North Carolina is a green state, full of long back roads and old red barns and farmland as far as the eye can see. 80 of our 100 counties are rural, and we wouldn’t want it any other way.

But here’s the thing. Our rural residents aren’t getting their fair share of the healthcare pie. Not by a long shot.

See You in Six Weeks

It’s an octopus of an issue, really: many, many arms. For one thing, rural areas just have fewer doctors. For instance, in Wake County there were 23.7 physicians for every 10,000 people in 2010; next door in rural Johnston County, there were only 7.6.

Specialists are also disproportionately undersupplied out in the country. Think cardiologists, oncologists, dermatologists, psychiatrists: basically, doctors for any specific part of you, any specific disease or disorder, are really hard to find. We know that because The National Center for Health Workforce Analysis found in 2010 that rural areas tend to have more providers who require less education, and fewer providers who require more education.

Here’s a specific example from the study: rural and urban areas had the same number of chiropractors for every 10,000 people: 1.9. But the number of surgeons was way, way off. Urban areas had well over twice as many of them per capita.


Why is this? In part, it’s a problem of education; people tend to live where they train, and specialized medicine training is more available in urban areas. The money’s also better in the city, and there are more opportunities for providers’ spouses to find work.

Whatever the reason, one thing is clear: with numbers like this, chances are people have to drive a long way or wait a long time to get to a doctor’s office.

The Cloud’s out of Reach

Then there are the technology issues. The internet isn’t all cute cat videos and your high school frenemy’s baby pics. It plays a role in good healthcare — your medical records, for instance, are probably hosted in the cloud, and telehealth is becoming a really big deal.

But the broadband access necessary for these services is often hardest for providers to get1 in areas with the lowest populations. Without electronic health records software, your providers are spending a lot of resources digging through paper files instead of focusing on patients. And video consultation and remote patient monitoring services — exactly the services most useful to rural patients — are impossible to provide without a good connection. As Alanis Morissette would say, “Isn’t it ironic?” (‘90s kids, take note: unlike most of the contradictions in that song, this one really is ironic.)

Medicare, Schmedicare

Senior patients are affected by the rural care gap, as well. A new study out of UNC-Chapel Hill has found that as of 2010, rural Medicare patients were 19% less likely to receive follow-up care after a hospital visit. This increases the likelihood that they’ll need a trip to the E.R. or even readmission into the hospital in the future.

Poor follow-up care is obviously a problem for patients, but it could also be a problem for the hospitals themselves; Matthew Toth, Ph.D., lead researcher on the study, points to the dangers of a proposed Medicare pay-per-performance model that would penalize hospitals for high readmission rates. Based on these data, rural hospitals would be disproportionately penalized.

We Just Can’t Afford It

And don’t forget the number one barrier to good healthcare outcomes: cost. The North Carolina Rural Health Action Plan by the North Carolina Institute of Medicine2 puts it this way:

Income is directly related to health. Increased income corresponds to better health outcomes, with the greatest impact on health for those with lower incomes. A person’s income or wealth is generally a proxy for their social conditions and community and economic opportunities. It is these factors more generally, rather than money specifically, that impact health.

The report points to a few broad solutions to income problems, like better education and stronger community support. And then they get to the part that really interests us at NCCFH: access to health insurance. If you can’t afford health insurance, you tend to lose access to the kinds of preventive screenings that catch major problems before they start. You’re more likely to be diagnosed with life-threatening diseases. You’re more likely to die younger.

North Carolina needs our rural communities to be strong, vital, and healthy. For that, we need them to be able to access the medical care they need. Many people are working on this problem from many different fronts, including these awesome folks, who have been hard at it since 1973 and aren’t stopping anytime soon.

As for us, we’re working on that cost thing. North Carolinians need to be able to afford health insurance to have access to care. Plain and simple, our healthcare needs to be less expensive. We’re going to shout about that until someone listens.


  1. Check out Section 8.1, page 136 — it talks about broadband being most difficult to get in areas with lowest population densities. And then while you’re at it, check out the very beginning of the document, the Executive Summary on page xi. Scroll down...did you catch the part that says that “broadband-enabled health information technology (IT) can improve care and lower costs by hundreds of billions of dollars in the coming decades, yet the United States is behind many advanced countries in the adoption of such technology?” What’s up with that?
  2. Page 35.

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