The neglected problems of rural poverty

by Brother David Andrews, CSC

Rural America has been left out of the economic boom that is heralded in newspaper headlines and political campaigns.

Poverty in rural America is often unseen, unacknowledged, unattended. Yet rural populations tend to be older, poorer, sicker, less educated and in poorer health than their urban counterparts.

According to the latest U.S. Census Bureau statistics, the poverty rate in rural areas is 14.3%, compared to 11.8% for the nation as a whole. And unlike inner-city areas, where the poverty rate declined from 18.5% in 1998 to 16.4% in 1999, the rural poverty rate is nearly flat.

Rural health care ailing

Access to quality health care is one of the biggest challenges facing rural Americans. People in rural areas suffer higher infant mortality and injury-related mortality rates, have access to fewer hospital beds and physicians and are much less likely than urban residents to have health insurance of any kind, public or private. The rate of uninsured is more than 20% higher in rural areas than in urban areas, with states in the Southwest and Southeast having the highest percentage of uninsured people. Moreover, fewer rural people enroll in Medicaid.

For years rural hospitals have been confronted with one obstacle after another. Hundreds have closed. Unlike our urban relatives and friends, most rural residents and Medicare and Medicaid beneficiaries do not have the option to choose another health care provider or to travel a short distance to seek health care services when those in their own community have been eliminated.

One problem is the decrease in Medicare reimbursements to rural hospitals. Under the Balanced Budget Act of 1997, the amount of money that rural hospitals and other health care providers are paid for their services to elderly and poor beneficiaries was reduced. Legislators had the misconception that people in rural areas were less in need of services. In practice, many people in rural areas do no know what services are available or else are unable to reach these services. Rather than cutting reimbursements, efforts should be made to disseminate information about available rural health services and to supply transportation to these services.

Rural hospitals also have fewer opportunities to perform procedures that would be economically enhancing (obstetrical or surgical units, etc.) which further decreases relative reimbursement rates.

And with pressure from managed care to contain costs, rural hospitals increasingly find themselves less able to provide uncompensated care.

Rural doctors face similar challenges. They derive a larger share of their gross practice income from Medicare and Medicaid patients than urban physicians. These public programs pay physicians at lower rates than private insurers. Providers in a small rural community usually do not have the option of refusing care to anyone, thus leading to potential bankruptcies. Rural physicians, on average, work more and earn less than their urban counterparts. They also face professional isolation and have fewer educational opportunities for their children As a result, less than 11% of the nation’s physicians are practicing in rural areas.

Pigs, poker, prisons

In the midst of the nation’s economic boom, employment opportunities are slim in rural areas accounting for only 3% of the U.S. labor force growth despite representing 19% of the U.S. population. What jobs are available tend to be part-time and minimum wage. In addition, low-population densities in rural areas hinder the development of workplace supports and infrastructure (education and training, childcare, public transportation).

The search for new employment opportunities tends to be one variant or another of "elephant hunting: on the part of state agencies. Rural communities compete for large-scale, low-wage industries, such as prisons, toxic waste dumps and huge animal confinement unites for raising or processing hogs, poultry or turkeys. Another growing rural-based enterprise is the casino. Rather than promote economic development that considers the needs of the community, with all its assets, capacity and potential, states seek enterprises which provide a quick fix. Thus pigs, poker and prisons make up three leading economic enterprises for rural development.

Given the dearth of job training, child care and transportation services, implementing "welfare to work" is also more difficult in rural areas. Local governments possess fewer resources to assist struggling people, and fewer "safety net services" are available. Rural recipients of TANF (Temporary Assistance for Needy Families) find it especially difficult to find work within the time limits imposed on them.

What can be done?

Improving health care should be at the very top of the agenda for rural America. Funding levels need to be increased to support rural health clinics, hospitals, and services for mental health. Medicare and Medicaid need to be organized with specific attention to rural conditions and rural culture. A one-size-fits-all approach is not adequate.

Rural America has a large share of poverty and difficulty, some of it for long periods of time with little appreciable improvements. Creativity in designing programs and strong support for increased funding is needed. But first we have to recognize the facts. Only then can we hope to make a dent in rural poverty.

Brother David Andrews, CSC, is Executive Director of the National Catholic Rural Life Conference

in Des Moines, IA.