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Rural Health Equity

For many people, rural life in Colorado may bring to mind images of fresh air, mountain vistas, vigorous hikes and days spent fly-fishing and eating farm-raised, wholesome foods. This Ralph Lauren-like vision of Americana presents a picture of healthy living — fit people living long lives, chopping wood and playing hard by clear blue streams.

Without question, this lifestyle certainly exists for some Coloradans who live well in rural, mountainous settings. But statistically speaking, this isn’t the reality for most rural Coloradans, who experience a greater incidence of chronic illnesses and obesity, who have more limited access to health care and who have shorter lifespans than people in urban areas.

According to the nonprofit Colorado Rural Health Center, 73 percent of Colorado’s 64 counties are rural, while 18 percent of the population lives in rural areas.

Here are a few sobering facts about rural counties, according to the organization:
• Median household income in rural counties is 26.5 percent less than in urban counties.
• Of families living in rural counties, 9.8 percent live below the federal poverty level, while only 8.9 percent of families in urban areas do.
• Meanwhile, 24.5 percent of kids in rural counties live in poverty, as compared to 15.8 percent for urban children.
• Deaths from coronary heart disease occur at a rate 14.4 percent higher in rural areas than in urban areas.

Access to care is certainly an enormous factor in health outcomes in rural areas, but so are social determinants like age, household income, race, gender and behavioral factors. According to the Disparities National Coordinating Center, an agency under the federal Centers for Medicare and Medicaid Services, only between 10 percent and 20 percent of health is explained by care received in doctors’ offices and hospitals.

“Broader issues such as poverty, lack of transportation, occupational hazards, poor environmental conditions, lack of education and behavioral factors impact these outcomes to a greater extent,” a recent report from the DNCC said.

According to the DNCC report, 87 percent of the difference in life expectancy between rural and urban populations comes from high death rates of individuals over 25 due to unintentional injuries, heart disease, Chronic Obstructive Pulmonary Disease (COPD), suicide and diabetes. In fact, COPD death rates are the highest for both men and women in rural counties, where smoking rates are higher and environmental hazards may be higher.

“Life expectancy for all U.S. population groups has increased by almost a decade during the latter half of the twentieth century, but a gap in longevity for rural populations has become apparent,” the DNCC report said. “Until 1990, the urban-rural disparity was not as significant; however, the gap is now more than two years and widening.

“Life expectancy in rural populations has increased over the past four decades, but rate of change has not kept pace with urban rates. In fact, the life expectancy for both genders in rural and urban populations from 1984-1986 was the same. The life expectancy for rural males in 2009 was 74.1, which was almost the same for urban males 10 years earlier at 74.5. It is this lack of progress which is the most disturbing aspect of this data.”

These troubling statistics on social determinants in rural America are coupled with a real lack of access and availability of health care.

The National Rural Health Association reports that only about 10 percent of physicians practice in rural areas, and rural residents are less likely to have employer-provided health care coverage for prescription drugs and less likely to be covered by Medicaid than residents in urban areas.

It’s also harder for folks in rural areas to get to medical providers. The Colorado Rural Health Center says 14 percent of rural adults have low incomes and lack transportation compared to a state average of 8 percent.

According to the NRHA, about two-thirds of all automobile fatalities occur on rural roads, which are frequently less safe than those in urban areas. Response times to accidents are on average eight minutes longer.
Besides car accidents, rural residents are nearly twice as likely as their urban counterparts to die from gunshot wounds. Alcohol and tobacco use rates are higher, with rural eighth-graders twice as likely to smoke as those in urban areas.

Rates of teenage pregnancy are also higher, with the rate of births by teens 15-19 in rural areas 1.6 times higher than in urban areas.

And despite stereotypes of fresh, wholesome, nutritious food in the country, the report from the Disparities National Coordinating Center shows that while only 8.2 percent of urban residents live in “food deserts” — areas more than 10 miles from a grocery store — 23.3 percent of rural residents do.
In fact, the rate of obesity in rural areas is 28.6 percent compared to 25.8 percent in urban areas, the DNCC report said. These disparities are even more pronounced among minorities.

Clearly, the long litany of health disparities in rural areas dispel any notion that country living in and of itself makes one healthier. But what is even clearer is that access to care in and of itself does not tell the whole story of health disparities in rural areas.

Jen Fanning – Executive Director, Grand County Rural Health Network