Rural Healthcare in Michigan
Rural Americans face significant barriers that impede their ability to access affordable, quality healthcare. Barriers stem from a myriad of challenges unique to rural areas. Current research suggests that a multitude of factors, ranging from economic and educational disparities, social and cultural differences and geographical isolation, create gaps in health care accessibility that disproportionally effect rural areas.
Approximately 51 million Americans live in rural areas yet only about 11% of practicing physicians practice there. This disparity exacerbates the already dire state of rural populations who are disproportionally older, economically weaker, and have poorer health status than their urban counterpart. The lack of access to health services in rural areas is an ongoing problem that necessitates prudent solutions to ensure health equity is achieved.
Status of Healthcare in Rural Michigan
According to the most recent Census (2010), the total rural population of Michigan is 2,513,683. That number accounts for 25.4% of the states total population, a nominal decrease from the 25.6% recorded in the prior census. Rural Michigan also comprises 75% of the states landmass.
While current data covering the full spectrum of rural health is not readily available, pertinent information compiled by Michigan’s leading rural advocacy groups provide sufficient data to create a tentative baseline. The Michigan Department of Community Health (MDCH), and the Michigan Center for Rural Health (MCRH) collaborated to produce the Michigan Rural Health Profile (MRHP), an exhaustive report that profiled the health status of rural Michigan. The MRHP collated extensive data on demographics, socio-economics, health indicators, and available health resources. The MRHP report found several factors contribute to the inaccessibility of health services; namely, lack of resources, sparse populations, geographic isolation, unaffordable services, and shortcomings with health providers.
The problems identified by the MRHP are not novel problems; they are problems that have persisted for decades. Over the years, lawmakers passed numerous initiatives aimed at increasing rural accessibility to health services. State legislations were supplemented by the ACA, which included provisions specifically aimed at increasing accessibility to health services in rural areas. Invariably, state legislations coupled with key provisions in the ACA have contributed to making health services more accessible in rural Michigan. However, many residents in rural Michigan remain unable to access health services. Hence, inaccessibility to quality health services remains a critical problem our state government must contend with.
What is the State’s Role?
To effectively address the various challenges preventing rural residents from accessing health services, lawmakers should begin with earnest efforts to view the issue through a “rural” prism to ensure policies and initiatives take into account the unique multilayered characteristics of rural Michigan. For instance, research suggests that state-level policies typically do not discern the varying differences between rural and urban areas, and how those differences might affect policy implementation. It would be counterintuitive to enact policies that overlook these differences because they induced the current climate of disparate health care in rural Michigan.
Lawmakers should also remain mindful of their limitations, irrespective of what they are. Invariably, any attempts at reform will have to play out against a backdrop of constraints, particularly health reform efforts. Hence, lawmakers should adopt alternative strategies, like building and cultivating strategic coalitions with medical schools and health institutions, to realize these reforms. In addition, they should make concerted efforts to refrain from any inclination that may prompt them to shift focus away from the underlying problems. Lawmaker should not assume rural residents would stay the course and continue to acquiesce to incremental policies that have been proven to be fairly ineffective in thoroughly addressing their health care concerns. It is conceivable that, sooner or later, insurmountable pressure may mount and lawmakers will then be forced to act. To evade a reactionary response that may be politically expedient but not necessarily pragmatic or canny, lawmakers ought to prioritize this issue and wholly commit to it.
Although inaccessibility to health services has been an ongoing problem, there exist a host of proven solutions – backed by sound research – lawmakers can pursue to achieve health equity in rural Michigan.
Given this orientation, lawmakers should assume a multi faceted approach and design prudent policies that address the whole gamut of healthcare inaccessibility in rural Michigan. This will entail our lawmakers be proactive and commensurate policy initiatives with the myriad of multi-layered challenges facing rural residents.
Challenges and Opportunities
Healthcare in rural Michigan presents several notable challenges that need to be addressed. Likewise, the challenges present numerous opportunities lawmakers can leverage to improve health equity in rural Michigan. Although the issue of healthcare is a complex one, with multiple layers interlaced with varying degrees of considerations, the crux of the issue points to three major themes, including:
- Limited availability and accessibility to health care insurance
- Limited availability and accessibility to health care services
- Issues with the recruitment and retention of practicing health care professionals
Challenge #1: Access to Health Insurance
Rural Michigan has higher rates of uninsured residents compared to its urban counterpart. Additionally, residents are more prone to being uninsured for longer periods of time. These disparities leave rural residents particularly susceptible to health ailments that could otherwise be prevented if they had been insured.
Granted, rural Michigan enjoyed a certain degree of relief with the passing of the ACA, however thousands of residents remain uninsured. The ACA expanded coverage to thousands of residents in rural Michigan by providing a continuum of coverage options through the Health Insurance Marketplaces (HIMs) and Medicaid. Medicaid plays a key role in insuring rural residents because it expanded eligibility to virtually all low-income adults with incomes at or below 138% of the federal poverty level (FPL, $16,242 per year for an individual in 2015).
Initially, states were required to expand their Medicaid programs under the ACA. However, the Supreme Court ruling on the ACA’s constitutionality relegated that provision, effectively granting states the option to opt out. Michigan elected to expand Medicaid, joining 29 other states and the District of Columbia. Titled the Healthy Michigan Plan (HMP), the Medicaid expansion went into effect on April 1, 2014, after months of delays.
The HMP diverged from the state’s traditional Medicaid program (which remains still), incorporating a number of modifications, including health saving accounts, co-pays and cost sharing (up to 5% of income for individuals with income of 100% of FPL or higher) and incentives aimed at rewarding healthy behavior.
Enrollment in the HMP grew very quickly, reaching over 240,000 individuals in the first two months. Enrollment continued to rise steadily until it eventually plateaued at a little over 600,000 individuals. As of August 2016, 614,012 residents enrolled in the HMP. HMP beneficiaries have access to a number of essential federal health benefits, including: outpatient, emergency, inpatient, maternity and newborn, mental health and addiction treatment, prescription drugs, rehabilitative, laboratory, preventative, and pediatric services.
The HMP supplements Michigan’s traditional Medicaid program, which currently covers 1.7 million beneficiaries. The traditional Medicaid program is a joint federal-state health care program and is administered by the state’s Department of Health and Human Services (DHHS). The two programs make up nearly one-third of Michigan’s total state budget and nearly one-quarter of its General Fund budget.
Current data specifying the enrollment of rural residents in the HMP is not readily available. The most recent data that provides specifics appears in a 2015 report by the RUPRI Center for Rural Health. According to the report, as of March 2015, just over half of rural residents eligible for Medicaid enrolled in the program (the next section extrapolates more on the findings). The finding propounds the view that more can be done to help rural residents access health care coverage.
There are several reasons that explain the barriers facing rural residents seeking health coverage in Michigan. First, rural residents predominantly are self-employed or work jobs that don’t offer health insurance. Most of them are farmers or seasonal workers and are not employed by businesses that offer health insurance. By contrast, the majority of the urban population in Michigan receives health insurance through their employer. This discrepancy contributes significantly to the disparities in health coverage between the two populations.
Second, rural residents are limited with their insurance options. One way the ACA aimed to drive insurance costs down was creating the Health Insurance Marketplaces (HIMs), an exchange designed to encourage competition among health insurance providers and grant consumers greater choice.
“A key foundation of the Affordable Care Act is that competition between health plans can lower the cost of health care to consumers,” said Marianne Udow-Phillips, director of the Center for Healthcare Research and Transformation at the University of Michigan. “We have a great demonstration of how important competition is to the success of the Affordable Care Act here in Michigan.”
While the marketplace did create more options for consumers in urban Michigan, those options were not extended to rural Michigan. Residents in Michigan’s largest urban counties like Wayne and Macomb can choose from over 55 insurance plans on the marketplace; in contrast, rural Michigan often has to choose from only 5 plans, and in the more remote areas, just one. For instance, Blue Cross Blue Shield of Michigan is the only company selling on the exchange in Delta County. The discrepancy in choices between urban and rural areas means not only a disparity in access to health services, but also higher costs for insurance coverage. A midlevel plan in Wayne County that covers 70 percent of health care costs is priced at $215.17 monthly for a 45-year-old smoker. In contrast, identical coverage for a nonsmoker in Delta County runs $377.56 per month. A recent report by the Kaiser Family Foundation suggests that in 2016, counties that are mostly rural will have an average of 2.9 Marketplace insurers participating, down very slightly from an average of 3.1 insurers in 2015.
Third, rural residents are increasingly becoming more reliant on Medicaid, which presents several notable challenges. Medicaid provides essential health coverage for rural Michigan, and is often the only option for residents. The ACA, through its HIMs expanded the Medicaid program, insuring more rural residents in Michigan than ever before. Despite the program’s expansion, research suggests that many rural residents eligible for Medicaid did not enroll.
According to the RUPRI Center for Rural Health, as of March 2015, 341,183 residents enrolled in Medicaid, which equates to 49.5% of the total number of residents eligible for the program. Of those that enrolled, 68,628 were rural residents. That equates to 52.9% of the total number of rural residents eligible for the program. That means during that time period, approximately 134,000 rural residents qualified for Medicaid, but only 68,628 enrolled. This evidence seems to suggest that there is room for improvement if steps are taken to insure the pool of eligible residents currently not enrolled in Medicaid. However, it should be noted that the number of enrollees since then nearly doubled, effectively expelling the data’s statistical relevance. Absent current statistics, it cannot be said with certainty the number of eligible rural residents currently not enrolled in Medicaid. The data is however consistent with common rural trends and thereby provides a meaningful baseline that warrants further research.
A Deeper look at Medicaid Expansion
Rural Michigan comprises approximately 90% of the state’s landmass. As a result, rural areas have low population densities. This makes achieving efficiency and the measurement of care quality – essential components of a value-based payment system like Medicaid – increasingly difficult. Furthermore, it places an undue strain on rural providers because they will be asked to share the financial risk, something they wont be inclined to do considering the low-volume environment.
Shortages in health professionals also exacerbate the problem because increasing the Medicaid pool will requires an equipped work force to meet the increased demand. Furthermore, state lawmakers are tasked with driving improvements in care delivery, cost, and outcomes in the Medicaid program. That is an ongoing process that entails implementing certain reforms aimed at managing costs without sacrificing quality. The implementations of these reforms also depend on an equipped workforce, the absence of which would undermine the efforts and effectively negate potential for progress.
The expansion resulted in numerous implications that continue to impact rural residents. Invariably, lawmakers should always be cognizant of the repercussions their legislations inflict, particularly on rural communities. It would belie prudent legislation if the unique characteristics of rural communities are overlooked. Often, lawmakers grapple with political and economic considerations, at the expense of overlooking other important considerations. Granted, those considerations merit considerable attention, but they are not the only ones – social considerations, too, must be heeded. It behooves all legislative efforts to append this consideration because collectively, they help to cinch encompassing reforms that address core problems.
As to broaden access to health insurance in rural Michigan, lawmakers should employ a two-pronged approach that addresses two critical deficiencies in the current rural Health system:
- Inaccessibility to health insurance
- Inefficient health delivery system
Research suggests health reform efforts typically focus on increasing the insured pool while neglecting to address core deficiencies within the health system infrastructure. This practice is counterintuitive, particularly in rural areas where the delivery of health services presents substantial barriers, even for those insured. Hence, lawmakers should adopt policies that increase the insured pool of rural residents while simultaneously working on revamping the rural health delivery system. It is critical reform efforts address both in parallel to ensure root problems are addressed efficiently and properly. The primary objective is to design thoughtful policies that contribute to the creation of a health system that integrates and coordinates different health disciplines, streamlines payment delivery, expands and enhances the use of technology, and revamps our current health service delivery system. The overarching goals are to increase the rural insured pool and to modernize the health system infrastructure making it more encompassing, sustainable, efficient, and cost effective. To that end, lawmakers should examine these focus areas:
- Integrate and coordinate the different health disciplines
- Expand and enhance Telehealth and HIT
- Adopt alternative models to improve health service delivery
Integrate and Coordinate the Different Health Disciplines
A health system is a collection of individual providers each focused on delivering particular services within the confines of their own respective practice. By contrast, a community health system is built by a community to maximize resources and delivers patient-centered health services to residents. This discrepancy between health systems and community health systems underpins the primary problem of inaccessibility to health services: rural residents belong to a health care system that makes it overly cumbersome, if not impossible, to access health services due to their unique circumstances. Given this observation, reform efforts should inherently aim to transform health systems to community health systems in rural Michigan. Accordingly, that means reform efforts should adhere to the basic premise that ultimately, the end goal is to cultivate a community health system because it is best equipped to meet the needs of rural residents.
Current health systems in rural Michigan are often fragmented; in part, this is due to low population densities common in rural areas. Bridging this divide is essential, particularly when trauma and specialized care facilities are significant distances away and necessitate timely care. Research indicates that only 24% of rural residents can reach a trauma center within one hour, compared to 85% of non-rural residents.
As a result of expansions under the ACA, Medicaid has grown significantly in its importance to rural health systems. Providers in rural areas are growing increasingly reliant on Medicaid programs because they are a key source of financing. As the Medicaid pool continues to grow, more states are beginning to develop and adopt alternative payment and delivery system models to help streamline services and manage costs. One notable example is the emergence of shared saving programs like accountable care organizations (ACO’s) and patient centered medical homes (PCMHs); alternative models that depart substantially from traditional payment models. State Medicaid programs gravitate towards these models because they allow them to deal directly with service providers. In addition, providers are held accountable through risk-sharing agreements and performance standards. Increased accountability is a catalyst to better health services because providers are incentivized to drive improvements because their financing is depends on it.
Research suggests rural residents stand to benefit most from these alternative models. Proponents assert these models are designed to mitigate barriers to accessing health services, challenges rural residents face too often. The key problem with this premise is it overlooks inherent challenges within the models.
Although geographic barriers present a daunting challenge, one way to circumvent them is integrating and coordinating different health providers. The objective is to enhance clinical integration in rural communities and increase communication and collaboration with urban facilities. This endeavor would require rural communities develop their technological capabilities to streamline communication and improve data sharing. Considering many rural residents seek treatment at urban areas, it is important that their medical information follow them and is readily available when needed.
Challenge #2: Limited Availability and Accessibility to Health Care Services
Accessing quality health services has been an ongoing struggle for rural Michigan, particularly those living in remote areas. Invariably, the sheer geographical isolation of rural areas lends to increased barriers to accessing health care services. The health professional shortage area (HPSA) is a useful tool that illustrates geographic areas that have shortages of health professionals. The HPSA designation is assigned by the United States Department of Health and Human Services (HHS) and is granted in three disciplines: primary medical care, dental care, and mental health care. According to the Health Resources and Services Administration (HRSA), as of September 2016, Michigan has a combined 835 HPSA designations, the majority of which belong to Rural Health Clinics (RHC). RHCs are federally qualified health clinics certified to receive special Medicare and Medicaid reimbursements. The Centers for Medicaid and Medicare Services (CMS) grants RHCs preferential reimbursement methods as a way to improve accessibility to primary care services.
The consensus view is that primary care is the most effective form of healthcare for ensuring health equity among different population groups. First, it is relatively cheaper compared to other health disciplines and concomitantly more apt to be delivered efficiently with fewer barriers to contend with. Second, it is arguably the most effective line of defense against disease progression because it serves as the first vestibule to health services.
Primary care plays a critical role in ensuring the health needs of rural residents are met, yet there is a shortage of primary physicians in rural Michigan. In Michigan, there are a total of 326 primary care HPSA designations, 181 of which belong to RHCs.
If the primary care shortage is left unabated, it will result in reduced efficiency of the healthcare system, increased costs, and diminished quality of care. In fact, not only will the shortage reduce access to health care services, but it will also increase the likelihood of price hikes as a result. According to the CRC report, “This occurs when shortages cause providers, such as hospitals, to compete for a small pool of workers, whereby they must increase wages or other benefits in order to entice workers.” Rudimentary knowledge of supply and demand principles indicate that if fewer healthcare providers remain in the market, then consequently they will attain increased leverage and bargaining power to charge higher prices.
Given that primary care is a central component to assuring quality health services, it follows then that an optimal health services delivery system include a robust primary care infrastructure.
The Centers for Disease Control and Prevention (CDC) estimates that almost 25% of adults nationwide have a mental illness and close to 50% of adults will experience at least one mental illness in their lifetime. This underpins the grimness of how essential mental health services are for those who need them.
Mental health services in rural Michigan are often lacking and warrant considerable efforts to make them more accessible to rural residents. According to the U.S Department of Health and Human Services, Michigan is among the states that have significant shortages of mental health professionals and facilities. There exist a total of 244 mental health HPSA designations in Michigan, 128 of which belong to RHCs.
“There is a shortage of service providers, psychiatrists and physicians that are able to work with people that have mental illness and prescribe medications,” said Kathleen Gross, executive director of the Michigan Psychiatric Society. “There is shortage of funding in the state for community mental health centers to provide a great deal of service to the citizens.”
Due to shortages of mental health services, the responsibility of care for issues of mental health is often shifted to primary care providers, further burdening an already depleted primary care sector in rural Michigan.
(Assess Michigan State Oral Health Plan)
With considerable attention being paid to primary care, oral care is often overlooked. Access to oral care has been a persistent problem in rural Michigan, resulting in high incidence of dental problems that could otherwise be prevented if access was readily available.
In Michigan, there are a total of 265 dental care HPSA designations, 133 of which belong to RHC’s.
Challenge #3: Recruitment and Retention of Rural Workforce
Ample research suggests that shortcomings in efforts to recruit and retain practicing health care professionals are major contributing factors for the stressed state of health care in rural Michigan. As a result, the health care workforce in rural Michigan is struggling to meet current demand for health services, effectively placing an undue burden on an already expended workforce. To rectify this matter, state lawmakers’ should craft proactive strategies that not only diminish current barriers hindering recruitment efforts, but also minister incentives to help retain health care professionals.
Primary care is the bedrock of quality health services, considering it serves as the entry point to all health service needs. Although a shortage of primary care physicians is a statewide problem, it is more acute in rural areas. The shortage has yielded detrimental consequences for rural residents. The fact that rural residents rely more on primary care compared to their urban counterparts exacerbates the problem.
While the number of primary care physicians in Michigan is almost equal to the national average, they are not distributed evenly across the state. A recent report by the Citizens Research Council (CRC), addresses Michigan’s primary physician shortage. The report identifies a host of factors that contribute to the state’s primary care physician shortage, including population growth, an aging population, increased number of physicians retiring, and considerations pertaining to birth locations.
It behooves the examination of primary care physician shortages, particularly in rural areas, to account for deficiencies in medical education and training because they carry various implications that contribute to the problem. Particularly related to rural Michigan, the report suggests that misdistribution of primary care physicians is behind the shortage of primary care in rural Michigan. Partially to blame for the misdistribution are lack of efforts on the part of medical education and training systems to encourage residents to practice in rural areas. Bolstering medical education by accommodating more students willing to practice in rural areas can alleviate physician shortages in rural areas. Moreover, enhancing training programs by incentivizing and prioritizing the preparation and production of rural physicians also helps. Research suggests this two-pronged approach is very effective in addressing physician shortages.
Equally as important to the aforementioned concerns is the challenge of retaining health care professionals in rural Michigan. Many health departments in rural Michigan have faced reductions in their workforces, particularly after the economic recession. Budget cuts as well as an increase in the number of physicians retiring compound the problem.