Episode 3: How did we get here? Rural health challenges in America

September 10, 2019

Not all health care is created equal. Join us as we discuss modern issues and challenges impacting rural health care and the historical factors that have influenced the basis of our current rural health system. We discuss rural access to elder care, dental care, health insurance and more.

Episode Notes

Join us as we discuss modern issues and challenges in rural health care and the historical factors that have influenced the basis of our current rural health system. We discuss rural access to elder care, dental care, health insurance and more.

Our guests are Drs. Erika Ziller and Yvonne Jonk. Dr. Ziller is the Chair and Assistant Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service where she teaches courses on health policy and the U.S. healthcare system. She is also the Director of the Maine Rural Health Research Center, and has directed numerous studies on rural health access, coverage and health reform. Dr. Ziller has served on the editorial board of the Journal of Rural Health, and has won national awards for her contributions to this field. Dr. Jonk is an Associate Research Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service, and is the Deputy Director of the Maine Rural Health Research Center. She specializes in rural health, access to health care and health insurance coverage. She is currently researching the differences in newly admitted rural and urban nursing home residents, elder abuse, and the use of health services by the aged.

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Produced by the University of Maine Graduate and Professional Center, with help from WMPG

Episode Guests

Dr. Erika Ziller is the Chair, and Assistant Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service where she teaches courses on health policy and the U.S. healthcare system. She is also the Director of the Maine Rural Health Research Center, and has directed numerous studies on rural health access, coverage and health reform. Dr. Ziller has served on the editorial board of the Journal of Rural Health, and has won national awards for her contributions to this field.

Dr. Yvonne Jonk is an Associate Research Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service, and is the Deputy Director of the Maine Rural Health Research Center. She specializes in rural health, access to health care and health insurance coverage. She is currently researching the differences in newly admitted rural and urban nursing home residents, elder abuse, and the use of health services by the aged.

Disclaimer

The information provided in this podcast by the University of Maine System, acting through the University of Maine Graduate and Professional Center, (the University) is for general educational and informational purposes only. The views and opinions expressed in this podcast are those of the author(s) and speaker(s) and do not represent the official policy or position of the University. Assumptions made in the analysis are not reflective of the position of any entity other than the author(s) and speaker(s) – and, since the author(s), speaker(s) and listeners are critically-thinking human beings, these views are always subject to change, revision, and rethinking at any time. All information in the podcast is provided in good faith, however the University makes no representations or warranties of any kind, express or implied, regarding the accuracy, adequacy, validity, reliability, availability or completeness of any information in the podcast and will not be liable for any errors, omissions, or delays in the information in this podcast or any losses, injuries, or damages arising from its broadcast or use. It is the listener’s responsibility to verify their own facts. Your use of the podcast and your reliance on any information in the podcast is solely at your own risk. The podcast does not contain nor is it intended to contain any legal advice. Any legal information provided is only for general informational and educational purposes, and is not a substitute for legal advice. Accordingly, before taking any actions based upon such information, the University encourages you to consult with an appropriate legal professional or licensed attorney.

Transcript

​This transcript has been lightly edited for clarity.

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The Greater Good: Episode 3

Carrie:
Welcome to The Greater Good, a podcast devoted to exploring complex and emerging issues in law, business, and policy. I’m your host Carrie Wilshusen, Associate Dean for Admissions at the University of Maine School of Law.

Today I’m talking with Doctors Erika Ziller and Yvonne Jonk of the University of Southern Maine’s Muskie School of Public Service about the state of rural health past and present.

Dr Ziller is the chair and assistant professor of public health at the University of Southern Maine’s Muskie School of Public Service, where she teaches courses on health policy and the U.S. healthcare system. She is also the director of the Maine Rural Health Research Center and has directed numerous studies on rural health access coverage and health reform. Dr Ziller has served on the editorial board of the Journal of Rural Health and has won national awards for her contributions to this field.

Dr. Jonk is an associate research professor of public health at the University of Southern Maine’s Muskie School of Public Service and is the deputy director of the Maine Rural Health Research Center. She specializes in rural health, access to health care, and health insurance coverage. She is currently researching the differences in newly admitted rural and urban nursing home residents, elder abuse, and the use of health services by the aged.

Erika and Yvonne we’re delighted to have you here today to talk about rural health issues from the Maine Rural Health Research Center. Thank you for being here today.

Erika:

Thank you so much for having us.

Carrie:

So today we’ve agreed that we’re just going to do a very broad overview of an incredibly intricate topic and raise some issues and hopefully be able to follow up on them in the future. Can you tell us a little bit about the Center?

Erika:

Certainly. The Maine Rural Health Research Center of which I am the director and Yvonne is the deputy director has been around since 1992, so going on 27 years here. We were established initially with funding from the Federal Office of Rural Health Policy, which was established by Congress. It’s within the Department of Health and Human Services in the federal government. It was established in the 1980s by Congress because there was a growing recognition that rural places and people were experiencing different health outcomes than their urban counterparts and had poor access to care and federal health policy wasn’t necessarily reflecting that or engaged in activities that were helpful to rural places. So the office was established and one of their first activities was to establish and create rural health research centers all across the country. And we’ve been one of them since 1992.

Carrie:
What percent of the population is considered rural, both nationally and locally?

Erika:
Nationally the estimate when I first started doing this work in the late 1990s, it was about 20%. And we have seen it decline a little bit since then, but, but roughly somewhere between 15 and 17% of the U.S. population over all lives in a rural place. And a lot of that depends on how you define rural and who you count. Within Maine as of 2010, in the 2010 census, 60% of our population was rural. So we are a hugely rural state. I think those numbers will look a little different with the 2020 census. Some of the annual updates suggest that we may be more like 50, 50, or even starting to flip where 40% of us are rural, but we are still one of the most rural states if not the most rural state in the country.

Carrie:
So I wanted to get a little background on each of you. What brought you into this area of study? Now I know Erika, you’re from Maine, but Yvonne, you recently came to us from North Dakota, right?

Yvonne:
Yes, I did and North Dakota is also a very rural state. I’m not actually sure what percent are living in rural areas but they are a good majority. We have some towns but they are not big. One of the biggest towns is the one where I just moved from is Grand Forks and that’s the size of Portland, 60,000 around that.

Carrie:

So what brought you into the study in this area?

Yvonne:

Mostly because I grew up on a farm, a potato and green farm, and realized how difficult it was for my parents to carry health insurance. They carried huge deductibles and it was very expensive, around the $10,000 mark. We really thought twice about driving into town to go to the doctor. It was a fairly rare occasion. And so I realized the challenges associated with staying healthy in rural areas.

Carrie:

Erika?

Erika:

I would say that my experience was pretty similar. I grew up in small town Maine, so not quite as remote and rural as Yvonne’s farm experience, but in South Paris, in Oxford County. And I definitely got to see firsthand how some of my neighbors, how my family struggled with a lot of different health care access issues. And later after I came to USM and got my undergraduate degree in social work, I went back to the South Paris, Norway area and provided family planning services there. I was a health educator and ran the family planning clinic there and seeing the experiences of women if that clinic had not been there and in so many rural places across the country, those services are not available. It just would have been impossible for so many people to just receive basic reproductive health services.

So that experience helped color in effect my passion for rural health. And then when I ultimately came back to graduate school also at USM I went to the Muskie School and that decision was really driven by my experiences in public health education. As a social worker, I was finding that my clients were really struggling because of the, you know, nonsensical systems and policies that they often had to deal with. And so I felt like if I really wanted to make a difference, it should be at a policy level, that that was the strongest lever that I could have to make changes and a difference in rural health. So I came back to USM, got my masters degree in health policy and while I was working there, the director of the Maine Rural Health Research Center at the time, Andy Coburn, who was the founding director, recruited me to be his research assistant and never let me go. I stayed and got my PHD as well and have worked since then about 22 years now on rural health issues.

Carrie:

And Yvonne, how long have you been working on rural health issues?

Yvonne: 

Well, my application to graduate school was all about rural health before even health economics was a field. And so how does that date me? But I wasn’t directly working in rural health until about 2007. And that’s when I started working at the University of Minnesota’s rural health research center. Then I went over to the University of North Dakota’s rural health research center. And from there I went to Maine.

Carrie:

We’re glad you’re in Maine. So can you talk a little bit both of you about the difference between the issues around rural health and urban health?

Erika:

Sure. I would say that rural health has been capturing more attention in recent years. I think in part that may be the result of the past presidential election, but it’s also the result of some pretty important research that has been emerging primarily from the Federal Center for Disease Control and Prevention (CDC). The CDC has been looking at rural and urban life expectancy and mortality rates and found a widening gap in life expectancy for rural populations compared to those in urban areas. Since 1999, we’ve seen the rate of mortality, the death rate, declining pretty precipitously for people who live in urban places. And that decline has been much more sluggish among rural populations. And it’s gotten to the point where on average, urban people are living three years longer than people in rural places. And you know, those averages, as we know in research and statistics, can hide a multitude of different things going on. But overall, the fact that people are living three years less [in rural areas] is pretty striking.

Carrie:

So we’re going to dig a little bit deeper into that later. But one of the things I wanted to talk about is we’re talking about urban culture and rural culture as if they’re kind of set ideas and all rural cultures are the same. Can you talk about that a little bit?

Erika:

Certainly, I would say it is extremely important to realize that rural culture is not monolithic. And a lot of times I think people, even people who are doing rural health research, think of predominantly white rural culture as being what it means to be rural. But there’s so much more going on than that in all different parts of the country. Rural populations include large swaths of black populations, tribal populations, growing high need latino populations, and other people of color. And those populations have different rural cultures and different health care outcomes. And in almost all measures that you look at, people of color in rural places are doing worse than their urban counterparts and they are doing worse than their rural white neighbors.

Carrie:

So, Yvonne, you are from a rural community in North Dakota. Do you want to talk a little bit about the culture there?

Yvonne:

Yes. It’s an interesting culture. You know, when I moved from rural North Dakota to the Twin Cities for graduate school, it was a bit of a culture shock for me. When you grow up in a rural area, there’s a mindset of, you know, they’re very independent people, but they’re a tight knit community so they know each other. If you’re in the ditch, you know someone’s going to stop and pull you out, and go, oh, there’s Yvonne! They know your vehicle and they know your family. So when I moved back to Grand Forks, North Dakota, within an hour the neighbors came with pizzas and desserts and they were like, welcome to the neighborhood. Who are you? Oh, you know, are you related to so and so? And it’s a very endearing, you know, type of thing. It can go both ways.

Carrie:

So we’re talking about life expectancy and many other discrepancies between the delivery of health care in rural and urban areas. Can we start with that and talk about some of the issues that caused that discrepancy?

Erika:

I think one of the most dismaying statistics for me is that a huge portion of this discrepancy and disparity and life expectancy is fundamentally driven by things that are preventable. So the CDC defines potentially preventable deaths as things that could have been averted if people had gotten the right sorts of public health interventions or preventive services if they’d been screened early for illnesses. If they had been encouraged to have healthier behaviors and take fewer personal risks, or if they had better health care access. So when you put all of those factors together, each of which is worse in rural places, you end up with this amalgam where rural people are consistently doing more poorly and in ways that could be prevented.

Carrie:

Can you break that down a little bit? Give us some examples of how that plays out on the ground?

Erika:

Sure. So one of the things we know for example is that rural people are much more likely to smoke cigarettes than urban people. And if you look over time those numbers have been decreasing. Ever since the surgeon general warning came out on cigarette packages, we’ve been doing better and smoking rates have been declining. But just like with the mortality rates, the experience in rural places has been much more sluggish and anemic. And a lot of that has to do with how tobacco is marketed. Some of it has to do with policies that are implemented on the ground in communities. Urban places are much more likely to do things that we know make a difference, like raise the cigarette tax or implement environmental policies like no smoking in restaurants or in workspaces. All of those things really make a difference. So that’s kind of one-way where the health behaviors are affecting things. But then rural people also have a whole bunch of healthcare access issues that they have to deal with. They are more likely to be uninsured. They’re more likely to live in places where there aren’t enough healthcare providers. They’re more likely to live in places where there isn’t a hospital or the hospital may have recently closed. So all of those things, and I can go into more detail about any one of them, all of those things work together to create situations where it’s harder for rural people to stay healthy.

Carrie:

Yvonne I wanted you to talk about your work with its focus on the aging and nursing homes. Can you give us an example of how that plays out in a rural community? Access to nursing care?

Yvonne: 

There have been some initiatives recently to try to decrease admissions to nursing homes. These try to promote the elderly to stay in their homes and make use of home health care services or assisted living just because nursing homes are expensive. But because of those initiatives, it’s sort of a double-edged sword with those initiatives that are well intentioned and they do work. They’re effective in reducing the cost of long-term care services. However, then you are also decreasing the number of patients who end up in nursing homes. So occupancy rates have been falling. There’s a pretty large proportion of rural populations who are on Medicaid, Medicaid reimbursement rates for nursing homes are low. So you combine those two things and nursing homes are having a hard time and because of that they’re shutting down. So there have been a fair number of closures. There’s around 16,000 nursing homes right now in the US and I think around 440 closures. About half of those are in rural areas. So it has been a pressing issue. We’ve heard stories of couples who have been separated. The closest nursing home, once their local nursing home closed, is 220 miles away. For couples who have been together for 60 some years, this is very traumatic for them. It is very difficult for them to go visit their loved ones, especially in inclement weather. The road surfaces are not always paved. And so they end up moving out of their home and the community that they’ve lived in for 60 some years and off to this other place where they don’t really have a very good support system. And so, you know, those are traumatic experiences for people who are at this stage of their life.

Carrie:

And then there’s dental care too. Access to all of the various screening tools and things like that.

Erika:

Absolutely. Rural people have much poorer access to basically any type of service. And dental care is one of those. Rural communities are more likely to suffer from severe dental shortages where there just aren’t providers in the community. If they are low income, and many rural people are proportionally more than in urban places, there are very few opportunities for sliding scale dental clinics. The type of things that we have more prevalently in urban places just aren’t available for people. And then for some people who may have Medicaid, which is what Yvonne mentioned, is much more common in rural communities. Almost no state has robust dental benefits for adults. And so you get into situations where your health insurance or Medicaid will pay for a tooth extraction when it’s a crisis, but they won’t provide preventive or restorative care when things could be caught early and averted. It’s really very shortsighted. As a public health professional, this is something that we talk about all the time. An ounce of prevention really being worth a pound of cure because when people have dental abscesses, they end up in the emergency department. Those costs are very expensive, things skyrocket cycle and people may end up leaving the emergency department with an opiate prescription and eventually become addicted. If only they had gotten preventive care right up front or that cavity filled, it would’ve been so much better for that individual person, but also for the community and the system and all of us that, that share in each other’s healthcare costs.

Carrie:

Is a piece of this issue the sorts of jobs that people tend to have in rural areas and access to employer-based insurances?

Yvonne:

So in rural areas there are largely blue collar jobs and employers have a hard time actually providing insurance because it is so expensive. A good majority of employers don’t actually offer insurance. There are regulations now with the Affordable Care Act (ACA) as to if you’re over a certain threshold that you’re required to provide health insurance. And there has been a lot of pushback from small employers as to how expensive it is. Up to this point with the ACA, at least then folks have had an opportunity to choose on the exchanges insurance policies that provide better coverage than the range of policies that they had in the past. But they are finding them more expensive. So there’s been a lot of pushback; because of that [cost], the impression that rural communities in general have about the ACA is not so good.

Erika:

If you think about the employers in rural Maine, they’re so much more likely to be, as Yvonne said, small employers who are really operating at the margin. So to be able to afford the very high and continually escalating costs of health insurance for their workers, it’s really difficult. And then so many rural people nationally and in Maine also are self employed or employed seasonally. You can think about many of our industries, like fishing, lobstering, carpentry, and to some extent agriculture, where people are self employed or maybe not working year round. It’s very, very challenging to be able to afford ongoing health insurance under those circumstances. One of our biggest industries, if not our biggest industry, is tourism. Those jobs tend to be very seasonal and people have to work and struggle to patch together coverage across a full year.

Yvonne:

Yes. Many of the states have expanded their Medicaid programs. Maine has just recently done that and that has definitely shown a positive impact for people in rural areas. They are now able to have coverage and these employers are sort of off the hook. That promotes entrepreneurial sorts of endeavors, if you will, because they don’t have to worry about insurance.

Carrie:

Thank you for tuning in to The Greater Good. Please join me next week for part two of our conversation with Doctors Ziller and Jonk as we explore how their experiences growing up rural has shaped their perspective on rural health policy and research.

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The information provided in this podcast by the University of Maine System acting through the University of Maine Graduate and Professional Center is free. General educational and informational purposes. Only the views and opinions expressed in this podcast are those of the authors and speakers and do not represent the official policy or position of the university.