People who live in rural areas of the U.S. are at greater risk of dying from heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke than their urban and suburban counterparts.
Rural residents also tend to be older and sicker and have higher rates of cigarette smoking, obesity and high blood pressure, according to the Centers for Disease Control and Prevention.
“The health trends in rural America are admittedly alarming,” AMA President Bruce A. Scott, MD, wrote in a Leadership Viewpoints column earlier this year.
“Our nation seems to expect that health outcomes will be worse—a lot worse—for people living in small towns, farming and ranching communities, and other places far from city lights and suburban sprawl,” added Dr. Scott. “Rather than accept this status quo, the AMA is working on multiple fronts to reduce these inequities, promote greater access to care, and significantly improve the health of people regardless of ZIP code.”
This commitment to end rural health inequity was demonstrated at the 2024 AMA Interim Meeting in Lake Buena Vista, Florida, where the AMA House of Delegates took several actions aimed at attacking this issue from several different angles.
Adopted at the meeting was a Board of Trustees report addressing shortcomings in a federal program designed to encourage primary care physicians and others to consider practicing in locations designated as health-professional shortage areas (HPSAs).
“Many HPSAs do not seem to receive scores that reflect their actual need and health indicators do not adequately measure health status” of residents, the report says. “These problems can lead to significant negative impacts on underserved populations.”
The potentially inaccurate scores can weaken the effectiveness of a federal program that offers vital scholarships and loan repayment in exchange for a commitment to practice medicine in underserved areas, according to the report, which was spurred by a resolution introduced at last year’s Interim Meeting by the Idaho Medical Association.
Delegates agreed that the actionable changes recommended in the report “can lead the way to better outcomes,” and called on the AMA to:
- Support the Health Resources and Services Administration’s effort to conduct a comprehensive reevaluation and assessment of the effectiveness and equity of the Health Professional Shortage Area scoring criteria to meet the physician-workforce needs of rural communities and underserved areas.
- Urge increased federal and state resources to improve the accuracy of the data used to determine HPSA scoring used by the National Health Service Corps loan repayment program to help meet physician workforce needs for the neediest rural communities and underserved areas.
"The primary care physician shortage is hitting rural areas hard, and it’s projected to get worse,” said AMA Trustee Alexander Ding, MD, MS, MBA. “Rural areas continue to face substantial challenges in getting scores that meet federal thresholds, and we urgently need to increase data accuracy and revamp the scoring system to ensure rural communities have access to health care they desperately need.”
This new policy reinforces the AMA’s long-standing commitment to bolstering rural health care access and follows past calls from the AMA urging Congress (PDF) to raise funding to strengthen the scholarship aspect of the National Health Service Corps loan repayment program.
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Recognizing systemic bias
Separately, a resolution introduced by the Iowa Medical Society called into question the fairness of Medicare’s Geographic Practice Cost Index adjustments, which some delegates said systematically puts rural communities at a disadvantage because the regional payment adjustments do not reflect practice costs. Others explained that rural practices incur higher costs because they have fewer patients to cover those expenses.
Ultimately, delegates adopted AMA policy to:
- Advocate health equity for all Americans, and to point out that Medicare payment policies have played a role in the shortage of rural physicians and the poorer health outcomes in rural America.
- Promote payment accuracy in the Medicare Geographic Practice Cost Index.
They also directed on the AMA to “review the results from its 2023–2024 Physician Practice Information Survey [PDF] to determine if the data can be used to generate statistically valid estimates of differences in physician practice expenses (e.g., urban vs. rural, or region).”
Critical threat to kids’ health
The House of Delegates also issued calls to help sustain the delivery of rural pediatric health services, and to develop a national strategy to eliminate rural cancer inequities in screening, treatment and outcomes.
Specifically, delegates cited statistics showing an almost 20% drop in the number of pediatric hospitals and units since 2008, and adopted policy to “recognize the closure of pediatric hospitals and units, including pediatric inpatient psychiatry units and hospitals, as a critical threat to children's health care access and quality.”
Delegates also directed on the AMA to back “federal and state policies to support the financial viability and access to pediatric care delivery organizations, particularly inpatient care units.”
The AMA also will work with interested organizations to:
- Improve access to care and reduce health inequities arising from pediatric hospital and unit closures.
- Increase awareness on the issue of pediatric hospital closures and develop strategies to preserve access to high-quality pediatric emergency, inpatient and critical care.
Reducing cancer-outcome inequities
Rural communities continue to face significant inequities in cancer screening, diagnosis, treatment and outcomes.
Delegates discussed how best to help promote equitable access to cancer care across geographic regions. This includes making use of innovations such as telehealth and teleconsultation services to expand rural access to care.
Delegates adopted a resolution directing the called on the AMA to:
- Work with relevant stakeholders to develop a national strategy to eliminate rural cancer inequities in screening, treatment and outcomes and achieve health equity in cancer outcomes across all geographic regions.
- Call for more federal and state funding to support research on inequities in rural cancer care, access and outcomes, and for the development of interventions to address those inequities.
- Advocate evidence-based collaborative models for innovative telementoring or teleconsultation solutions between health systems, academic medical centers and community physicians to improve access to cancer screening, treatment and patient services in rural areas.
“It is unacceptable that people living in rural communities in the U.S. have a higher death rate from cancer than people living in metropolitan areas of the country,” said Dr. Ding. “We must continue to support policies and initiatives that improve health outcomes for all people, regardless of where they live.”
