Virtual Symposium on Rural Health and Poverty

Some of the highest poverty rates and least access to health care  in Oklahoma can be found in the state’s rural counties. Recently, we asked a group of Oklahomans with longstanding expertise on rural issues to respond in 400 words to the following questions : Does Oklahoma need a different approach to fighting poverty in rural areas, compared to urban and suburban parts of the state? What policies might help us address this problem? We received the following contributions from Denna Wheeler, Jeff Hackler and Chad Langraf; Karla Finnell; Tim Starkey; and Andy Fosmire.

Denna Wheeler, Jeff Hackler & Chad Landgraf: Develop integrated rural delivery systems

According to U.S. Census Bureau estimates, poverty in Oklahoma is at a ten-year high, and rural areas of the state have significantly higher poverty rates than urban areas. For example, Oklahoma’s four most urbanized counties (Tulsa, Oklahoma, Cleveland, and Canadian) have poverty rates ranging from 9 percent to 18 percent, while Oklahoma’s poorest counties located in rural areas of the state (Okfuskee, Harmon, Adair, Hughes and Tillman) have poverty rates of 26-27 percent.

Poverty and poor health are inextricably linked through complex associations with education, employment opportunities, and access to health care.  Persons living in these persistent high poverty counties are less likely to have health insurance and, as a result, a higher proportion report a poor health status. While access to care is a significant concern, we must also address the cultural issues in rural Oklahoma that lead to poor health outcomes.  In many cases, poor health outcomes stem from unhealthy behaviors.  It will be difficult to improve the health of rural Oklahomans without changing these underlying behaviors.  To effect behavioral change we need to develop interventions and deliver health care with a specific focus on this population’s unique culture.

One of the few organizations actively developing policy related to rural poverty and health is the Rural Policy Research Institute (RUPRI) at the University of Missouri-Columbia. RUPRI advocates regionally integrated rural service systems that combine community organizations, healthcare delivery systems, faith-based programs, and others to allow rural residents to get information and multiple services in a single location. This makes communication related to available services more efficient and reduces required travel for services.

RUPRI has produced a number of reports to help guide public policy.  These reports highlight rural-based programs that have successfully integrated human services programs with health programs to maximize service delivery in resource-limited rural areas. Successful program implementation will require a shift from population-based allocation of resources and funding, which disadvantages sparsely populated rural areas, in favor of place-based policies. Additional features of successful programs include shifting emphasis from treatment to prevention, and a shift from public and non-profit ownership of health and human services to a shared community-based ownership that ultimately empowers the community. 

Denna Wheeler, Ph.D., Jeff Hackler, J.D. and Chad Landgraf, M.S. are with the OSU CHS Center for Rural Health

Karla Finnell: Build on the core strengths of rural communities

Poverty and access to health care are interrelated in rural Oklahoma. At one point in my career, along with other team members, I worked with small family farmers in western Oklahoma to develop sustainable operations. If any farmer even considered purchasing health insurance, it was certain that the farm would not have a positive cash flow. However, most had accepted the reality that health insurance was out of reach, and few asked. The Affordable Care Act, and its exchange, will ameliorate much of this problem. The next step is to expand the Medicaid program to cover adults with household income below $1,962.50 a month. Together, these initiatives will insure most Oklahomans. Regrettably, the issue has become mired in rhetoric. Yet, Oklahomans are compassionate; expanding Medicaid is a compassionate option. We have existing systems that can be built upon, allowing the state to expand Medicaid in its own “Oklahoma way”.

Another issue is the availability of doctors, equipment, and facilities. We must accept that health care delivery is expensive. It is difficult to recruit physicians and other providers to rural areas. A minimum threshold of patients is necessary to create a high quality health care system. Some services can only be feasibly delivered at a regional level such as a county seat. To ensure accessibility, transportation and other enabling services must be provided in tandem. Other services, such as preventive health care, can be delivered locally. Extending the scope of practice of nurse practitioners and dental hygienists will make these services accessible and affordable. With advancements in electronic health records and telemedicine, an integrated health care system can be achieved, reducing cost and improving quality.

Persistent and entrenched rural poverty requires a long-term, multi-faceted strategy. A core strength of rural communities is that residents have known each other since childhood, and they continue to frequently socialize. Strategies to reduce poverty should build on these social networks to enhance civic participation and leadership. The emerging “Go Local” movement in urban areas can be exported to rural areas to create small businesses and self-sufficiency, while further strengthening social networks. In addition, small manufacturing operations employing less than 100 people can have a major impact. Grants and technical support should foster these opportunities. None of these ideas are new; however, for change to be successful it should be integrated into and consistent with local cultural values.

Karla Finnell, J.D., is a Ph.D. candidate and a staff research assistant with the University of Oklahoma Health Sciences Center

Tim Starkey: Expanding Medicaid would provide the biggest impact

Great Salt Plains Health Center, Inc. is a Federally Qualified Health Center with sites in Cherokee and Medford Oklahoma.  Both sites were established through federal grant funding to counties where little or no healthcare existed before the grant. The hospital in Cherokee (Alfalfa County) was closed in 1994, and along with it went the local physicians.  If it were not for the federal government stepping in, residents of these two counties would be traveling up to 70 miles for primary health care.  In comparison to other states, Oklahoma provides very little or no assistance to areas of the state where patients are medically underserved.  I believe this greatly impacts the overall health of our citizens and in turn results in our poor health ranking among all 50 states.

The citizens of Oklahoma must start taking responsibility for the health care needs of citizens of all social classes.  I personally have been told by a local citizen that low-income uninsured citizens should not receive the same quality and level of healthcare that he receives as an insured patient.  He stated that these individuals are a drain on the system and cause his insurance premium to increase, so they should be turned away by providers.  This is just an example of a somewhat elitist attitude about the needs of our most vulnerable citizens.  While I realize that most Oklahomans do not take this radical approach, I also believe that we are guilty of being complacent to the needs of a population that we sometimes know absolutely nothing about.  We must be responsible and find ways to address this inequality.

Recently, Oklahoma has declined to accept federal funding to expand Medicaid.  This federal funding would bring billions of dollars into Oklahoma in the years to come to provide vital health care to our neediest of citizens.  Not only would this directly impact the economy of Oklahoma, it would ease the burden of uninsured care on the system and in turn the burden on private insurance premiums.  The only plausible explanation for refusing to accept these dollars can be found by looking at the politics involved.  It is time we got beyond our political opinions and worked to improve the health of all Oklahomans.  Medicaid expansion would provide the biggest single impact toward improving the health of rural (and urban) Oklahoma and serving the poor.

Tim Starkey, MBA, FACHE is CEO of Great Salt Plains Health Center, Inc.

Andy Fosmire: Addressing rural poverty requires a different strategy

According to data from the Working Poor Families Project, Oklahoma ranks 42nd in the nation with 37.4 percent of working families with incomes less than twice the federal poverty level.  The rate for minority families in Oklahoma is 48 percent. Many of these households have persons in them working full time. They are in low wage/low skill jobs that very rarely offer any security or benefits like health insurance or paid time off.   This has a drastic effect on access to healthcare.  These families have limited ability to pay, limited access to transportation, and are not able to take time off from work to seek care.

Rural poverty brings even more complications, because of the geographic distribution of the target audience and because rural residents tend to be distrustful of what could be seen as “government intrusion” of any assistance or training programs.

There are several policy points that could help address rural poverty and ultimately access to healthcare.  First, the state could adopt a minimum wage at a level that would assist rural working poor to function above the poverty level.  Currently the state is tied to the federal minimum wage of $7.25; there is no law that would preclude Oklahoma from instituting a minimum wage above that level.  Second, Oklahoma should accept and promote the Affordable Care Act, rather than legislatively oppose all parts of the ACA on political grounds. Third, accept the expansion of Medicaid.  Not only would this allow numerous rural Oklahoma families access to health care, but it would bring some economic stability to rural health care providers who end up as the non-compensated safety net for the uninsured or unindersured people who seek primary care in rural hospital emergency rooms.

Andy Fosmire, M.S., has been Executive Director of Rural Health Projects, Inc. since 2001 and Managing Director of the Rural Health Association of Oklahoma since 2006.