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As state legislatures begin their 2020 sessions, more are grappling with how to increase access to medical care in rural areas.

Most rural areas have significantly worse health outcomes than cities and suburbs. Rural mortality rates for the top five causes of death (heart disease, cancer, accidents, low respiratory disease and stroke) and the gap has been growing at least since 2009, Michael Ollove reports for Stateline. Rural areas also have higher suicide rates. And though urban areas have a higher overall rate of deaths from drug overdoses, rural areas have higher overdose rates for some drugs, such as methamphetamines and oxycodone. Rural women are also more likely to die from a drug overdose than their suburban and urban counterparts.

The health gap has multiple reasons: poverty (which reduces access to health insurance and nutritious food), higher rates of smoking and obesity, and lower rates of exercise. Another big reason: "Since 2005, at least 163 rural hospitals have closed, more than 60 percent of them since 2012. Nineteen rural hospitals closed in 2019, the most in a year," according to the Rural Health Research Program at the University of North Carolina, which tracks rural hospital closures, Ollove reports. Rural health clinics are faring poorly, too: 388 clinics closed between 2012 and 2018, leaving 4,245 in operation.

Partly because of hospital closures, rural areas have a hard time attracting and keeping medical professionals. "Nearly 80% of rural counties are short on primary-care doctors, and 9% have none, according to the National Rural Health Association’s Policy Institute," Ollove reports. "The shortage of providers is likely to only get worse. More than 25% of primary care physicians in rural areas are 60 or older, compared with 18% in urban areas.

Though Medicaid expansion and the Patient Protection and Affordable Care Act have helped many rural residents get health insurance, rural areas are still grappling with these systemic problems. "Many states are focused on making improvements, both large and small, to address the deficiencies," Ollove reports. "Among the ideas: creating private-public partnerships to increase access to care, sending mobile medical units into remote areas, expanding telemedicine and encouraging young people in rural communities to go into health professions."

Several Republican-run states are fielding initiatives to expand Medicaid, which would increase rural coverage and thus rural hospitals' revenue. "Some states are trying to help rural hospitals deliver preventive care and chronic illness management beyond their walls, improving the collective health of the community while reducing health care costs," Ollove reports.

Pennsylvania, for example, has an initiative in which it guarantees 13 participating rural hospitals the revenue they'll receive in the coming year and rewards hospitals for keeping patients healthy and out of hospitals. The hope is that hospitals will be better able to focus on prevention and treatment without having to worry so much about the budget, Ollove reports.

"Brock Slabach, senior vice president of the nonprofit National Rural Health Association, said big ideas are needed to truly change the trajectory of rural health. The good news is that because of scale, rural areas are promising places to test out innovations in the delivery and financing of health care." But, he told Ollove, "we don’t have the luxury of having years to spend finding solutions."