Rural Health in the United States This page intentionally left blank Rural Health in the United States Edited by Thomas C. Ricketts, III North Carolina Rural Health Research and Policy Analysis Program Cecil G. Sheps Center for Health Services Research The University of North Carolina, Chapel Hill New York Oxford OXFORD UNIVERSITY PRESS 1999 Oxford University Press Oxford New York Athens Auckland Bangkok Bogota Buenos Aires Calcutta Cape Town Chennai Dar es Salaam Delhi Florence Hong Kong Istanbul Karachi Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Paris Sao Paulo Singapore Taipei Tokyo Toronto Warsaw and associated companies in Berlin Ibadan Copyright © 1999 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 Oxford is a registered trademark of Oxford University Press Materials appearing in this book prepared by individuals as part of their official duties under contracts and cooperative agreements with the federal government are not covered by the above-mentioned copyright and any views expressed therein do not necessarily represent the view of the United States government. Such individuals' participation in the work is not meant to serve as an official endorsement of any statement to the extent that such statement may conflict with any official position of the United States government. Library of Congress Cataloging-in-Publication Data Rural health in the United States / [edited by] Thomas C. Ricketts III p cm. Includes bibliographical references and index. ISBN 0-19-513127-4 —ISBN 0-19-513128-2 (pbk). 1. Rural health—United States. 2. Rural health services—United States. 3. Medicine, Rural—United States. I. Ricketts, Thomas C. [DNLM: 1. Rural Health Services—United States. 2. Rural Health—United States. WA 390 R95145 1999] RA771.5.R859 1999 362.1'04257'0973—dc21 DNLM/DLC for Library of Congress 98-52112 68975 Printed in the United States of America on acid-free paper Foreword This volume is a long-awaited update to Health Care in nation and willingness to see this through, the parts Rural America, published in 1990 by the U.S. Office of might not have been assembled as effectively as they are. Technology Assessment. Health Care in Rural America He and his team not only made important contributions proved to be an important tool in the debates over sig- to the book, but oversaw the daunting task of coordi- nificant rural health legislation, such as changes in nating its creation with numerous research centers, fed- Medicare Prospective Payment rules and the creation of eral agencies, and national organizations. In doing so, Rural Health Outreach and Rural Health Networks pro- they have compiled a useful, comprehensive reference grams. This Office is very grateful that this updated vol- guide to rural health care delivery. ume has been developed. I am sure that this new book will also be a valuable We at the federal Office of Rural Health Policy, in tool for future policy making, and I and the rural health HRSA, want to thank the book's editor, Tom Ricketts, community are grateful to Tom and to everyone who for his two-year long effort to make the current book, contributed to Rural Health in the United States. Rural Health in the United States, a reality. Although this is a book that includes the work of many outstanding re- Wayne Myers, M.D. searchers in rural health policy, without Tom's coordi- Director, Office of Rural Health Policy, HRSA, DHH v This page intentionally left blank Preface When confronted with the realities of the size and scope ogy Assessment, Health Care in Rural America. The re- of the rural population in the United States, it is hard to port was the result of 2 years of concentrated work by a think of these 61 million people as a disadvantaged talented and dedicated OTA staff and has served as the group. Their numbers exceed the total population of primary reference tool for rural health policy makers, many nations, including Great Britain, France, Spain, journalists, analysts, and researchers ever since. Almost and Italy. Yet, in many ways, but specifically in health 10 years have passed since the report's release and much care access, rural Americans are distinctly disadvan- of the data and information it contained have changed. taged. Rural Americans make up 20% of the nation's That same decade witnessed the development of several population, but only 9% of the nation's physicians prac- policy initiatives including legislation to assist rural hos- tice in rural counties. Medicare beneficiaries in non- pitals, strengthen efforts to place professionals in rural metropolitan counties receive 15% less in the way of all areas, and modify payment systems to be more equitable physician services and a striking 40% less in cardiology. to rural citizens that were supported by that report. De- Rural patients see doctors less often and usually later in spite these efforts, many of the same problems that con- the course of an illness. When a person living in a rural fronted rural America in the 1980s remain in the 1990s, area goes into the hospital, it is usually for a longer stay despite the best efforts of interested policy makers and even though the hospital will be paid less for that patient their supporters. if the hospital is located in a rural area. This pattern The Office of Rural Health Policy sought to provide evolved early in this century and despite major efforts to current policy-relevant information by supporting the change the distribution of resources, rural communities creation of an information service in the National Agri- lag well behind their city cousins in health care. The U.S. culture Library—the Rural Information Center, Health Congress, state legislatures, and regional governments Services (RICHS). The RICHS staff collected published recognize this disparity but the solution to the imbal- articles, reports, working papers, findings, and policy ances continues to elude them. briefs issued by rural health services researchers, rural The facts of this disparity between rural and urban re- policy analysts and other authoritative sources, and de- main and this book is intended to bring those facts once veloped a number of focused, annotated bibliographies. again to the attention of the people who can make a dif- In addition, RICHS has served as a clearinghouse for ferences in policies. Rural Health in the United States is those interested in rural health issues. This "virtual" ref- also meant to inform rural communities themselves, to erence source was effective as a clear demand emerged provide them with the information they need to effec- for a comprehensive reference book that would more ef- tively argue for change. Facts, data and statistics cannot ficiently answer the many specific questions often di- create solutions: they must be turned into information on rected to RICHS, ORHP, and its network of research which arguments can be based and comparisons drawn centers. Likewise, many of the summary tables, charts, to support options that are favorable for change. This maps, and graphs presented in the OTA report had not book is designed to take data and turn them into infor- been updated by researchers and were not available to mation that can be used to create the policies that help either RICHS or ORHP. By 1996, ORHP made the de- Americans—especially rural Americans—build a better cision to assign the task of updating the OTA report to and more effective health care delivery system. its research centers. In 1997 the Office of Rural Health Most who are involved in the field of rural health pol- Policy (ORHP) in the Health Resources and Services Ad- icy analysis or rural health research are familiar with the ministration (HRSA) and its research and policy analy- report published in 1990 by the U.S. Office of Technol- sis centers at the Universities of Minnesota, North Car- vn Vlll PREFACE olina, Southern Maine, and Washington, and Project services (EMS), little progress had been made in the Hope, recognized the great value of the OTA compendi- decade since the OTA report or it was not a "hot" polit- um and set out to update its contents. The Rural Health ical issue but one that was likely to rise in importance in Research Program at the Cecil G. Sheps Center for the future. The final set of chapters represents a consen- Health Services Research at The University of North sus view of issues in rural health policy that the con- Carolina at Chapel Hill assumed the task of coordinat- tributing authors felt will be important in the near future. ing the work of the research centers to create a compre- Key investigators at the five centers were assigned the hensive and contemporary document. task of authoring chapters, which were shared across The goal of the project was to create a comprehensive all centers as they evolved. Nationally recognized experts reference book as practically useful as Health Care in were recruited to review and comment on chapter drafts. Rural America, but more "user-friendly," with less text Twenty-three outside experts worked exceptionally hard detail and more graphical detail, making use of figures, to improve and correct the chapters and to focus the tables, and maps. The OTA book was encyclopedic in its work. A managing editor in the North Carolina center treatment of publicly funded programs and included responsible for integrating the chapters in a way that background material and historical trend data on the would make the book more of a unified effort than a col- growth of publicly supported rural programs and the dis- lection of separate issue-focused chapters. The process of tribution of resources in rural America. The current vol- negotiating with a publisher was also an important step ume is intended to summarize policy initiatives in a more along the way. The book was to be primarily a public concise way while covering all aspects of rural health document with no copyright restrictions, thus the choice care. Where Health Care in Rural America placed a of a publisher hinged on a willingness to produce the heavy emphasis on federal programs, Rural Health in the book under that condition. In keeping with the goal of United States includes all of the major federal programs producing a user-friendly product, the ability to publish and projects, but attempts to include more attention to the book with full-color maps was also an important cri- the broader set of resources and the private market terion for selection of a publisher. The experience of Ox- changes affecting rural health care delivery. The OTA ford University Press in these two critical areas was in- book proved to be very popular. The Office distributed strumental in their selection by the rural research centers its first printing of 2,000 copies free of charge to key pol- and ORHP. icy makers and sold out two additional printings through The goal of ORHP and the collaborating centers was 1993. To tap this level of interest inside and outside of to assemble the basic facts and trends that affect the government, it was decided that the book would be pub- health and health care resources of rural people. The lished by a commercial firm, and Oxford University Press strategy of creating a single reference volume that de- was chosen because of its proven track record in pub- pended upon data and the visual representation of data lishing important books in the health policy field and its using charts, graphs, and maps might have seemed obvi- willingness to work with our graphics-intensive format. ous after the commitment was made to do this. Howev- The task of dividing the rural health policy field into a er, the effort to make that commitment required the fo- limited number of chapter headings was not straightfor- cused leadership of the Director of Research Programs in ward. Some areas had the focused attention of policy ORHP and the dedicated resources of the Office through makers and were clearly delineated as "domains" such as its funding and coordination to make this book happen. hospitals, health professions, and maternal and child health issues. In other areas, such as emergency medical Chapel Hill, N.C. T.C.R. Acknowledgments This book would not have been developed without the search Center, and Curt Mueller at the Project HOPE, leadership and vision of Pat Taylor, Ph.D., Director of William Walsh Center for Rural Health Analysis, each Research Programs in the federal Office of Rural Health entered the project with a spirit of cooperation and a de- Policy in the Health Resources and Services Administra- sire to create a useful product. They were able to involve tion. While many people in the field of rural health pol- key staff to the drafting and revision of chapters and the icy may have suggested the need to update Health Care creation of special analyses to display new data. in Rural America^ Pat Taylor was the only person to step Each chapter was reviewed by outside experts (listed forward with the focused vision to move this project to- below) from across the United States and they did so ward reality. Putting the book together required a care- with a thoroughness that helped improve each chapter. ful process of persuasion to make the otherwise very in- We want to express our thanks, once again, for their help dependent academic researchers collaborate to create a with this project. unified piece of work. Pat was able to do this with a style that moved the group's members along without their Reviewers feeling pushed or overly prodded. The Office of Rural Health Policy added the impor- Calvin L. Beale, M.S. tant stimulation of funding for the centers to support this Senior Demographer work: all of the centers were able to include work on the Economic Research Service book in their formal research agendas. This structure re- U.S. Department of Agriculture flects Pat's commitment to this project as well as the sup- Washington, D.C. port of the former Director of ORHP, Jeff Human, and acting director, Dena Puskin. David E. Berry, DrPH The flow of materials from multiple authors repre- Professor and Chair, Health Care Administration senting individual centers and, in some instances, coop- University of Nevada at Las Vegas erative projects between centers, had the potential of Las Vegas, Nevada becoming very complex and unwieldy. However, the pro- ject's managing editor, Heather McCary Edin, kept the Richard J. Bogue, Ph.D. project and the authors organized and motivated with Senior Director of Governance Programs her energy and persistence. The project kept as close to Division of Trustee and Community Leadership its timetable as was humanly possible, even when American Hospital Association Heather took a few days off to get married. In the days Chicago, Illinois leading up to the delivery of the many chapter manu- scripts to the publisher, Heather doubled, then redoubled, David L. Brown, Ph.D. her commitment to achieve accuracy and consistency in Professor and Chair, Rural Sociology the text, tables, charts, and graphs. Any errors that may Cornell University have crept into the book will have been due to the editor's Ithaca, New York meddling in the process and not Heather's careful re- working of every chapter. Leslie L. Clarke, Ph.D. The four other center directors, Gary Hart at the Assistant Research Professor, Health Policy and WWAMI Rural Health Research Center, Ira Moscovice Epidemiology at the University of Minnesota Rural Health Research University of Florida Center, Andy Coburn at the Maine Rural Health Re- Gainsville, Florida IX