The federal Affordable Care Act is designed to make it easier to get health insurance coverage. A couple clicks of a mouse, and one can get insured (but generally only during the enrollment periods). But there’s still the issue of receiving medical care - an insurance card is no good if a primary care provider isn’t nearby.
That’s the number of medically underserved areas, or MUAs, across the commonwealth, according to the US Health Resources and Services Administration. Lisa Davis is confronted by the issue every day as director of the Pennsylvania Office of Rural Health.
"The issue of access to health care services in rural communities and trying to establish parity between access in rural areas and access in urban areas has been an issue for many, many decades."
An area is designated medically underserved by using four factors: ratio of primary care physicians, the infant mortality rate, the poverty rate, and the percentage of senior citizens. Now, not nearly all of these MUAs are rural. They can be in urban areas too. But today, let’s look at the rural issue.
The Cornerstone Rural Health Center in Frackville is in an unassuming building just off Route 61 in Schuylkill County. It’s only been open for a couple years, and yet it’s a bustling place – a full waiting room, nurses and physician assistants checking on patients, and Doctor James Greenfield going from room to room.
"It makes it challenging, but it also makes it very rewarding because we're dealing with patients that a lot of times can’t have access to health care. And so after you've been able to provide health care and help make a difference in someone's life, it's definitely very rewarding."
Keith Cleghorn is one of those patients. He went searching for doctors that would take his insurance before Cornerstone opened.
"I would have to call around and somebody who would take me, or I’d have to go the ER. I spent a lot of time in the ER because I either couldn’t get into a doctor or because of all the meds that I need, they wouldn't take me."
Cleghorn is diabetic, has sharp pain in his knees, and also recently had a hernia. Cornerstone acts as the gateway for him -- just like a primary care doctor -- and keeps him out of the extraordinarily expensive emergency room.
"We accept all Medicaid insurances, all Medicare insurances. There a lot of places that don't accept those just because of the poor reimbursement. That definitely does come into play."
Based in a medically underserved area, Cornerstone is classified as a rural health clinic. That means it gets Medicare reimbursements based on the cost to the clinic, not what Medicare says it should cost.
When it comes to challenges, it’s a lot of little things in rural areas – like transportation. In M-U-As without public transportation, how do lower income residents without a car get to an appointment?
"Most of the people that come here don't have cars, they don't have transportation," says Dr. Greenfield. One of the reasons he picked the current location is because its right next to a bus stop.
That’s just the start. There’s a long list of things for doctors practicing in a rural area to overcome, but two stick out to most experts – the economics and the lifestyle.
"Some of it is just a question of making sure that people understand the opportunities that are presented to them as they're going through their medical training. What we're trying to do is make sure that everyone has opportunities to go to those places, and we're trying to make sure they're pursuing those opportunities if they want to," says Michael Wolf, state Secretary of Health. He says about one-sixth of Pennsylvania’s population is medically underserved.
"A lot of this is also a question of not only the financial and economic side, but making sure the right people want to get into working in those communities."
The department recently announced about 40 grants aimed at medical facilities in MUAs, and Wolf pledges similar state support in the near future. But it doesn’t address a fundamental issue.
Says Sheri Rinehart, CEO of the Pennsylvania Community Health Centers group: "It is more challenging to run a practice in a rural area, you don't have the economies of scale."
There also aren’t as many private insurance patients in rural areas, who can help defray the cost of treating those with Medicare. So, it comes down to long-shot help from the federal level. That’s not to say there isn’t money to be made for medical staff, but often, there’s more money in cities.
Working in a MUA in a city is one thing – doctors have things like cultural events, restaurants, sports and more surrounding them. But in a rural area, entertainment options might be the town theater, a diner, a couple bars, and a summer festival.
"I don’t know it’s something you can convince any one particular person. I think it goes back to your values, your beliefs, and why you believe we're here."
Dr. James Greenfield, working in Frackville, says doctors just have to have an innate desire to work in a rural area. There’s no doubt, there are the advantages – closer to the patients, they know them, and a better sense of community. If rural health care expands, it could actually benefit the health system as a whole.
"Those individuals then not only have the ability to avoid future health concerns, but any issues that might be brewing can be identified earlier and treated earlier," says Lisa Davis.
That could mean no more visits to the ER for what was once a routine problem. No more scrambling for a doctor who will accept Medicare. Those are some of the goals for those committed to health care in rural areas. Because when asked if other clinics would take them, Keith Cleghorn and his girlfriend Jessica Vogel answered simply.
For Cleghorn, and thousands like him across Pennsylvania, a rural clinic helps turn their health around. But, there are only so many clinics up and running – which means for low income residents in parts of the midstate, the ER is the only option.
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