Many of North Carolina\’s so-called rural counties bear little resemblance to the pastoral villages people tend to picture when they think of rural life.
In fact, the 78 counties that fall under the common statistical definition of \”rural\” are home to about 40 percent of the state\’s population, and North Carolina\’s rural population is, next to Texas, the largest in the U.S.
The issues faced by these disparate communities can vary, especially when it comes to health care.
\”I get asked all the time, \’How are you doing in rural areas?\’\” said Patrick Woodie, president and chief executive officer of the NC Rural Center. “My answer always starts by saying that it really depends on where you are in rural North Carolina because it looks very different from different places. Different parts of the state have different challenges. In general, they\’re all dealing with the same thing, but it looks a little different as you move around.\”
In fact, the main common denominator among the state\’s rural counties is population density. A county is considered rural if it has 250 or fewer residents for every square mile of land, as used by the NC Rural Center and other organizations. Nonetheless, of the state\’s 78 rural counties, about 30 are part of metropolitan statistical areas, a designation used by the US Census Bureau to delineate how socially and economically integrated these areas are with the \”core\” county.
“If you look at those 30 or so counties, from an economic vibrancy standpoint, they\’re doing markedly better than some of our more isolated rural parts of the state. Western North Carolina, in general, is doing significantly better than some of our communities along the I-95 corridor,” Woodie said.
For all their differences, rural counties are disproportionately affected by some problems. They have fewer health-insured residents than their more densely populated counterparts. They are losing a higher percentage of people to drug overdoses. In some cases they are served by hospitals that are about to close.
While by no means new, these challenges have become more acute during the COVID-19 pandemic. At the same time, the global crisis has spurred changes that could improve future health outcomes for rural North Carolina residents.
“There are good and bad things we are learning from COVID,” Woodie said. “One of the positives is that we are seeing for the first time nationwide, and it is also true in North Carolina, that the rural population is increasing after decades of steady decline, at the aggregate level. We think it won\’t be an equal increase everywhere, but we think it\’s a COVID-related trend.\”
She added, \”Everyone everywhere is rethinking their total approach to life, their approach to work-life balance, and their approach to where they choose to live their lives.\”
hospitals at risk
Eleven rural hospitals in North Carolina have closed or stopped providing inpatient care since 2005, according to data from the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill. The only states that had multiple shutdowns in the same 18-year period were Texas and Tennessee.
Mark Holmes, director of the Sheps Center, said a record number of rural hospitals are expected to close across the United States ahead of the federal public health emergency, which went into effect in May 2020 and expired earlier this month. That federal filing provided a \”lifeline\” to struggling facilities in the form of vendor relief funds, he said.
\”We\’re starting to move up again this year,\” he said. \”Something we\’re constantly keeping an eye on is this concern that all these hospitals that probably would have closed in 2020 but were able to hold on for a couple of years now have no support.\”
He said many of those hospitals could close in the next 12 to 18 months.
The Center for Healthcare Quality and Payment Reform recently identified seven North Carolina hospitals that are \”immediate.\” risk of closure due to the severity of their financial problems”. A 2022 report by NC Health News found that the state\’s at-risk hospitals are largely located in rural counties that are poorer and have more racially and ethnically diverse populations than most rural counties.
Holmes believes the infusion of pandemic-related funding has helped create the false impression that imperiled hospitals have achieved financial stability. While some of the state\’s wealthiest hospital systems have posted record profits during the pandemic, the gains made by rural hospitals haven\’t been enough to get them out of the red.
\”There\’s this idea, particularly in Washington, that hospitals have had a record year and that the rural hospital crisis is over,\” Holmes said. “That narrative, we don\’t believe, is an accurate representation of where we are. Rural hospitals, even though they have prorated twice as much as urban hospitals, still lag far behind urban hospitals in terms of survival.
Substance use
The opioid epidemic has taken a toll on the state\’s rural communities.
An NC Health News analysis of substance use data from the NC Department of Health and Human Services found that rural counties accounted for 42.6 percent of reported drug overdose deaths statewide in 2021 , the latest year for which complete data are available. About 30.6 percent of fatal overdoses that year were tied to suburban counties, while 26.7 percent were tied to urban counties.
The historic national deal with the drug companies that fueled the outbreak is intended to provide state and local governments with money to support services for people who struggle with substance use. Payments of the state\’s $750 million portion of the settlement, which will be dispersed in blocks over the next 18 years, began last May.
“All of our rural programs are fully mobile and rely on a delivery system where people go to a care worker and the care worker comes to them instead of having to go to a physical space,” he said . “This helps address both transport barriers, which are rampant in rural areas, and the stigma of attracting the attention of people who don\’t like what we do, which can create a kind of intimidating environment for people in small towns. cities and in rural areas where everyone knows everyone”.
Wilson said the coalition and like-minded organizations have received \”a lot of backlash\” from critics who question the effectiveness of services that seek to minimize the cost of substance use. Common harm-reduction strategies like providing clean syringes to people who aren\’t quite ready to enter recovery, she said, are sometimes seen as \”unacceptable\” alternatives to programs that ask clients to stop using altogether.
“The idea of having a non-judgmental space where there is no pressure to achieve abstinence from drug use can be very counterintuitive for people because we have an abstinence-based culture and an attitude towards drug use. of drugs in general,” Wilson said. “It can be quite shocking to people who are being introduced for the first time to the idea that there are spaces and services where the goal is not necessarily to help people achieve abstinence from drug use, but to help people to improve their health and well-being, whatever it seems to them.
Health insurance gap
Rural North Carolina residents are 40% more likely to be uninsured than residents of urban counties.
Expanding Medicaid will go a long way in addressing this disparity. Signed into law by Gov. Roy Cooper in March, the expansion will provide coverage for an estimated 600,000 people who currently lack health insurance. Many of these people are low-income workers such as farmers, pastoralists, day workers, and others making less than about $41,000 a year for a family of four.
\”It will disproportionately affect working, rural people who don\’t have health insurance and can\’t afford it,\” said Woodie, president of the Rural Center. \”It will be a game changer.\”
The expansion, he added, will have a \”major impact on the economic development\” of rural communities. In terms of scale, Woodie said it\’s on par with auto company VinFast\’s plan to build an electric vehicle factory that will bring 7,000 jobs to Chatham County.
\”The expansion of Medicaid is a huge boon and a big win,\” he said. “We should feel good. But boy, do we have our work cut out for us.
Probably the biggest challenge is ensuring that newly insured people in rural areas have access to health services. Rural counties have historically suffered from a shortage of providers, with the Sheps Center estimating that there are only 13 doctors for every 10,000 residents in rural North Carolina. Urban counties, meanwhile, have about 36 doctors for every 10,000 residents.
“One of the things we are most excited about in the coming years is to see how the expansion of Medicaid can impact people\’s access to health care in general, particularly when it comes to opioid use disorder medications. \”Wilson said. “Most of our participants, not all by any means, but most of them are uninsured and having access to health insurance would be transformative in terms of not only their substance use disorder but many different issues as well.
\”Many people often have other chronic health conditions that they are managing, so just having access to healthcare or even primary care would improve people\’s quality of life.\”
North Carolina Health News is an independent, nonpartisan, non-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.
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