Putting Rural Minorities on the National Health Agenda

 August 2000

     Restoring health to rural American life will require bold national initiatives, community activism reminiscent of the civil rights movement, and a bigger commitment to rural minorities according to guest speakers at the most recent Capital Area Rural Health Roundtable. The July 20th forum drew 130 representatives of government and national associations to look at national gaps in health status for the nation’s minorities living in rural areas.

     Shedding some light on that question was a new study by the University of North Carolina’s rural health services research center concluding that rural minorities are worse off than urban minorities (as well as urban and rural whites) with respect to cancer screening, heart disease, and diabetes.

    Presented by researcher Laurie Goldsmith, the study looked at six national indicators of health status:  infant mortality, cancer screening and management, cardiovascular disease, diabetes, AIDS death rates, and child and adult immunizations.   The Clinton Administration’s Initiative on Race measuring these indicators documents considerable gaps in status for minorities nationally.  However, much less has been known about health disparities for minorities living in rural areas where rural poverty, poor transportation, and limited availability of providers are contributors to poor health.

      According to Goldsmith, rural mi norities also suffer along with their urban counterparts on some of the other measures of health status, although the evidence of rural disadvantage is not as consistent.  

A Changing Rural Landscape

The nation’s archetypal memory of rural life with a vegetable garden, a little store and a family doctor down the road belie the rural realities of today, said speaker Theda McPheron, who chairs a committee on minority health for the National Rural Health Association.  “Remember it with fondness,” she said, “because it does not exist anymore.”   Agri-business, suburban development, meatpacking plants and other factories employing the desperately poor have subsumed much of the lifestyle once organized around small farms, small business, and churches, she said.

     A Native American, McPheron said “what’s left” for the heirs of rural life -- who include minority communities of Black Americans in the Southeast, many Asian Americans in the West and Midwest, and Hispanics and Native Americans throughout the country – are boarded up hospitals, poor roads, and too few jobs for the educated young who must go elsewhere. “Every one of you here represents somebody,” she told the room full of national representatives.  Rural communities and rural minorities need national support to help solve their problems, she said, but they need to be listened to.  Too many ‘would-be’ supporters and analysts drive through without really stopping to find out what the community, itself, knows it needs.   

Disadvantaged on the National Agenda

     What’s going on in rural parts of this country…with rural minorities, and with health care is a crying shame,” said Congressman Ronnie Shows of Mississippi, especially “given the nation’s budget surplus.”  Invited to open the forum discussion, the congressman said the 1997 Balanced Budget Act reigning in Medicare costs has severely affected rural hospitals in his district, which covers 15 counties whose residents are two-thirds rural and 41 percent African Americans.  Shows said recent congressional efforts to redress those budget cuts were merely “a band aide approach” to health care issues. 

     Pointing to pervasive poverty in his region, the congressman called for bridging the minority health gap through a “comprehensive solution” that fosters better education and also “access to decent jobs that pay a living wage.” He also called for greater emphasis on health promotion, disease prevention, and health protection, saying that nutrition, anti-smoking,  and fitness classes have failed to adequately target the non-white population. 

     Shows said he is a co-sponsor of Congressman Jim Nussle’s Triple-A Rural Health Care Act, which expands emergency services and offers tax refunds to support rural-based health care facilities, and the Health Care Access and Rural Equity Act of 2000, which offers support for vulnerable hospitals.  Referring also to “inequities in the Medicare funding formulas for rural providers, Shows called for “an adjustment mechanism” that would permit rural facilities to move beyond a year-to-year struggle for survival.  “This is not the way to run a world-class health care system,”  he said.  Shows said he doubts the new Medicare prescription drug program recently endorsed by congressional leadership will reach rural areas.  The Mississippi Congressman gave a favorable nod to the Health Care Fairness Act, which would elevate the National Institutes of Health Office of Research on Minority Health to the status of an NIH center.   Recently marked up in the House Commerce Committee and sent to the House floor as H.R. 3250, the bill sponsored by Mississippi representative Vincent Thompson would also establish grants for health care education to improve minority health.

Data Limitations

     Absent a stronger national priority on rural minorities, health researchers face considerable obstacles in attempting to draw a more complete picture of minority Americans. 

North Carolina's Goldsmith said rural residents are under-represented in national survey data in part due to the higher cost ofsurveying outside metropolitan areas. When they are included in national surveys on proportional basis, they comprise small numbers in absolute terms, especially if they are minorities. Subgroups with particular health conditions may not offer enough cases to draw clear conclusions.

     Nevertheless, the university study showed the highest diabetes death rate in the nation to be among rural African Americans, with urban blacks following close behind and other rural minorities following on their heels. Diabetes death rates for all other urban populations were uniformly lower than for the rural groups.

     Similarly with deaths from heart disease, rural blacks lead the nation, followed by urban blacks. While other minorities studied had lower rates than urban or rural whites, there was still a large urban/rural discrepancy for them, with a higher rural rate. For infant mortality, urban and rural blacks led the nation with urban blacks having slightly higher rates than rural blacks. Among other minorities, rates were substantially higher for rural than for urban members. For AIDS death rates and child immunizations, the researchers found rural minorities faring better than urban minorities, and better than rural whites.

     Goldsmith recommended improving national data collection by over-sampling rural populations and rural minorities. “There were some aspects of these health conditions that we could not even examine because there were not enough individuals in the data sets,” she said, adding that in other cases, federal agencies that are keepers of the data restrict access to it on the basis of confidentiality. She also recommended that rural minorities be targeted in the Healthy People 2010 program, a national campaign to eliminate health disparities that is part of a World Health Organization initiative.

Invisible Minorities

     According to speaker Anne Nolon, chair of the National Center for Farmworker Health, an estimated 3–5 million African Americans, Hispanics, Haitians and Jamaicans harvest 80 percent of the nation’s fruit and vegetables and generate $93 billion annually in GNP.  Yet this population is not easily found on a map because they move in migratory “streams” that fan northward in all directions -- human rivers of men, women, and children whose labors wash annually through the nation’s great agricultural fields in virtually every state.

     The very mobility that nurtures the agricultural enterprise, however, keeps migrant and seasonal farmworkers at a profound disadvantage for health care.  Ninety percent live in poverty and 95 percent are without health insurance, she said.   Their health problems are staggering and complex, mixing back pain with chemical injuries, dental disease, respiratory infections and the highest rates of malnutrition. 

     The new state-based Children’s Health Insurance Program is a fixed shoreline when it comes to reaching such moving waves of people.  Nolan said without “portability” -- the ability to use an insurance card across state and even county boundaries – retention is difficult. Nolan called for a national ambulatory health plan for migrant children.  She also said the migrant and community health care system, the one program that’s national in scope, needs to be financially stabilized and doubled in size, with an appropriation of $2 billion instead of $1 billion.  Some 125 of the nation’s 1,000 community health centers are migrant health centers and they reach only 600,000 migrants at 400 sites, she said.  One legislative proposal, the Safety Net Preservation Act, she said would assure reasonable cost reimbursement from Medicare and Medicaid. 

Border Health

“The highest uninsured rates in this nation today are in our border states at the U.S. Mexico border,” said guest speaker Dr. Andrew Nichols, adding another large piece to the mosaic of rural minority health.  Fear, language and cultural barriers, and problems generic to rural areas help keep rates of diabetes and other diseases high, he said.  Nichols is director of the Arizona office of rural health and also an Arizona state legislator.  

     He said the Border and rural needs require a bold initiative.  He touted indigenous community health workers, who play a liaison role for their neighborhoods with the formal health care system, as a cost-effective way to reach and empower rural communities. 

     Another key strategy that should be employed, he said, is to concentrate resources over an entire region through joint program and agency efforts.  Nichols cited the Border Vision Fronteriza initiative, a four-state undertaking by California, Arizona, New Mexico, and Texas as an example of a coordinated regional effort to improve health care.  Funds are distributed throughout the four-state border area, and universities from each state are involved in evaluation.  As many as 10,000 children have been enrolled in Medicaid and CHIP programs, he said, contrasting this success with states losing federal matching funds because they’re not getting enrollments.

     “The bureaucracy tends to want to particularize projects” by scattering them to get more political mileage, said the Arizona legislator.  “Those projects come and those projects go,” when the real need is for integrated, regional, and Border-wide projects that “last five, ten, or fifteen years.”  

Setting a Bold Agenda

     “You can’t imagine the debate that went on around whether [the goal] should be to eliminate or reduce health disparities,” said Deputy Secretary for Minority Health Nate Stinson, in recalling discussions within the U.S. Department of Health and Human Services to set new objectives for the Healthy People 2010 campaign. “Without a bold audacious goal, where are you going to say enough progress is enough progress?” he asked. 

     The director of the department’s Office of Minority Health said the approach of the Healthy People 2000 campaign, which established different targets for different groups, “quite frankly makes no sense to me.”  Stinson, who holds both a medical degree and a Ph.D. in environmental biology, said that to become a truly healthy nation, the goal must be the same across all groups  – to reach a standard “better than the best,” by using the lowest disease rates, wherever they happen to be.

     Stinson also said the department is supportive of the Health Care Fairness Act because it would help focus both the financial resources and the intellectual capacity of the National Institutes of Health on national minority health needs.  He praised the bill’s additional provisions for more provider education, cultural competency, and incentives for providers to go to underserved areas.   A companion bill in the Senate, S. 1880, also calls for a study that would identify data needs pertaining to the effects of race and ethnicity on disparities in health and access to health care, although it does not mention rurality. Stinson said, there is also a civil rights portion of the bill, “because believe it or not, there are still places in this country where if you are a person of color, you can't get your prescription filled in a local pharmacy; and there are still hospitals in this country that have segregated wards.”    Stinson said he agreed with Congressman Shows’ view of national priorities under a hefty national surplus, “exploding personal wealth,” and the lowest unemployment in decades:  “If  we can’t do what we need to do so that everyone who lives in this country  has the likelihood of a long and fruitful life, then shame on us.”

Capital Area Rural Health Roundtable
Center for Health Policy Research & Ethics
George Mason University
Fairfax, Virginia
703-993-1907