As you may not know, to stay current in my nursing skills and to give back to the community I do some clinic nursing in a rural clinic, now and again. I also reside in a very rural place, and so the health care issues which impact rural families are really underscored to me.
As I see it, these are some of our issues. First of all, even the wealthier inhabitants of rural counties are less likely to have a good health insurance plan, the type that would be given through an employer. Many have only a catastrophic health care insurance plan, and many have had to let individual health insurance lapse as the economy has worsened. They vehemently do not want the government ordering them to buy a plan which would take their choices, but they also just now, aren't making enough of a profit to cover their entire families with good health insurance. Of course, this makes health issues, when they occur, much more stressful than they would be otherwise. The second issue I see, is the aging of America. A large number of rural inhabitants who still somehow run farms, often with cattle, horses and other challenges, are really elderly. They manage by either having children and grandchildren come on key days to help with animals, or by hiring specific people to do things for them, when it's time to relocate cattle, or sheer sheep, or do whatever the seasonal cycles on their farms dictate. Interestingly, most of these people tend to do well, so long as nothing interferes with the momentum they have set up over the years. They are, however, many times without support and assistance, when something does happen. Many of them have Medicare, but know little about it. Some of them don't have routine screenings done, which could be lifesaving or could catch an evolving health issue before it becomes life threatening. A few actually have a Medicare supplement, and some of these have been very helpful to them. Interestingly, I see very few elderly people out here with a raving dementia. Cognition seems to slow here in a gradual way, as I think mine probably is, and the requisite adjustments are made in the lives of the citizens.
Another issue is health care access. We have a couple of rural physicians here. Some of them are good, but they aren't set up to provide state of the art urban care. A lot of patients want only what can be done for them here. They have the same reticence for the city that I do, and they don't wish to go there. This is sad because sometimes their best chance at being cured or surviving, is to spend some time seeing a specialist in a city within a day's drive. My family is unusual in that we have commuted to get state of the art care for our children. Many people here are struggling with some fairly major health challenges with children, and they are only seeing a local family practitioner for management. This is also something a fair number of rural people don't realize. For example, the asthma your child sees the family physician for, for three years, might have been solved by a particular regime used in a nebulizer ordered by an allergist-immunologist a days drive away. Two visits with an allergist-immunologist might have solved their problem, and yet, they won't go.
In many rural patients prevention is simply not within their view screen. They aren't going to spend for cholesterol lowering drugs. They aren't getting a mammogram, or a colonoscopy. Some of the cancers, and some of the heart attacks here, perhaps could have been prevented. Prevention needs to become a priority in rural health care, more than it is. We are spending time putting out fires, when we shouldn't have held the cigarettes in the first place !
In many rural communities there is little or no mental health care for inhabitants. This is actually not true of my own community, where a psychiatrist, psychologists and psychiatric social workers are part of the clinic and take care of a large number of situational crises as well as those with a known chronic mental health issue. This is one of the things our county does very well.
One of the barriers to getting the care people need, in terms of preventive care, and in terms of treatment while the issue still remains manageable is transportation and commuting distance. In a neighboring county, we have a health care bus which takes disabled or elderly people to their doctors visits and to labs for labwork and then drops them back at home. We don't have this in our county, and the slack is picked up my family, friends, neighbors, and friends from churches. Too often, it becomes driving someone back and forth for cancer treatment, rather than the ladies from a particular church arranging to have mammograms done on the same day, and then all heading in to a hospital for screening on one day which could be set aside for them.
Our clinic provides free or low cost services to citizens with no insurance, Medicaid, or inadequate insurance. It includes dental care, although a significant waiting list for this type of care exists. The physicians including specialists volunteer their time, as do nurse practitioners, pharmacists, and registered nurses, all provide care free of charge, and receive a tax credit on state taxes. So does the office staff who qualify patients, and often arrange a drug supplier to provide an expensive medication to one of our patients free of charge for a period of time. Psychiatric care is not handled at my location. We see anything from new onset hypothyroidism, to diabetic ketoacidosis in a person who has had Type I diabetes for years, and who can no longer afford his insulin or his test strips. New respiratory infections, and new onset autoimmune disorders are seen. An awful lot of hypertension is an issue. Obesity is about as much an issue here as in any American urban area. Some patients are referred to hospitals who will do a certain amount of surgeries in a given year, free for our clients.
For my community, fundraising and some aid from the state have allowed us meet many of the needs in our own community. Many other Virginia counties have also organized their own county clinics with various results. Some of providing really excellent life changing care for rural county residents. Others are struggling to meet a need for appointments which is beyond their capability.
In any event, the challenges of rural health care aren't likely to change much regardless of the Obamacare delivery system. We still have the same challenges.