In 1976 over 53 million Americans lived in roughly 900 rural counties, which together make up about 40% of the land mass of this country. These areas are characterized by low population density, a disproportionate share of the country's poor and elderly, and shortages of all kinds (Bayer, Caplan, Daniels, 1983). Most important, however, are the critical shortages of health manpower and health services delivery systems.
In 1977 rural areas averaged less than one primary care physician for every 3,500 people. According to Bayer, Caplan, and Daniels (1983), the number of physicians in rural areas decreased from 1967 to 1977, while the number of counties without functional access to primary care increased by nearly 35% between 1970 and 1977. While rural America was facing this decline in available medical services, the total number of practicing physicians in the United States actually increased by 14%!
Access to health care is a major problem in rural America. In some instances, driving through dangerous, winding, mountainous roads, which can be impassable in winter or when it rains can hinder people receiving medical services. Winstead-Fry, Tiffany, and Shippee-Rice (1992) stated that low incomes and high poverty rates are suffered by great amounts of the rural population, making health care insurance a relative luxury. Because of this, many ailments and injuries tend to go untreated.
Another problem is the lack of physicians willing to work in rural areas. The Hill-Burton Act of 1946 represented a major effort by the federal government to increase health resources in underserved areas. This subsidized construction program made it possible for many communities without a hospital or with inadequate facilities to obtain better health care. This had its shortcomings because hospitals without doctors were, of course, of little value. There were other approaches used during the decades since Hill-Burton to redistribute resources in favor of underserved communities. A substantial private sector initiative with funds from Sears, Roebuck made grants and loans available to help small towns attract and retain physicians (Lee, Estes, and Ramsay, 1984). The foundation determined, after about twenty years of effort, that the program was to be liquidated due to only modest results. There were still other approaches such as foundation and state government fellowship programs to cover the expenses of a medical education for qualified young people from rural areas. These programs were started with the hope and expectation that, after graduation and residency training, these graduates would return to practice in their home areas. Unfortunately, this was a disappointment. According to Lee, Estes, and Ramsay (1984), the federal government tried once again in the 1970's, on a larger scale, with much more money, and with what federal officials believed to be ironclad agreements. This agreement was if a young doctor trained under this program and failed to serve his obligated years of service in the National Health Service Corps, he or she had to repay the loan in full, plus pay a substantial financial penalty.
Raffel and Raffel (1989) stated that the lack of appeal for rural practice stems from fear of professional isolation: lack of professional interactions, inaccessibility to hospitals, absence of consultation and continuing medical education opportunities, lack of opportunity for their spouse, and cultural deprivation. Professional, as well as personal isolation are very real factors, reinforced by some extent by medical school faculty and preceptors in residency programs who caution about going to the very rural areas for fear that he or she would get out of touch with medical developments (Raffel and Raffel, 1989).
Although there are numerous problems concerning rural health care delivery, there are many innovative solutions to these problems implemented all over the country by dedicated professionals and volunteers alike.
One such solution is Project Good Health, which provides health care for children in low-income families in rural southeastern New Hampshire. In 1992, a comprehensive assessment of the health care needs of low-income families in this region found that these families were often forced to go without medical care, or to postpone care until situation warranted a trip to the emergency room. By the time treatment was sought, easily treated problems often became more serious, thus more costly to alleviate. Because these families were generally unable to establish sustained relationships with family physicians, their children were growing up without having established a continuous medical record that would help ensure effective treatment for problems that might persist over the long term.
To accomplish this difficult task, Rockingham Community Action (RCA) established a task force made up of physicians, nonprofit health and social service providers, local welfare administrators, and consumers to examine several health care delivery options. They determined that a physician's office-based model that provides care to children through a network of primary care doctors would be the most effective and practical way to ensure that low-income families receive the health care services they required.
With a two-year, $112,000 start-up grant from the Robert Wood Johnson Foundation in 1992, plus additional funding from United Way, and other private foundations, RCA developed Project GoodHealth in partnership with the Visiting Nurse Association. RCA then recruited all eight of the local medical practices that provided primary pediatric care in Portsmouth and the six surrounding communities to participate in the program. Through Project GoodHealth, families select a primary care physician from among the participating doctors. These doctors agreed to reduce the cost of office visits for children enrolled in the project. The fees are about half of what the doctors normally charge. The families make a small co-payment of about $5 to $15 dollars, and Project GoodHealth covers the balance. Prescriptions resulting from office visits are also partially covered by the project.
Specialist care is available on a case-by-case basis. The referring physicians and Project GoodHealth work informally with the specialists to negotiate fee reductions. The patients pay what they can afford, then Project GoodHealth pays the balance.
In 1994, Project GoodHealth began providing free counseling services to families. The therapists that volunteered insisted that the only fee be a small co-payment worked out between the therapist and the patient. All family members are eligible for counseling.
Since its inception, more than 500 children have been enrolled in Project GoodHealth, and they have made about 1,200 pediatric office visits. These families have established a consistent relationship with a single doctor, who can become familiar with the child's particular medical history and needs.
Another innovative solution to the rural health care delivery problem was the development of a primary care center in Lincoln County, West Virginia. Like many rural areas, Lincoln County had for years attempted to gain funding necessary for the construction of a hospital. After four unsuccessful years, a better alternative and better choice arose. Organizers discovered, after careful research, that grant money was available from the Appalachian Regional Commission ...