. This may be caused by personal relationships with their healthcare provider or others that work within the healthcare facility. In addition, concerns about other residents noticing them utilizing services such as mental health can be a concern. Co-location or integration of behavioral health services with primary care can help.
Poor Health Literacy
Health literacy, which impacts a patient's ability to understand health information and instructions from their healthcare providers, is also a barrier to accessing healthcare. This is a particular concern in rural communities, where lower educational levels and higher incidents of poverty often impact residents. To learn more about low health literacy in rural America, see What are the roles of literacy, health literacy, and educational attainment in the health of rural residents? on RHIhub's Social Determinants of Health for Rural People topic guide.
How many rural Americans are without health insurance?
According to the 2014 policy brief, The Uninsured: An Analysis by Age, Income, and Geography, 22.3% of non-elderly rural residents were uninsured, compared to 21.4% of non-elderly urban residents.
Within each age group of the uninsured, more rural uninsured residents than urban residents would be eligible for some form of health insurance assistance under the Affordable Care Act, either subsidized coverage in new marketplaces or through Medicaid. According to the 2014 Kaiser Commission issue brief, The Affordable Care Act and Insurance Coverage in Rural Areas, uninsured rural residents are primarily adults who are working in low-paying jobs and are not able to afford health insurance coverage on their own. Rural uninsured, when compared to the urban uninsured, have more barriers to healthcare access because of the limited supply of rural healthcare providers who offer low-cost or charity healthcare. See RHIhub’s Medicaid topic guide for more resources on Medicaid’s implications for individuals, healthcare providers and rural communities.
What types of healthcare services are frequently difficult to access in rural areas?
According to the report, Why Are Fewer Hospitals in the Delivery Business?, there was a reduction in the availability of hospital-based obstetric services in rural communities from the mid-1980s to the early 2000s. This was due to a decline in the number of rural hospitals in the United States and a significant drop in the fraction of those hospitals providing obstetric services.
The 2014 committee opinion from the American College of Obstetricians and Gynecologists, Health Disparities in Rural Women, reports that “prenatal care initiation in the first trimester was lower for mothers in more rural areas compared with suburban areas.” The authors report that “less than one half of rural women live within a 30-minute drive to the nearest hospital offering perinatal services.”
A 2013 report titled, Obstetric Services and Quality among Critical Access, Rural, and Urban Hospitals in Nine States, reports on the results of a study to assess the quality of childbirth-related care in different hospital settings. The authors conclude that Critical Access Hospitals performed well on obstetric care quality measures when compared to urban hospitals.
Mental Health Services
Access to mental health providers and services is a challenge in rural areas. Because of the scarcity of mental health providers, primary care doctors often provide mental health services while facing barriers of lack of time with patients and adequate financial reimbursement. Due to the shortage of behavioral health providers, new models for providing behavioral health services using allied behavioral health workers have been developed.
According to the 2012 report, Behavioral Health Aides: A Promising Practice for Frontier Communities, many states are developing behavioral health aide (BHA) models. Some models of care include:
- Behavioral health aides as care coordinators
- Behavioral health aides as support workers
- Peer counselors and peer specialists
- Promotoras with supplemental training in mental health
Due to the lack of mental health providers in rural communities, telehealth is increasingly being used to provide services. Using telehealth, mental health services can be provided in a variety of local community settings including rural clinics, schools, residential programs, and nursing homes. Telehealth also makes it easier for mental health professionals to receive continuing education without having to travel long distances. RHIhub’s Telehealth Use in Rural Healthcare topic guide has many more resources on how telehealth can improve access to care. Also, RHIhub’s Mental Health topic guide has more resources on rural access to mental health services.
Dental Health Services
Dental health services are very important to rural residents. Oral health affects physical health, emotional health, and the ability to get a job. Despite its importance, access to dental services is very limited or difficult in many communities.
One barrier to dental access is the fact that most health insurance plans do not cover dental services. According to the 2011 National Academies report, Advancing Oral Health in America, a smaller proportion of rural residents have dental insurance compared to urban residents.
Another issue limiting access to dental services is the lack of dental health professionals in rural areas. According to a 2009 report, The Crisis in Rural Dentistry, of the 2,050 United States rural counties, 60% are designated dental Health Professional Shortage Areas (HPSAs). There are federal and state programs to increase the supply of dentists who practice in rural communities to increase access and improve oral health outcomes for rural populations. The report offers potential solutions to increase the dental health workforce with the goal of improving access to services including:
- Provide rural training tracks during dental education.
- Admit dental students who have a background in rural areas and who are more likely to practice in a rural community.
- Provide dental students the opportunities to obtain a broad range of dental skills which will be needed in a rural practice.
- Help rural communities recruit and retain oral health providers through local community development programs.
RHIhub’s Oral Health in Rural Communities topic guide has more information about oral health disparities in rural America and ways to address those disparities.
Substance Abuse Services
Few detox centers are available in rural areas, according to Few and Far Away: Detoxification Services in Rural Areas. The authors report that “82% of rural residents live in a county without a detox provider.” This results in patients having to travel long distances, which is a barrier to care and patients might forgo or delay care that they need. In addition, if a rural area does not have a detox provider, that service is often delegated to the local emergency room or the local jail which are not the most appropriate location for detoxification services.
According to the report, Distribution of Substance Abuse Treatment Facilities Across the Rural – Urban Continuum, access to substance abuse treatment is limited in rural areas. Key facts from the study include:
- Rural areas contain fewer inpatient and residential treatment beds than urban areas.
- A higher proportion of treatment facilities in non-metro counties provide outpatient care compared to metro counties.
- Rural areas lack opioid treatment programs.
RHIhub’s Substance Abuse topic guide has model programs for addressing substance abuse treatment in rural areas.
How does the lack of healthcare access affect population health and patient well-being in a community?
Health Status and Health Care Access of Farm and Rural Populations, states that "both farm and rural populations experience lower access to health care along the dimensions of affordability, proximity, and quality, compared with their nonfarm and urban counterparts." Nonmetropolitan households report that the cost of healthcare limits their ability to receive medical care. In more remote counties, patients have to travel long distances for specialized treatment. These patients may substitute local primary care providers for specialists or they may decide to postpone or forego care from a specialist due to the burdens of cost and long travel times.
According to the 2014 report, Access to Rural Health Care - A Literature Review and New Synthesis, barriers to healthcare result in unmet healthcare needs including lack of preventive and screening services, treatment of illnesses, and preventing patients from needing costly hospital care. A vital rural community is dependent on the health of its population. Access to medical care does not guarantee good health; however, access to healthcare is critical for a population’s well-being and optimal health. RHIhub’s Rural Health Disparities topic guide includes initiatives being implemented to reduce rural health disparities.
How do rural healthcare workforce shortages affect access to care?
Healthcare workforce shortages have an impact on access to care in rural communities. One measure of healthcare access is “having a regular source of care” and having an adequate health workforce to provide that regular source of care. Some health researchers have argued that determining access by simply measuring provider availability is not adequate to fully understand healthcare access. They argue that access measures should include healthcare service use and nonuse. For example, including people who could not find an appropriate provider of care.
In order to increase access to care, rural communities may look to other providers, in addition to physicians. Providers could include physician assistants and nurse practitioners, public health workers, community health workers, community paramedics, care coordinators, and health coaches, which all provide new roles for healthcare teams. There are many initiatives to increase the qualified healthcare workforce in rural areas. RHIhub’s Recruitment and Retention for Rural Health Facilities topic guide has more information.
How do closures of healthcare facilities and services impact access to care for rural citizens?
The closure of rural healthcare facilities or the discontinuation of services will have a negative impact on the access to care in the community. Factors impacting the severity of the impact may include distance to the next closest provider, availability of alternative services, the availability of transportation services, and the socioeconomic and health status of individuals in the community. Having to travel to receive services places burden on the patients including cost and time. For people with low incomes, no paid time off of their jobs, physical limitations, or acute conditions, these burdens can significantly affect their ability to access care.
Maintaining pharmacy services in rural towns can be a challenge, particularly when the town’s only pharmacist nears retirement. When a community’s only pharmacy closes, it creates a void in services to which residents must adapt and find alternate ways to meet their medication needs. According to Causes and Consequences of Rural Pharmacy Closures: A Multi-Case Study:
“Rural residents rely on local pharmacies to provide pharmacy and clinical care management and coordination. The absence of a pharmacy may be disproportionately felt by the rural elderly, who often have a greater need for access to medications and medication management services…Increased distance to the nearest pharmacy may result in decreased access to pharmacy services for this population. Access to medications may be maintained through mail-order, delivery, or telepharmacy; however, providing clinical and in-person consultative services to remote populations may be a challenge.”
A recent increase in rural hospital closures, particularly Critical Access Hospitals, have been in the news frequently, with articles such as What Happens When a Town’s Only Hospital Shuts Down? and When a Hospital Closes discussing the negative effects in particular rural communities. A significant concern for rural communities losing their hospital is the loss of emergency services. In emergency situations, any delay in receiving care can have serious adverse consequences.
The North Carolina Rural Health Research Program has a list and map of rural hospitals that have closed from January 2010 to the Present. Rural health experts believe that rural hospital closures are likely to continue because many rural hospitals have such a tight operating budget with little room for financial losses.
The 2013 report, Change in Profitability and Financial Distress of Critical Access Hospitals from Loss of Cost-Based Reimbursement, discusses how changes in reimbursement to Critical Access Hospitals could have a large negative effect on their profitability and financial stability. If more Critical Access Hospitals across the United States close, rural residents will need to travel longer distances to receive care.
What happens when your nearest hospital is not in your network of providers?
Many people are purchasing health insurance plans through the Health Insurance Marketplaces (HIMs). HIM plans often have what are called narrow networks where the insurance companies have negotiated less expensive rates and reimbursements to providers in exchange for being included in the health plan. Many rural providers are unable to accept the smaller compensations because of their already narrow profit margins and are being left out of the narrow networks. Therefore, patients may have to pay for a more expensive health insurance plan that covers their rural provider or choose a cheaper plan that means they will have to travel farther to an eligible provider. When local facilities are not included in health insurance networks, this can mean that rural residents have to travel further to reach a provider, have fewer providers to choose from, may have to see new and unfamiliar providers, and have less support at the local level.
The policy brief, A Guide to Understanding the Variation in Premiums in Rural Health Insurance Marketplaces, discusses state variation in the design of health insurance marketplaces. The authors report that “urban counties have, on average, approximately one more firm participating in the marketplaces, representing about eleven more plan offerings, than rural counties have.” In rural settings, the exclusion of certain providers could force residents to travel long distances to find care and could be an unreasonable delay in accessing services.
What are some strategies that have been used to improve access to care in rural communities?
Many strategies are being used to improve access to healthcare in rural areas:
Two rural healthcare models that have been supported by the Federal Office of Rural Health Policy (FORHP) include:
Frontier Extended Stay Clinics (FESC)
Clinics in frontier communities which help seriously ill patients or injured patients who cannot be immediately transferred to a hospital due to adverse weather conditions or other concerns.
Frontier Community Health
Integration Program (FCHIP)
A program to develop and test new models to improve access to quality healthcare services in frontier areas.
Telehealth can allow rural patients to see specialists without leaving their communities, permits local providers to take advantage of distant expertise, and improves timeliness of care. RHIhub’s Telehealth Use in Rural Healthcare topic guide has more resources, including funding opportunities.
Targeted Support for Workforce Shortage Areas Shortage Designations
Shortage designations are used to identify and assist areas that lack access to healthcare providers. Some programs to improve access to healthcare in Health Professional Shortage Areas, Medically Underserved Areas, and Medically Underserved Populations include:
- Health Center Program
- Rural Health Clinic Program
- Medicare HPSA Bonus Payment
- National Health Service Corps Loan Repayment and Scholarship Programs
- Indian Health Service Scholarship Program and Loan Repayment Program
- J-1 Visa Waiver
- Conrad State 30 Program
What are some challenges that Veterans face in their access to healthcare?
One of the primary barriers for veterans to access healthcare services is the long travel distance to the nearest Veterans Affairs (VA) health facility. Some veterans do not qualify for certain VA benefits or they are not aware of facilities that are available to them. VA health facilities create partnerships with local community health facilities to provide telehealth services. The VA also works to improve access by using mobile VA clinics and community-based outpatient clinics. To learn what the VA is doing to address Veteran’s healthcare access, see RHIhub’s Access to Healthcare for Rural Veterans topic guide.
What are some challenges that Native Americans face in their access to healthcare?
According to the Kaiser Family Foundation brief, Health Coverage and Care for American Indians and Alaska Natives, American Indians and Alaska Natives face health disparities including high uninsured rates, barriers to accessing care, and poor health status.
The Indian Health Service (IHS) provides healthcare and prevention services to American Indians and Alaska Natives. The Indian Health Services has been historically underfunded to adequately meet the healthcare needs of American Indians and Alaska Natives which has been a barrier to access for this population.
IHS is a provider of healthcare services and is not considered to be healthcare coverage. According to the 2013 report, Health Coverage and Care for American Indians and Alaska Natives, nearly 1 in 3 American Indians and Alaska Natives is uninsured. The Affordable Care Act offers opportunities to increase health insurance coverage and therefore improve access to healthcare for American Indians and Alaska Natives. RHIhub’s Rural Tribal Health topic guide has more resources on this topic.
What organizations work to improve rural healthcare access?
Organizations that help meet the needs of rural communities and work to ensure the availability of essential healthcare services include:
- Federal Office of Rural Health Policy (FORHP) focuses on rural healthcare issues and is part of the Health Resources and Services Administration.
- Rural Health Research Centers funded by the Federal Office of Rural Health Policy to produce policy-relevant research on healthcare issues in rural areas.
- National Rural Health Association (NRHA) provides leadership and resources on rural health issues for healthcare providers and organizations working to improve the health of rural communities.
- State Offices of Rural Health and State Rural Health Associations help rural communities build healthcare delivery systems by coordinating rural healthcare activities in the state, by collecting and disseminating information, and by providing technical assistance to public and non-profit entities in the state.
- Primary Care Offices (PCOs) are state organizations which know healthcare providers and sites in their state, including National Health Service Corps approved sites.
- Primary Care Associations (PCAs) are state or regional nonprofit organizations that provide training and technical assistance to safety-net providers.
- National Rural Recruitment and Retention Network (3RNet) is a national organization which works on recruiting and placing healthcare providers in job openings in rural communities.
- Area Health Education Centers (AHECs) build partnerships between academic institutions and communities to improve the supply and distribution of health professionals.
Last Reviewed: 10/31/2014