Rural Americans—nearly 20% of the U.S. population—face far more difficulties accessing health care than do urban and suburban residents, a problem exacerbated by socioeconomic, racial, ethnic, geographic and health workforce factors.
A group of nine legislators and 10 legislative staff from six southeastern states attended NCSL’s first Rural Health Regional Roundtable in Asheville, N.C., to explore policy solutions for strengthening rural health in the region.
The group visited the Tallulah Health Center, a federally qualified health center and part of the Appalachian Mountain Community Health Centers that provide care at six locations throughout western North Carolina. The Tallulah Health Center is the only primary care provider in a county with over 8,000 residents, 16% of whom live in poverty.
“The vast majority of (our patients) are good, honest people who just can’t get access to the care that they need,” Chief Medical Officer Dr. Timothy Plaut said.
“Access to care is a really important issue in rural areas, but it’s not the only issue,” said Michael Meit, director of research and programs at the Center for Rural Health Research at East Tennessee State University. “Underpinning all social determinants is poverty.”
Integrating Services
To address these needs, Tallulah Health Center is a one-stop shop integrating primary care, behavioral health, pediatrics, medication-assisted treatment and pharmacy services. It delivers “timely, comprehensive and quality health services to the most vulnerable and high-risk populations with dignity and respect, regardless of a person’s ability to pay,” said Shantelle Simpson, president and CEO of Appalachian Mountain Community Health Centers.
Funding is a persistent challenge for health centers. Most centers depend on funds from Medicaid, Medicare, private insurance, patient fees and other resources. Health centers may also receive grant funding from the federal Health Center Program . For Tallulah Health Center, 18% of total funding comes from the HCP—which doesn’t even cover staff salaries.
Other financial challenges include procuring equipment needed to deliver care via telehealth; time and effort required to shift to value-based care; and staff recruitment and retention. “Staffing is huge. With more staff we can provide more services,” Simpson said. Plaut added, “We need to make sure we have an adequate number of providers, and that providers can practice at the highest level of their degree.”
Behavioral health needs in the U.S. have never been higher, and Tallulah Health Center deals regularly with the opioid epidemic, Plaut said. The center provides an array of coordinated behavioral health services including peer support specialists, paramedics delivering buprenorphine, medication-assisted treatment and harm reduction. Integrating behavioral health into primary health care and school-based health settings shows promise as a way to reduce siloed care and to provide universal screening and assessment for behavioral health issues.
The peer support specialist model in particular shows positive outcomes with discontinuation of substance use. At the health center, a peer typically comes in after a patient discloses to a primary care practitioner a desire for behavioral health services; the peer will then assist in referring the patient to a licensed counselor and providing ongoing support.
Increasing Access With Telehealth
Brianna Lombardi, deputy director for the Carolina Health Workforce Research Center, told the group about the challenges and policy levers affecting access to behavioral health services for rural communities. She highlighted ways to support the treatment of opioid use disorder, such as medications, peer recovery models and harm reduction models—all of which are used by Tallulah Health Center.
Lombardi cited telebehavioral health as a strategy for increasing access to services, especially in rural areas, where they represent one-third of visits. According to NCSL, all states have some form of reimbursement for mental health services delivered via telehealth, though policies vary widely. When it comes to telehealth, another challenge is broadband.
When asked how state legislatures can support health centers, Brendan Riley, from the North Carolina Community Health Center Association, suggested addressing the uninsured and closing coverage gaps; reviewing Medicaid reimbursement rates; safeguarding the 340B Drug Pricing Program; and providing direct appropriations.
Meit, the East Tennessee State University researcher, believes the solution to rural health challenges “is to create jobs and opportunities.” He adds, “we need to lift up the positive stories and change the narrative.”
Kelly Hughes is an associate director in NCSL’s Health Program.
NCSL would like to acknowledge the Health Resources and Services Administration, Appalachian Mountain Community Health Centers, North Carolina Community Health Centers Association, Michael Meit, Brianna Lombardi, and the attendees for their contributions to the meeting.
This resource is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services as part of an award totaling $767,749 with 100% funded by HRSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the U.S. government.