Against the Grain: Expanding Rural Health Care in a Climate of Closure

By Leah B. Thibault

Margaret “Peggy” Brown of rural Rumney, New Hampshire, population 1,480, doesn’t just love to sew; it is her therapy, her passion. Daily, she can be found in her sewing nook, creating her signature pieces — colorful, reversible fleece vests, jackets and snowsuits for children. At the same time, she may also be piecing together her next “hope” quilt.

But things began to unravel for Peggy a couple of years ago when she couldn’t breathe, let alone sew. Her son brought her to the Emergency Room at nearby Speare Memorial Hospital late one evening. While her EKG and other testing didn’t indicate any problems, she was kept overnight and scheduled for a stress test in the morning. As Peggy puts it, “That didn’t work out too well.”

The exercise physiologist saw significant evidence of cardiac disease, and Peggy was whisked to another hospital over an hour away in a more urban setting where she underwent a six-way cardiac bypass to restore blood flow to her heart. A month later she was back at Speare as a patient in its Cardiac Rehabilitation Program, where healthcare professionals worked with her and progressed her slowly so that she could get back to her everyday activities and sewing. After two months she was ready to graduate, but decided to stay on in Speare’s maintenance program.

Today Peggy is back to sewing and going to craft fairs. She credits having cardiac rehab and cardiologists just 10 minutes from home. “It’s easy to get to,” she says. “I don’t have to go to Manchester.”

Peggy’s healthcare story is atypical for America’s rural communities that have seen no fewer than 70 hospitals close since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

Approximately 17 percent of Americans live in a non-metropolitan, or rural, areas. Compared to their urban counterparts, residents of rural areas are older and sicker. While the average resident of a major city can expect to live to 79.1 years of age, the average rural resident will live for 2.4 years less, a disparity that has only widened over time, according to the U.S. Department of Health and Human Services. While that may seem counterintuitive to some, the longer average life expectancy in urban areas simply points to fewer early deaths. Rural residents who live past middle age are more likely to suffer from heart disease, chronic obstructive pulmonary disease (COPD), lung cancer,  stroke, and diabetes than their urban counterparts.

Why the disparity? First, rural residents tend to be poorer overall than their urban peers. People in poor households (those living below the Federal poverty line) generally experience less access and a lower quality of healthcare, whether they live in the city or the country. Around 25 percent of adults ages 19 to 64 living in poverty report fair or poor health, compared with about 8 percent of those living above 200 percent of the poverty threshold. They are also less likely to be insured, with a 19.3 percent un-insurance rate for those below the poverty line, compared to 10.4 percent in the country overall and are more likely to delay or not pursue medical care due to cost (13.2 percent verses 10 percent).

But on top of the economic difficulties, rural residents like Peggy must also cope with unique factors, like a lack of providers (only 10 percent of physicians nationwide serve rural communities), a lack of  public transportation to get to and from facilities, and a greater distance to those facilities overall.

That’s what makes the story of Speare Memorial Hospital all the more compelling. It is located in Plymouth, one of New Hampshire’s most economically distressed communities in a federally-designed Medically Underserved Area, where 64 percent of the population served comes from low-income communities.

This data, however, is what qualified Speare for New Markets Tax Credit financing, and counter the national trend of rural hospital closure and instead enable its expansion. With it, Speare was able to construct the building that is home to the rehabilitation services Peggy received, as well as an orthopedics and sports medicine clinic, an internal medicine practice, and an ophthalmologist. Diagnostic support services are also on site, including laboratory and X-ray. In addition to the healthcare services, the project created four dozen jobs.

Nearby Mid-State Health Center (Mid-State) shared many factors in common with Speare: cramped working conditions that limited services and growth, and a mission to provide healthcare to all who needed it, regardless of their ability to pay. Mid-State utilized the New Markets Tax Credit program to find the flexible funding it needed to expand. Since 2005, Mid-State constructed a new facility more than double the size of its previous one and has been able to employ an additional 77 individuals to better serve its 10,024 patients from 29 New Hampshire towns.

In many ways, living in a rural community is like living on an island. And if living in a rural community is like living on an island, imagine how difficult it is to access healthcare if that community actually is on an island.

This was the difficultly faced by the residents of Lāna’i, Hawaii’s smallest publicly-accessible inhabited island. To get to the island, residents and visitors have two options: a $20 roundtrip flight from Honolulu or a $60 ferry ride from Maui. With a limited flight schedule, patients often need to stay in a hotel overnight and miss a day’s work. For the 44 percent of island’s population that live at or below 200 percent of the Federal Poverty level, either choice can be financial burden, meaning most residents receive their healthcare on-island, or not at all.

At Lāna’i Community Health Center (LCHC), no one is turned away for lack of money. For years, LCHC had operated out of a converted three-bedroom home, limiting its ability to attract physicians and provide specialty services.

With the help of New Markets Tax Credit financing targeted at low-income communities, LCHC was recently able to construct a new 6,800-square-foot facility, which includes four exams rooms, two behavioral health consultation rooms, one specialty consultation room, an optometry and three dental operatories (one dedicated to children), allowing LCHC to double its patient capacity and hire adult dentists and a pediatric dentist.

For the communities of Plymouth and Lāna’i, these health clinics are making a major difference in the quality of health, and life and helping to balance some that rural disparity.

Images courtesy of the author. 

Featured image: Pixabay 

Leah B. Thibault is Director of Executive Administration and Special Projects for CEI Capital Management LLC. CEI Capital Management increases opportunity in rural low-income communities through the New Markets Tax Credit program. It is a wholly owned subsidiary of CEI.