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High Stakes for Rural Health in Fight over Affordable Care Act

(Photo: Edgar Zuniga, Jr. via Flickr)

By Robin Pam

According to a new report from the Center for Rural Affairs, conditions such as diabetes, heart disease, cancer, and stroke are responsible for 75 percent of all health care spending. Rural Americans experience these diseases and chronic conditions in higher numbers than the general population. This happens for a variety of factors, including heavier tobacco use, physical inactivity, poor diet, and alcohol abuse.

The health challenges facing rural communities are even further exaggerated in the West. Here rural and frontier communities are farther away from urban centers or larger towns with more sophisticated health care facilities. The large distances and extreme isolation place a greater strain on community health providers. 

Encouraging healthier behaviors and preventing chronic conditions is critical to controlling costs in the health care system. These goals are a major part of the Affordable Care Act, the health reform law passed in 2010. Residents of rural communities, and especially those in the West, stand to benefit greatly from the increased emphasis on prevention.

“The prevention and public health provisions are among the most important provisions of the law, particularly for rural people and communities,” said Jon Bailey, author of the Center for Rural Affairs’ report, “Prevention and Public Health,” and Director of Rural Research at CFRA. “If the health care system is truly to be reformed and costs lowered, Americans simply have to become healthier."

The Affordable Care Act allocates $15 billion to a Prevention and Public Health fund to invest in prevention programs over the next 10 years. Several immediate priority areas determined by the Department of Health and Human Services target important issues for rural communities. These include assisting communities with care coordination for primary care and mental health; supporting obesity prevention, fitness programs, and tobacco cessation; and building public health infrastructure and workforce. According to Bailey’s report, every dollar invested in community-based prevention saves six dollars in future costs.

Other provisions will provide longer-term benefits to rural communities. The act makes available free of charge many preventive services such as routine physical exams and screenings. Small businesses will have access to grants to promote workplace wellness. An oral health prevention campaign promises to ultimately improve access to dental care. Loans and recruitment programs to add health professionals in rural areas will provide more primary care and preventive services to help keep chronic conditions in check. Investing now, says the report, will help reduce mortality rates and save money in the long term.

The many provisions to help create healthy communities have been largely overlooked in the increasingly divisive political rhetoric surrounding the law. In April, the House of Representatives passed a bill that would repeal the Prevention and Public Health Fund. Lawsuits filed by the attorneys general of 26 states are winding their way through appellate courts. Recent conflicting rulings from the 11th Circuit in Atlanta striking down the ACA’s insurance mandate and 6th Circuit in Ohio upholding it virtually ensure the Supreme Court will rule on the constitutionality of the law sometime next year.

Repeal of the health reform law, either through congressional action or lawsuits currently working their way through the courts, would fall heavily on rural people.  “Less emphasis on prevention and wellness would affect rural areas disproportionately. It would lock in the status quo that exists in rural places, which is not a healthy status quo right now,” says Bailey.

Typically, says Bailey, prevention investment and support for the rural health system are uncontroversial, bipartisan goals. But these are not typical times. Recently he’s seen the daily hammering against the Affordable Care Act contribute to growing fatigue among rural residents about any discussion of its benefits.

“The unfortunate thing is that the benefits are not immediate,” says Bailey. “The provisions are so long term that no one knows how successful they’re going to be or when they’ll be successful. And the sad irony of a lot of these provisions is that for a long time they had very strong bipartisan support in Congress. The ACA has taken away the bipartisan nature of some of the rural health issues.”

Health insurance reforms included in the ACA would also benefit rural residents, who are less likely to have insurance than urban residents (17.8% uninsured vs. 15.3% for the general population in 2005-6, according to the South Carolina Rural Health Research Center). The insurance half of the Affordable Care Act is designed to help low- and middle-income Americans purchase insurance through subsidies and tax credits. In fact, it’s estimated that 32 million people, many of them rural residents, will gain coverage under the law.

Yet a Kaiser Family Foundation poll released last week revealed that less than one-third of uninsured Americans believe that the Affordable Care Act will help them get insurance. A majority of those who are skeptical believe that they will not be able to afford to buy insurance, even though credits for low- and middle-income Americans to buy insurance are central to the Act.

“Experts see the entire law and form a judgment either for it or against it, or come out in the middle. People will more likely see only pieces,” wrote Drew Altman, CEO and President of the Kaiser Family Foundation.

The effects of most investment in prevention would not be felt for a long time. It takes years to train, recruit, and hire new primary care physicians. Obesity, diabetes, and heart disease do not disappear overnight, or even over a decade. In the long term, rural Americans may well see lower mortality rates from chronic disease, improved quality of life, lower costs, and better insurance because of the Affordable Care Act. But getting there will not be easy.

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Last modified Thu, 8 Sep, 2011 at 8:36