map shows most of North Carolina counties colored ingreen to indicate they are shortage areas. experts say this impedes economic development
70 of the 80 rural counties in North Carolina are currently designated “medical deserts” for their lack of primary care availability. Data source: US DHHS, Health Services and Resources Administration. Map compiles by: NC Rural Center

By Taylor Knopf

As people migrate toward urban centers, the rural infrastructure is crumbling. The population is aging. Jobs are dwindling. And rural hospitals are struggling to stay afloat or closing.

In North Carolina, 20 counties do not have a pediatrician; 26 counties do not have an OB-GYN; and 32 are without a psychiatrist, according to the North Carolina Health Professional Data System.

In response, state lawmakers held their first meeting on Monday of a study committee examining Access to Healthcare in Rural North Carolina. Health and economic experts spoke to the committee about the problems facing rural North Carolinians and some ways to address them.

The committee will meet a few more times and give a report with legislative recommendations to the General Assembly by April 20.

One major issue prominent in each presentation was the lack of physicians in rural areas.

Providers are distributed along the I-85 and I-40 corridors, said Chip Baggett, vice president and associate general counsel for the North Carolina Medical Society.

“We’ve been seeing the urban communities grow dramatically, and we’ve been seeing the rural communities flatline,” he said. He said that young people with ambition leave their rural communities and never move home, they way he left his hometown of Tarboro.

And he said that to induce a physician to move to a rural area and then stay, it has to be a place with good school systems for their kids and where spouses can find a job.

Incentives

Baggett suggested enhancing incentives for physicians to serve in rural areas, such as student loan payment programs. He also said to make sure there is good reimbursement for care, including paying good Medicaid rates.

During another presentation to the committee, Mark Holmes from UNC’s Sheps Center, noted that rural areas have poorer health on almost every measure, they are older, poorer, more isolated, have fewer health care resources and have persistently higher mortality than urban areas. Graph courtesy: Sheps Center for Health Services Research.

John Kauffman, the dean of Campbell University School of Osteopathic Medicine, said many physicians in the state settle in urban areas and around academic medical centers.

Campbell is working to recruit medical students from rural areas and also train them in those areas, with residency programs to increase the likelihood that they stay in rural burgs to practice medicine.

If a medical student completes medical studies in North Carolina, there is a 38.5 percent chance she will practice medicine here, Kauffman explained. If she only completes a residency program in the state, there is a 42 percent chance she will stay.

But if she does both in North Carolina, there is a 67 percent chance she will live in North Carolina and practice here.

“If we are going to address health care access, we are going to have to address lots of different factors,” Baggett said. “There’s not one silver bullet that’s going to get any kind of medical provider to move to a rural community.”

Telemedicine

The experts who testified overwhelmingly supported expanding telemedicine to reach more rural patients.

“It’s the future of health service delivery in rural areas,” said John Coggin, an economist who directs advocacy for the North Carolina Rural Center. “It’s one of the ways of reaching the most remote areas in rural North Carolina, where a large health care system is never going to make economic sense.

“In the future, it’s going to be one of the most efficient ways of targeting those areas.”

Coggin said the biggest problem is that the areas in most need of telemedicine services also lack broadband necessary to deliver them.

Map courtesy: NC Rural Center

“Broadband is the rural economic development issue of our time,” he said. “It has profound implications for health care, education, business development and public safety.

“Finding a solution to this isn’t going to solve all the problems we face in rural health care, but tackling broadband access, affordability and adoption would have immediate and widespread effects on rural health care.”

Baggett echoed this sentiment, explaining that while North Carolina has allowed telemedicine, lawmakers need to encourage it more. The service is a key way for rural patients to see specialists at a moment’s notice, he said, because it’s nearly impossible for a specialist to make a living in rural areas due to the sparse population.

Economic development

Coggin emphasized how economic development and rural health care go hand-in-hand.

Job creation depends on a good education system, physical and digital infrastructure, and a robust health care system, he said.

“New entrepreneurs need access to health care in order to take the risk of opening their own business,” Coggin said. “A community that doesn’t have a good health care system isn’t going to get to first base in recruiting new companies.”

Rep. Greg Murphy (R- Greenville) noted this as well.

“Listening to everyone today, this is not just a health care issue, this is an economic development issue,” he said. “Across the nation, people leave rural communities, get educated, and there are not the opportunities available to them back home.”

Committee co-chair Sen. David Curtis (R-Denver) said the more rural health issue data he sees, the more concerned he becomes.

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“We clearly have two North Carolina’s, both economically and medically,” Curtis said. “Both of those issues are intertwined to some degree. The fact that we have such poor health care in rural areas is one of the reasons we can’t seem to get the rural areas doing better economically.”

Why now?

Rep. David Lewis (R- Dunn), the second most powerful member of the House, leads the subcommittee examining rural health. He said he’s been aware of the plight of rural North Carolina for a while, but a recent presentation in his district reinforced the need to act.

“I’ve always had a great concern about this,” he said. “Yes, the listening session sort of put it into focus.”

Lewis added that people need better access to preventive and primary care to stay healthy.

“Our model of health care is fee for service,” he said. “Treating people when they are sick as opposed to trying to keep them well is a flawed and weak system.”

Lewis said the problems surrounding rural health cannot be solved entirely with one solution, but he said he hopes to improve at least some part of it during the upcoming “short” legislative work session, which begins later this year.

“It’s something that I believe is absolutely necessary that we tackle,” Lewis said. “If we can just make one difference or one thing better… making things perfect is not an option that we have. But if we can make things a little bit better somewhere, then we are doing our jobs.”

Rep. Greg Murphy (R-Greenville) told people at a press conference in April to introduce Carolina Cares that he often sees low income patient without insurance. “They receive subsequently much more expensive and honestly less effective care,” he said.
Also pictured (l to r): Rep. Donny Lambeth (R-Winston-Salem), Rep. Gale Adcock (D-Morrisville) and Rep. Jean Farmer-Butterfield (D-Wilson).

Coggin proposed passing something to close the insurance gap, such as the bill introduced last session called Carolina Cares. That bill proposes a way of extending Medicaid coverage to help  more low income working North Carolinians get covered.

He estimated at least 400,000 people in the state who currently lack insurance would be able to get covered under the Carolina Cares plan.

“Who is in that gap?” asked Coggin during his presentation. “[It’s] people who are working hard, working one or two jobs. They are making ends meet but barely. They are not able to save for things like a house, a car or education or unexpected expenses.”

And he added that it’s one small thing lawmakers could do that would have a statewide impact.

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Taylor Knopf

Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...

2 replies on ““No Silver Bullet” for Solving Rural Health Care Problems”

  1. I was a Rural ER Doc in California for ten years – also doing Rural Hospitalist work for those admitted. Physicians will come in for 2-3 day shifts if you have a little house across the driveway with Internet, microwave, refrigerator, etc. A wife can visit or stay back in the city. Then the closure of such hospitals has to stop – now 750 across the US which can be traced back to the Balanced Budget Act of 1997 and HHS folks who care only about urban zip codes. The Rural ER needs to be called First Aid so the doc can go to get groceries and no surgeon is needed backup. Payment is often about perks and nice MD bosses not the normal ones trying to get the doc to overcharge everyone. Staff your own hospital – forget the Staffing factories. Chuck Phillips, MD

  2. Dr. Bill Roper, CEO of UNC Health Care announced approximately 2 years ago – to a group of major donors in Raleigh, NC – that he had established a program to address the needs of improved health care in rural N.C.

    Dr. Roper stated that UNC Medical School would provide scholarships to the best and brightest high school graduates from rural N.C. – he said the Valedictorians of their class – if they would agree to stay in the rural area and practice medicine.

    I would like a progress report from Dr. Roper/UNC Medical School as to how many students have been granted scholarships – and how far along they are in their training. Are current undergraduates from rural N.C. candidates also?

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