Panel 3: Speaker 2

Abstract

In addition to my position as distinguished adjunct professor at the University of Alabama, I spent 58 years working with the Federal government, 30 years with the Veterans Administration, and 28 years with the U.S. Department of Health and Human Services. I have also advised the past four presidents in the area of mental health and aging. I am a nurse, clinical psychologist, medical sociologist, and policy maker. I have also been involved in directing research and funding. I think it is important, for this conference, to know that I was an old “county” nurse who worked in rural Alabama. There are 39.6 million females who are members of racial and ethnic minority groups.1U.S. Census Bureau, Population Division, Population Estimates Program, Resident Population. Estimates of the United States by Age and Sex: April 1, 1996 to October 1, 1999. Internet Release. November 26, 1999.Google Scholar Of the 274 million persons living in the United States in 1999, 140 million are female. Of this number 39.6 million females are members of racial/ethnic minority groups. Each group of minority women has many subgroups, who have diverse languages, cultures, degrees of acculturation, belief systems, and unique histories and lifestyles. Of all women in the United States, 12.5% are black (17.5 million); 11.2% of all females are Hispanic or Latinos (15.7 million); 3.8% (5.4 million) are Asian American/Pacific Islander; and 0.7% (1 million) are American Indian/Alaskan Native (AIAN). In the rural and frontier areas, 14.8% of the population in 1995 was over 65 years of age compared with 12.3% in urban areas.2Ormond BA, Wallin S, Goldenson SM. Supporting the rural healthcare safety net. Occasional paper number 36. In: Assessing the New Federalism. Washington, DC: Urban Institute, 1–43.Google Scholar The elderly have three to five chronic illnesses or conditions apiece, and need an array of acute, long-term, and supportive institutional and community-based services. Women with disabilities constitute a high-risk group in rural areas. Eight percent of the U.S. population are disabled women; 26% of these women live in rural areas.3Rural facts: women with disabilities, employment, income and health. June 1999. Internet: RTC: Rural Home/Rural Institute: University of Montana, http:/ruralinstitute.umt.edu/rtcrural/ru.dis/dis.womenfact.htm.Google Scholar Between the ages of 16 and 64, there are 2,008,436 females with disabilities in the rural areas, and 1,936,269 females 65 years and older with disabilities. High-risk groups have low immunization rates for pneumonia and influenza. Only 23% of black women age 65 and over have received pneumococcal vaccination compared to 19.6% of Hispanic elderly women and 36% of white women.4Office of the Director, National Institute of Health. Women of color health data book. 1998:1.Google Scholar High-risk groups in the rural areas often do not get preventive tests such as screenings for cervical cancer, mammograms, or blood pressure screenings. Moreover, the likelihood that minority women will get their preventive services declines with age.4Office of the Director, National Institute of Health. Women of color health data book. 1998:1.Google Scholar Large percentages of minority women reported that they had not been screened for cervical cancer within the past year: 55% of Asian American women, 43% of Hispanic women, 37% of black women, 40% of AIAN, and 44% of white women. High-risk groups in the rural areas include women who are limited in their Activities of Daily Living (ADL), and need assistance in eating, dressing, personal hygiene, and so forth, because of existence of a chronic health condition. For example, 17.6% of black women reported some limitations in their ADL in 1996 compared with 13.1% of white women.5Health, U.S. 1999, Health Status, Morbidity, P. 8.Google Scholar High-risk groups in the rural areas are poor and they perceive their health as poor. Based on self-assessments, 27.8% of black women, 21% of Hispanic women, and 21% of white women considered their health as poor. More women whose family income is below the poverty level, considered their health as poor in 1996.5Health, U.S. 1999, Health Status, Morbidity, P. 8.Google Scholar High-risk groups in the rural areas have limited access to transportation. Many of them have to routinely travel 50 miles for a physician visit. Some rural alliances and smaller hospitals have a heliport for the use of transporting patients to larger urban hospitals.2Ormond BA, Wallin S, Goldenson SM. Supporting the rural healthcare safety net. Occasional paper number 36. In: Assessing the New Federalism. Washington, DC: Urban Institute, 1–43.Google Scholar High-risk groups in the rural areas have gender-linked lifestyles and behaviors that produce risks to health, eg, smoking, excessive use of alcohol, use of illicit drugs, physical inaction, and excessive consumption of fatty foods. Smoking is the single most preventable cause of death and disease in the United States. As of 1996, roughly 22 million adult women and at least 1.5 million adolescent girls smoked cigarettes. Among women, the use of tobacco has been shown to increase the risk of cancer, heart disease, and respiratory diseases, and reproductive disorders.6Centers for Disease Control and Prevention. Office of Women, Health, Tobacco Use. March 1996. http://www.cdc,gov/od/owh/whtob.htm.Google Scholar Researchers have found more than 40 chemicals in tobacco smoke that cause cancer in humans and animals, yet more than 140,000 women die each year from smoke-related diseases. Among AIAN women 18 years of age and over, 33% smoked cigarettes; however, 54% of the AIAN on reservations have never smoked. 21.3% of black women smoke; however, 38% of black women have never smoked. A total of 13.7% Hispanic women are current smokers in contrast to 23.9% white women.7CDC’s tips. Targeting tobacco as the nation’s leading causes of death, 1999.Google Scholar, 8Women of Color. Tobacco use among women of color. 50.Google Scholar High-risk groups in rural areas often use dual health care systems, the use of curanderos, herbalists (yerbistas), voodoo (by blacks) Puerto Rican faith healers, acupuncturists, and santeros (Cuban) faith healers.9Skaer T.L. Utilization of curanderos among foreign-born Mexican Americans attending migrant health clinics.Culture Divers. 1996; 3: 29-34PubMed Google Scholar, 10Jordan WC. Black American folk medicine. In: Harper MS, editor. Minority aging: essential curricula contents for selected health and allied health professions. U.S. Dept HHS/HRSA, DHHS, Publication No. HRS (P-D.V.-90-4). Washington, DC: U.S. Government Printing Office, 1990:269–74.Google Scholar, 11Cuellar JB. Hispanic American aging: geriatric education, curriculum development for selected health professionals. In: Harper MS, editor. 1990:365–413.Google Scholar Frequently, the patient will not inform the Western health care provider that she is using other healers. This is a frequently used source of health care by many first-generation immigrants. High-risk groups in the rural areas are experiencing an increasing number of Federal J-1 Visa (immigrant) physicians, particularly in the South. These physicians placement programs have detractors as well as defenders. Detractors argue that cultural barriers exist between patient and physicians, particularly foreign-born physicians, which impede the delivery of care and the processes involved in making a culture-free diagnosis. Contracts for these physicians are usually for 3 years only, so the physician turnovers are high, harming the continuity of care and the reputation of the clinic or hospital that employs the physicians. The defenders argue that the program has been successful in bringing physicians to communities that otherwise would have no or insufficient health resources, and some physicians have integrated well in the community and chosen to remain beyond their obligation period.12Capital Area Rural Health Roundtable Notes. Vol. 3, No. 1, Fall 1998.Google Scholar These physicians are usually placed in Health Professional Shortage Areas (HPSA). There are 336 HPSA, where the physician rate is no higher than one physician to a population of 3,000. The J-1 Visa Program is up for reauthorization.2Ormond BA, Wallin S, Goldenson SM. Supporting the rural healthcare safety net. Occasional paper number 36. In: Assessing the New Federalism. Washington, DC: Urban Institute, 1–43.Google Scholar The HPSA Program has been revised recently. HPSA is now a subset of another category, which focuses on medical Medicare underserved populations (MUP). This designation is driven more by factors of poverty, financial, and cultural access to available services than by geography and the availability of physicians. This change may eventually affect the quality and quantity of care in rural areas.12Capital Area Rural Health Roundtable Notes. Vol. 3, No. 1, Fall 1998.Google Scholar “Health” is operationally defined as the ability to live and function effectively in society, to exercise self-reliance and autonomy to the maximum extent feasible—but not necessarily total freedom from disease and/or disabling conditions. According to the Bureau of the Census, “rural” is defined as territory outside an urbanized area, which has a minimum of 2,500 persons. Using this definition, approximately 26.3% of the U.S. population is rural and 85% of these inhabitants live in places with fewer than 1,000 residents.13U.S. Department of Commerce: Statistical Abstract of the United States, 108th edition. Washington, DC: U.S. Government Printing Office, 1998.Google Scholar A second definition by the Office of Management and Budget (OMB) defines a Metropolitan Statistical Area (MSA) as an urban population center and those adjacent communities that have economic and sound integration with an urban center.14Hewitt M. Defining “rural” areas impact on health policy and research.in: Gesler W.M. Ricketts T.C. Health in rural North America the geography of health care services and delivery. Rutger University Press, New Brunswick, NJ1992: 25-54Google Scholar Approximately 23.4% of the U.S. population live in nonmetro areas. These nonmetro areas (rural) constitute 83.8% of the U.S. land and 77% of its counties. In either definition, there seems to be agreement that 25% of the U.S. population resides in rural areas. In 1996, this amounted to 56,687,000 rural Americans. In defining women’s health we must consider the social construction of health; culture; race; ethnicity; physiologic, psychosocial, and biologic health-seeking behaviors; access to support; social network; satisfaction with employment or work; interplay of negative and positive experiences; growing up in an intact family; as well as insurance coverage. The health care provider assessing the high-risk woman should also be concerned about gender-linked inactivity, use or abuse of alcohol, and capacity of flexibility to handle change.15The social and historical context of women’s health care. In: Weisman CS, editor. Women’s health care. Baltimore, MD: John Hopkins University, 1998:10–36.Google Scholar Many minority women may not experience their health problems as a function of gender, but as a problem of poverty, racism, or lack of access to the most appropriate technology. It must be remembered that many of our black elderly have never known anything but a segregated health care system. Although the health care system is not physically segregated, there are tenets of the old system still experienced by some women. Blacks hospitalized for ministrokes are less likely than whites to receive diagnostic tests, see a specialist, or have surgery. This was the findings of a Prevention–Patient Outcome Research Team at Duke University. It is important that we do research pertaining to women because they are unique in the presentation of their illness and have higher morbidity rates for selected illnesses. Much of the transmission of health information is done by women, who frequently act as repositories of folk beliefs and practices, as well as gatekeepers of health care for the family. Issues which place older rural minority women at greater risks for impaired health include: •limited income and poverty•lack of insurance coverage•frequent exclusion from clinical trials and clinical research•lower educational levels•early onset of selected diseases, eg, arthritis before age 45, heart disease before age 50•substandard housing•malnutrition•delay in seeking health care•comorbidity, with 50% of all women age 65 or older reporting at least two chronic diseases•lack of access and lack of health provider’s willingness to use the new and/or appropriate technology•poor health status•disproportionately higher risk of heart diseases and other chronic diseases such as diabetes, hypertension, arthritis, and disabling diseases16Collaborative care: Teaming up to tackle osteoarthritis. Fact of Life, Issue Briefing for Health Reporters, 5(6):1, July 2000.Google Scholar•lack of transportation, and•lack of consistency in supportive family functioning. In the high-risk groups in the rural area, there are between-group and within-group differences, as well as regional and generational differences. As an example of difference according to place of birth, for example, U.S.-born Hispanic women have a higher risk of developing cancer than foreign-born Hispanics who have immigrated to this country. However, because the more acculturated Hispanic women tend to have less body fat than their less acculturated peers, their risk for diabetes and heart disease is lower.17Women of Color Health Data Bank. Office of the Director. National Institute of Health. Bethesda, MD, 10–11.Google Scholar For Hispanic women, diabetes is the fourth most common cause of death responsible for 2,455 deaths or 5.9% of deaths from all causes. Almost 30% of Hispanic women suffer from diabetes.18Women of Color. Diabetes Mellitus, 78.Google Scholar Across the country, the health care delivery system becomes increasingly market-oriented, and the financial balancing act that allowed providers to meet the needs of privately insured residents plus those on Medicaid and the uninsured is increasingly threatened. The small size of the rural health care systems greatly increases their vulnerability to change. The core health care providers in the rural areas include physicians, primary care nurses, registered nurses, nurse practitioners, licensed practical nurses, nursing assistants, radiologists, laboratory technicians, physician assistants, and family caregivers. There are many counties without a physician. In many of those areas, the nurse practitioner or a physician assistant serves as the lead/or coordinating health providers. In each state the role, duties and function of the nurse practitioners varies, but in most states, the nurse practitioner has prescriptive authority. The family caregiver (a relative, friend, kinship person, or significant other) provides at least 80% of the long-term care and acute care in the home. In the rural area, there is a need to develop ways to train the family caregiver and monitor or supervise the care given in the home. Because of shortage of physicians and nurses, it is almost impossible to provide frequent supervision. Some rural areas use telehealth/telemedicine programs or 800 call-in lines to provide guidance and monitor care. Some states have developed a system to monitor wound care or other procedures through the telephone system. Funding the training of home health or community aides has proven successful. The use of mobile clinics for care, physical examinations, dental and nutritional services, immunization and screening for cancer, blood pressure, and osteoporosis has proven satisfactory in some rural areas. Some areas use visiting specialists from schools of medicine as lecturers and/or consultants. Training family caregivers before their relative is discharged is desirable. Most rural health care systems have problems recruiting and retaining qualified staff. Financing health care in the rural area is a challenge because of the high poverty rate, number of uninsured, high numbers of charity cases, high percentages of elderly, and number of changes in Medicare/Medicaid policies. The poverty rate nationally is 14.5% of overall population, but the rate for the rural area is 16.5%. In some states (Mississippi), it reaches 21.7%, and in others it is lower: 10.5% in Minnesota.2Ormond BA, Wallin S, Goldenson SM. Supporting the rural healthcare safety net. Occasional paper number 36. In: Assessing the New Federalism. Washington, DC: Urban Institute, 1–43.Google Scholar The high poverty rate in rural areas means that rural residents, if insured, are more likely to be publicly covered than urban residents. Medicaid is the dominant form of public insurance for the nonelderly. Restrictions and entitlements for Medicaid vary from state to state. In Alabama and Mississippi, there are limitations on the number of inpatient days, physician office visits, and nonemergency outpatient visits. Rural hospitals have been able to keep going, thanks to a patchwork of special fixes and protective policies by Congress. For example, some rural hospitals can apply for payment reclassification to a higher urban wage area rate. Some hospitals are exempted from the inpatient regulations by virtue of their classification as a sole community hospital, status as Medicare-dependent, or their willingness to become a limited service hospital with a restricted average patient length of stay. The Balanced Budget Act recently introduced four new prospective payment systems, namely, outpatient care, skilled nursing, home health, and ambulance services (ambulance fee schedule for nonhospital ambulances). These new payment systems will have a compound impact on rural hospitals and the rural health infrastructure. Seventy-two percent of all rural hospitals will come under two of the new Medicare PPS payment policies. Rural hospitals are more dependent on Medicare reimbursement than urban hospitals. Medicare payment expenses in 1998 accounted for 47% of the total patient care expenses in the rural hospitals compared with 36% in urban hospitals. Medicare requires hospitals to shoulder a disproportionate share of low-income patient cost. These hospitals are known as disproportionate share hospitals (DSH). Under the present reimbursement allocation formulas, hospitals with the same proportion of low-income patients can have different payment adjustments. Current policy favors urban areas. Almost half of urban hospitals receive DSH payments compared with only about a fifth of rural hospitals. Ninety-five percent of all DSH payments ($4.5 billion) go to urban hospitals. In summary, high-risk groups are numerous in the rural and frontier area. An unstable financing and staffing system exists. There must be more studies of needs, resources, and infrastructure to be followed by the development of a national strategic plan for rural health.