Healthcare Care Access Disparities in Appalachia
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Health Care Access and Disparities within the Appalachian Region Sherri Drake
PIMA Medical Institute
Health Care Access and Disparities within the Appalachian Region (NIH, 2002-2006) Health disparities are defined as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States”. Health care access is the ability of a person to receive health care services as a function of access to medical personnel, supplies and the ability to pay for those services. The Appalachian region consists of thirteen states and 420 counties, in which the entire state of West Virginia is in Appalachia, along with the mountainous portions of Alabama, Mississippi, Georgia, South Carolina, North Carolina, Tennessee, Kentucky, Virginia, Ohio, Pennsylvania, Maryland and New York. According to Borak (2012) the Appalachian region of the U.S. has lower income levels, poor educational achievement, and worse overall health than the U.S population in general. Exploring the mortality, socioeconomic conditions, behavioral risks and medical care resources are serious concerns within the Appalachian region and is the focus of this discussion.
The Appalachian Regional Commission (ARC) was created in the mid 1960’s with the goal of the commission to develop a comprehensive program for economic development in the Appalachian region. The ARC reported 33% of Appalachians lived in poverty and the per capita income was 23% less than the U.S. average in the 1960’s. Some improvements have been made and the ARC (2010) reported 2008 results of a decrease to 18% of people living in poverty with a 20% per capita income less than the U.S. average. Those results indicate a decrease in the percent of poverty in the region as a whole, but disparities remain in the subregions. The ARC will continue to be instrumental in implementing policy and programs to help decrease the gap within the subregions. “The ARC’s mission is to be a strategic partner and advocate for sustainable community and economic development in Appalachia” (ARC, 2013). They meet these goals by researching and providing solutions to decrease those disparities within the region. Priorities include increasing employment and per capita income levels to meet the U.S. national average, to develop and improve the infrastructure for health care access, increase primary care resources, physician incentives to work in rural areas, education and resources for communities for cancer screening. The Appalachian region is divided into five subregions with the purpose of providing data at the state and local levels to further identify specific clusters where disparities exist within the region.
Premature mortality is more prevalent in the central and southern subregions where there is a correlation between rural geography, a less educated population, higher behavioral risk factors and a shortage of medical care resources. (Halverson, 2004) A study between 1990 and 1997 shows the mortality rates for ages 35-64 in Caucasian men and women and African American men were found to be in excess of the national average in heart disease, cancers, stroke, lung cancer, accidental deaths, and COPD, diabetes and motor vehicle accidents. African American women exceeded all categories but two, cancers and lung cancer where they were below the national average. Heart disease continues to be the leading cause of death in the U.S. as well as in Appalachia, central and southern Appalachia being the most affected.
Poor socioeconomic conditions persist in the central and southern subregions despite some improvements made in the region as a whole. Those subregions are the most geographically rural with less access to metropolitan areas and the unemployment rates are higher with lack of industry and opportunity. The 18% poverty level of 2008 is improved from the 33% level of the 1960’s, this decrease is attributable to an increase in educational attainment and income, resulting in lower levels of poverty. Borak, Salipante-Zaidel, Slade & Fields (2012) state the following Education is also strongly linked with health status; limited education is regarded as a “precursor to poor health”…In general, the counties with lowest educational attainment were “concentrated in central Appalachia, especially in the mining regions,” where health status is generally worst. Even with some improvements in the region, Appalachia continues to linger below the U.S. average. (Halverson & Bischak, 2008) Suggests that two socioeconomic factors stand out when evaluating health disparity among mortality rates and those are poverty levels and the percentage of persons who do not have health insurance coverage.
Behavioral risk factors in the region have a higher prevalence of obesity, smoking, lack of exercise and poor use of cancer screenings available than the U.S. national average. Again, the central subregion of Appalachia is among the most affected as this area tends to be more geographically rural. Nutrition is a major issue and low income levels often dictate poor food choices. Some areas may have only one small grocer with limited selections available. Exercise becomes more difficult for people who become obese, which often leads to depression and other chronic conditions. Studies show that smoking not only contributes to pulmonary diseases like COPD, emphysema and asthma exacerbations but also cardiovascular disease, stroke and several types of cancers. Thus, increasing the premature mortality rate for those who continue the behavior. Behavior modification programs to help with smoking cessation can be implemented by telephone as well as person to person counseling, which may make access to those programs easier.
Medical care resources can be found more often in the metropolitan areas of the region leaving the rural areas at risk. Rural community residents may have to travel several hours for health care services. A shortage of primary care physicians in the small rural communities have been thoroughly documented in literature. The availability of public and private transportation is often an issue and travel in the winter months in the Appalachian Mountains which can be problematic. Poverty levels and lack of employment in the region coincide with not having health insurance or the ability to pay for those services. These are all issues that lend themselves to barriers to heath care access. Logistically speaking, the more rural areas have the least amount of access to hospitals, clinics and specialized care physicians and are the most underserved. (Baldwin, 2013) There are opportunities being seized upon to change those shortages mostly through government funding. The use of “traveling” medical care coming into the rural areas to educate and treat chronic illness such as diabetes. Pediatric obesity and diabetes are issues which will be a lifelong battle and can lead to premature mortality.
Offering obesity screening by school nurses to assess school age children, could also have positive long term benefits in preventing cardiovascular related illness and diabetes, in the future of those children. Some short term and long term solutions to the shortage of physicians and health care workers in Appalachia are a tremendous challenge, one option available is The J-1 Visa waiver program. The J-1 Visas are given to foreign students who come to the U.S. to complete a residency program, upon completion of the program they must return to their home country for two years to practice medicine before returning to the U.S. One initiative taken by the ARC is to have those physician’s practice in a rural community for three years rather than return to their homeland. This is only be a temporary solution for the problem and more permanent solutions are needed. In eastern Kentucky, a medical school has been established to meet the needs of rural Appalachia. Medical school applicants are prioritized by their desire to work in rural communities as family practitioners. All applicants considered for admittance are from rural communities with the emphasis on them returning to or working in Appalachia. Rural service is not a condition of admittance into the program, but by choosing “homegrown” student, the hope is that they will choose to serve the communities they call home upon completion.
Another aspect of particular concern is that of cultural training for the students. This is particularly critical as many of the practitioners may be technically competent, but may not understand the culture of people in the region leading to derogatory comments as described by Blakeney “These Appalachian patients are often described as ignorant, uncooperative, difficult to manage and unwilling to communicate with health care providers” (Blakeney, 2006, p. 108). Thus, making a difficult situation with implementation of health care treatment and trust building between the provider and the patient strained. (Blakeney, 2006) describes an example of mistaken use of phrasing in her book. The patient was asked if she would like to begin therapy. The patient responded “I don’t care to” meaning “I don’t mind”. The therapist interpreted that as the patient “refused”, when in fact the patient was agreeable. The therapist noticed a colleague using that same expression and realized her mistake.
The culture in Appalachia can easily be misunderstood as noncompliant and patients can quickly be dismissed by health care workers. This is one more reason to stress the importance of recruiting “homegrown” health care workers. However, (Blakeney, 2006) noted that students who are recruited and attend college may find their culture to be devalued in the educational system which may cause them to shy away from and discard the cultural values they grew up learning out of feelings of shame. This is an unfortunate reality and most certainly an area for improvement within the educational system. One solution might be cultural diversity training focused on the Appalachian culture in particular, especially for those outside the region who plan to work in those rural communities.
Having identified some of the issues that affect the Appalachian region compared to the Non-Appalachian U.S. a health care disparity is clearly evident in the region. The question now becomes how to resolve the disparities? As mentioned, some important steps are being made to recruit and retain physicians to rural communities in the Appalachian region. The ARC is helping individual states in the region to develop programs and they also provide grants and funding for outreach programs. Initiatives include building rural health care clinics and staffing those with health care providers that are from the local communities. Going into high schools to recruit students for college and providing scholarships in health care careers and incentivizing them to work in their communities. The Appalachian states like most states across the country are struggling under the burden of rising debt and budgeting issues. The unemployment rates in 2009 were 9.8% in Appalachia compared to 9.5% in the U.S. as reported by (ARC, 2010). With the lack of jobs also comes a lack of health insurance as the two are closely tied. As noted previously one of two factors leading to premature mortality is lack of health insurance. (HHS, 2013)
The Affordable Care Act (ACA) will be fully enacted in all states beginning January 2014. One measure of the ACA will be increasing enrollment into the state’s Medicaid programs. It is also the intent to make private health insurance options more affordable to the “working poor” who do not have employer sponsored coverage. This process will be funded by the federal government for the first three years, after which time the states will be responsible for funding the plan. So many states are currently in financial woes, adding to the additional health care cost which will be exorbitant. (The Daily Briefing, 2013) Many states are opting out of the Medicaid expansion because the cost is simply too steep. Grassroots efforts, community and faith based programs used to educate and uplift these people out of their poverty, may be a less costly alternative. However, there are no easy answers to combat the poverty and disparity that can be found in Appalachia. The ARC has grant monies currently available that is dedicated to improving the conditions in rural Appalachian communities. Tapping into those resources would seem to be more cost effective than expanding Medicaid and other social programs.
Taking responsibility for one’s own health and giving them the tools needed to be successful will be immensely important for the future in Appalachia. (Squire, 2012) The Appalachian people are traditionally a proud people, who are independent, self-sufficient and who help family and neighbor when in need. They are slow to accept help from outsiders; therefore, avoiding getting the healthcare services they need. In addition, if they are not insured or are not able to pay for those services that is an added barrier to health care. Which creates the problem of chronic illness not being treated which in turn leads to premature mortality.
The U.S. will only be able to financially support its citizens for so long, the U.S. national debt is at an all-time high with no end of spending in sight and heath care costs are almost 18% of the GDP (Appleby & Kaiser Health News, 2012). Fiscal responsibility is imperative for the future of the country and the Appalachian region as well. The disparities that are prevalent in the Appalachian region have been documented and followed for the past four decades some subregions are making positive strides and others continue to lag behind. The ARC will continue its work to improve the lives of the residents within the Appalachian region and to help slowly pull the region out of poverty. However, it is a contradiction to realize all the richness of natural resources available within the region that are unobtainable to the some of the poorest Americans.