Table of Contents
- Health Policy Analysis of Arkansas Delta Region
- Health Delivery System
- Services for Isolated and Secluded Communities
This brief was prepared for the US Senate Committee on Health, Education, Labor and Pensions (HELP) hearing on rural health. It serves as an analysis of the health issues affecting the Delta Region (DR) of Arkansas; also known as the Mississippi Alluvial Plain. This analysis explores the geographic characteristics of the DR, as well as underserved populations and their barriers to delivery. Further, it examines the structure of the current health care delivery system and its effects on the overall community health outcomes. The Affordable Care Act (ACA) is also explained—with emphasis on the opportunities it provides to the residents of the DR. Finally, recommendations are outlined to help meet the health delivery challenges of the DR.
Health Policy Analysis of Arkansas Delta Region
The Delta Region of Arkansas, also known as the Mississippi Alluvial Plain, has been plagued by numerous socioeconomic issues that have adversely affected the overall health of the community. Unemployment, extreme poverty, and illiteracy, among other factors, have negatively impacted health status of individuals in the region. There is a high incidence of mental and behavioral health concerns that must be addressed. It is paramount to understand the extent to which underserved populations are correlated to the structure of the Arkansas health system, barriers to delivery, and the ACA. What follows is an analysis of rural health in the DR, with special attention to the population and how individuals consume health services.
Medically Underserved Populations
The US Health Resources and Services Administration (HRSA) defines medically underserved populations (MUP) as those with a lack of access to primary care services. These are groups of people living in a specific geographical area experiencing a shortage of health care delivery. Underserved groups often include, but are not limited to: homeless individuals, low-income, Native American, or migrant farmworkers (HRSA, 2016). MUP designation is derived from the Index of Medical Underservice (IMU), which is calculated based on the following four factors:
- Population to provider ratio
- Percentage of population below poverty level
- Percentage of population over age 65
- Infant mortality rate
IMU ranges from 0-100, with 0 representing completely underserved. Populations with an IMU score of ≤ 62.0 are designated as MUP. Currently, the MUP is estimated at 3 million people nationwide, with Arkansas listed as the 19th most medically underserved state (HRSA, 2019). Of the 15 entire counties and portions of the other 10 that make up the DR, the highest IMU is 59.8 (Lee County) and the lowest is 34.2 (Crittenden County). This indicates that the entire DR is medically underserved. Further, the highest IMU in all of Arkansas is 62.0 (Oachita and Van Buren Counties) and lowest is 29.6 (Lafayette County), meaning that there are no counties in the entire state that are adequately served.
Lack of access to health care in rural areas is an unfortunate truth. Individuals residing in rural communities face barriers to primary care services that other communities often take for granted. In the DR, 100% of the population is considered rural by Federal guidelines. As such, they face difficulties preventing them from accessing primary care services conveniently and confidently. One common factor is distance and transportation, a barrier exacerbated by the fact that six of the Delta counties have no hospital. This implies longer travel times and farther distances. Travel time, cost, and time off work can affect an individual’s decision whether to pursue health care services or not, due to limited methods of transportation. Rural areas are not often served by public transportation services, as evidenced by statistics such as transportation spending per household. For example, in 2016, rural households spent, on average, $10,300 on transportation, 15% more than did urban households, since rural households have higher rates of vehicle ownership and lower levels of access to public transit (Bureau of Transportation Statistics, 2017). Taking these barriers into consideration, it is easy to see that rural nature of the DR makes it an underserved group in itself.
The DR lies on the eastern portion of Arkansas, which contains the highest concentration of cities in the state with a predominantly African American population. Consequently, slightly more than 50% of the DR’s 1,114,480 inhabitants are African American. Health disparities among African Americans have been widely researched to determine why they are one of the most underserved ethnic groups. Past research has determined that income, employment, and education are associated with uninsurance and higher propensity to poor health outcomes. Specifically, low income and tendency to work jobs with no health benefits are largely responsible for poor health.
Perceived discrimination and poor communication are also significant barriers experienced by African Americans. Reports of African American patients that have perceived discrimination in health care settings are associated with lower quality treatment, poor medication adherence, and underutilized health services as compared to other ethnic groups (Napoles-Springer et al., 2005). Ineffective communication between patients and their clinicians is also linked to lower rates of health services for African Americans. The notion that a large percentage of African Americans are of low socioeconomic status often results in these patients receiving minimal amounts of information or education about their conditions. They report that doctors spend minimal time with them in the appointment and question their intelligence (Gordon et al., 2006). Additionally, lack of engagement from patients results in less of their questions/concerns being addressed (Gordon et al., 2006)
Because of the aforementioned barriers, African Americans are more likely to present with unfavorable health outcomes. The District of Columbia reported that African American males lives 15 years less than white males; and African American women live 9 years fewer than white women—a trend also reflected at the national level (Millett, 2018). Rates of chronic diseases and death rates are also higher among African Americans than whites. Coronary heart disease and strokes kill African Americans at 2x the rate of whites, and deaths from complications of diabetes are 6x higher in the African American community (Millett, 2018). Unfortunately, this is a cycle where the socioeconomic disadvantages experienced by African Americans lead to inadequate health and socioeconomic disadvantage.
Individuals experiencing homelessness are another important group currently underserved in the DR. These are people who do not have stable housing and rely on shelters, transitional housing, or public and/or abandoned spaces to live and sleep. Social service agencies in the DR report a significant homeless population, living seasonally in tents, campers, cars, etc., many of whom are families with children.
Homelessness can be caused by poor health; just as poor health can be caused by homelessness. It is a vicious cycle to which many fall victim. The homeless population is highly vulnerable to poor health and is 6x more likely to become sick than those living in stable housing (Health Outreach Partners, 2013). According to the National Healthcare for the Homeless Council (2015), the top five diagnoses given to homeless individuals upon receiving medical attention are:
- Depression/other mood disorders
- Mental disorders
The unstable nature of the indigent, and their vulnerability to social and environmental hazards present significant barriers to health care. When additional obstacles like lack of education, unemployment, financial hardship, and no physical address are factored in, it can be reasonably predicted that the homeless population will be greatly underserved. If they successfully navigate these barriers and are able to obtain medical attention, still 73% of adult homeless individuals report poor quality of care, indicating that at least one or more of their health needs were unmet (i.e. prescription medication, surgical care, mental health care) (Baggett et al., 2010).
Health Delivery System
The current structure of health delivery services in the DR has several areas for improvement. While health care may be adequate for other parts of the state, the alluvial plain is in high need of a system that works, not one that hinders delivery in addition to the barriers that are present. The following are points to be considered to increase the quantity and quality of medical services provided:
According to the US Census Bureau, Arkansas is largely rural, as it only has 6 urbanized areas/clusters throughout the whole state (Ratcliffe et al., 2016). A total of 73 community hospitals serve the state of Arkansas. Within them, only 20 hospitals serve rural areas, with approximately 5 serving the southwest region and the remaining serving the delta region (Matthews, 2010). That leaves 15 community hospitals to serve the 25 counties of the DR. Six of the DR counties have no hospital, further reducing access to health services to the rural citizens. This means that many of the 1.1 million DR residents will have to find a means of transportation and travel long distances to receive primary care. This fact intensifies the previously identified barriers to services that are transportation, travel time, and cost.
Mental and Behavioral Services
Recent surveys of the DR behavioral health system have shown high rates of depression, PTSD, schizophrenia, and substance abuse disorders among inhabitants. The prevalence of these behavioral and mental disorders is thought to be positively correlated to increased rates of suicide and domestic violence. There is a lack of mental health services for a population already at-risk. For example, more than 50% of the DR population is African American, and research has shown them to be 20% more likely to report serious psychological distress than other adult whites. Further, African Americans living in poverty, such as those in the DR, are 3x more likely to report serious psychological distress than those living above poverty (US Office of Minority Health, 2016). It is a historical fact that African American communities experience unique and significant challenges when trying to access mental and behavioral health services. This lack of mental and behavioral support services in the DR highlights this fact and further hinders their ability to receive adequate help.
Services for Isolated and Secluded Communities
Only 23% of DR residents live in towns of 20,000 or more. The remaining 77% (858,000 people) live in more secluded areas, isolated from the conveniences of more populated zones. Some parts of the DR have the lowest population densities in the South, with less than 1 person per square mile in some areas. Those 858,000 individuals that live away from towns experience unstable work, often resorting to seasonal jobs, part-time positions, or self-employment. These types of work opportunities very rarely offer health benefits, which suggests that most, if not all, of these individuals have no access to what they need most: medical attention. The low-income population greatly suffers by being uninsured and, thus, is not able to get the quality of care they need, as often as they need it. Roughly 25% of the uninsured are between 45-64 years old, and 25% of those report being in fair health or worse condition. Again, this is another instance that depicts one of multiple issues with the current structure of the DR health delivery system.
Impact of ACA
President Barack Obama signed the Patient Protection and Affordable Care Act into law in 2010. The ACA, also known as Obamacare, “expands access to affordable health care to all Americans, gives consumers new rights and protections that make coverage fairer and easier to understand, improves quality of healthcare, strengthens public health infrastructure, and lowers health care costs” (USICH, 2014). It has been effective in its overarching goal, as evidenced by the number of uninsured individuals which has dropped from 46.5 million in 2010 to 26 million in 2017 (Kaiser Family Foundation, 2019).
The ACA benefits the DR population in a few ways. First, it offers subsidies aimed at helping working class, low-income families and those without employer benefits afford private insurance plans. Simply put, this gives the 77% of the population that lacks job stability and health benefits the opportunity to acquire coverage that they feel is best tailored for them. Obamacare eliminates stable employment as a factor for health insurance and makes it possible for the self-employed, seasonal workers to obtain coverage at lower costs. The ACA is not a cure all, as those living in rural areas may still face other barriers such as limited provider availability, but it does provide some assurance to residents that they will have access to some kind of coverage.
The Affordable Care Act provides relief for the homeless population as well, decreasing their need to rely solely on emergency room visits and uncompensated hospital care for medical attention. Before the ACA was enacted, many homeless individuals viewed the ER as their primary or only option of care. According to the American Hospital Association, there were 35,000,000 total admissions in US registered hospitals in 2018 (AHA, 2018). Research done by the National Alliance to End Homelessness revealed that the prevalence of homeless patient visits to ERs annually before Obamacare was enacted was 11.1%, and dropped to 8% afterwards (Feldman et al., 2017). As a result, the number of homeless people seeking health care at hospital ERs dropped from 3.5 million pre-ACA to 2.8 million post-ACA.
USICH (2014) outlines three main ways that the ACA aids people experiencing homelessness:
- Makes health insurance more accessible and affordable—through private and expanded Medicaid eligibility—giving them greater protection from financial instability that can lead to more significant housing hardships.
- Ensures coverage of the kind of health services that support individuals as they transition out of homelessness such as behavioral, rehabilitative, and tenancy support.
- Shifts focus of health delivery from quantity to quality and value based, emphasizing a holistic approach, and fostering relationships between health care and other needs like social services and housing.
Another positive impact of the ACA is that it extends children’s coverage under their parents’ health insurance from 19 years old to 26. For many families living in the DR, especially those experiencing unstable housing, this eases what was previously a financial burden due to parents having to pay for their children’s insurance after 19 if they could not afford it themselves.
Overall, the current health infrastructure of the DR is positively impacted by the ACA, making insurance affordable, emphasizing preventive care, and improving how health care services are delivered.
Residents of the DR do not have the best access to health services nor are they provided with sufficient opportunities to receive them. Modernization of farming technology in recent years has decreased employment rates, leading to people moving out of the region. The declining tax base has weakened efforts to improve infrastructure development and community health, but this does not mean that health outcomes of the remaining population should be cast aside. Tax revenue has decreased as the population has shifted out of the region, but there is still some. The case for the state and federal government to provide monetary assistance for the improvement of community health in the DR is sufficiently justified. The health delivery system would benefit from support in the following three efforts:
Freestanding Emergency Departments
To address rural areas’ lack of access to health care services, freestanding emergency departments (FESDs) can be established in areas with most high-risk/at-risk populations. The American College of Emergency Physicians defines FESDs as a facility that is structurally separate from a hospital that provides emergency care (Lukens, 2016). FESDs have an emergency room, imaging, an on-site laboratory and can function as two different models: IFECs or OCEDs.
Independent freestanding emergency centers (IFECs) operate independently from hospital licensure and are not eligible to receive Medicare or Medicaid reimbursements for facility fees. Hospital-based off-campus emergency departments (OCEDs) operate under an affiliate hospital and adhere to the same CMS regulations, thus making them eligible to receive reimbursements for physician and facility fees. OCEDs are the more financially viable option for the DR, as their relationship with parent hospitals makes them more sustainable in rural areas.
Mobile Health Clinics
As new alternatives are evaluated to improve health outcomes and increase health care accessibility in disenfranchised communities, a common and effective method is the implementation of mobile health clinics (MHCs). Mobile clinics are a rapidly growing alternative that can help mitigate health disparities in at-risk and underserved populations like the ones previously discussed. The importance of MHCs has increased in recent years due to their ability to provide sustainable care on par with traditional health care settings.
Today, there are approximately 2,000 MHCs across all 50 states of the US, providing primary care, preventive screening, disease management, pediatric care, etc. (Mobile Health Map, 2017). Mobile Health Map also estimates that these units are significantly improving access to health services, registering 6.5 million visits annually—60% from uninsured patients. Additionally, the cost-effective operating model of MHCs allows them to save $12 for every $1 spent (Mobile Health Map, 2017).
The efficacy of MHCs well noted, as they deliver services directly to the communities in need. The MHC is an invaluable tool that can be used to tackle the medical and social determinants of health in the DR.
In order to address the high rates of mental and behavioral disorders, the HRSA awarded a $600,000 grant in 2018 to the Arkansas Rural Health Partnership (Arkansas Rural Health Partnership, 2018). This award was for the development of outreach programs to promote the importance of mental and behavioral wellness in southeast Arkansas. The Federal government can continue to lend assistance by awarding more grants to non-profit CBOs in the DR, and by increasing the award amount to $1 million. This will ensure there are sufficient funds and a greater collaborative effort for the creation of an outreach curriculum that expands health care service delivery by increasing prevention, education, referrals and access to mental and behavioral services. The recommended increase in funding can also be allocated towards the creation of a preventive network that includes 24/7 telemedicine mental health counseling, mental health first aid training to first responders, and early detection public awareness campaigns.
The Delta Region of Arkansas is a blue-collar community whose residents have been presented with suboptimal opportunities for quality health care. Its designation as a rural area and shifting economy has led to a loss in tax revenue and declining education and employment rates. As a result, a significant portion of the population is low-income, homeless, and affected by behavioral and mental health disorders. While some health care services do exist, they are merely insufficient, as the DR residents face several barriers when attempting to access quality care. It is the hope that with the recommendations discussed, these barriers can be eliminated and the high percentages of medically underserved population will decrease over time, increasing access to quality care for all.