Texas moved to town in the mid-20th century, but Texans cling to the state’s image of itself on horseback. The state became officially urban in the 1950s, when the rush toward its cities that started during World War II finally tipped the population scales.
Even so, romantic visions of Texas rural life still flood the airwaves and our imaginations. Those romantic fantasies, however, mask some unpleasant realities about the availability of health care out yonder.
A life expectancy gap between the state’s urban and rural residents will continue to grow as health care gravitates toward where a majority of Texans live, even as the need for efficient, financially accessible health care grows in the rural areas where the population is older and poorer. In fact, that rural population — usually associated with Texas past — may well yield clues about how to deal with an aged Texas population of the future.
According to a recent comptroller’s report: “By 2040, the Texas state demographer projects that the share of the population aged 65 or older in Texas will nearly double, to 18.0 percent.”
The state’s changing demographics will challenge policymakers to make choices now and in the foreseeable future as fundamental as how big a life expectancy gap is acceptable or whether to devise ways to close it. Those choices will prove expensive.
As the American-Statesman’s Andra Lim reported last week, financial hardships forced 100 rural hospitals to close in the 1980s. Back then, life expectancies of rural and urban residents were virtually the same. Now, rural males in Texas live to an average age of 74.2 years; women to an average age of 79.2 years. Urban males live to an average age of 75.1 and women to 79.8 years.
Old notions about clean air and clean living out in the country collide head on with the reality of a rural population that is older, poorer and less likely to have health insurance. Those who depend on Medicaid assistance take a direct hit when Medicaid payments — a favorite political target — can’t keep pace with increased health care costs. Not expanding Medicaid coverage effectively cuts it.
“Any further reductions in Medicaid payments will strain rural providers. A certain repercussion is decreased rural services or (fewer) providers accepting Medicaid leaving many rural Texans without health care access,” warned the Texas Rural Health Organization in 2012.
“If access to care declines, and access to emergency care declines, that could contribute to shorter life expectancies in rural areas,” Don McBeath, director of government relations at the Texas Organization for Rural & Community Hospitals, told Lim.
That decline in access to health care is compounded by the realities of rural life that challenge cherished myths about it. The National Rural Health Association — which has scheduled an October conference in Austin — reports that rural residents suffer from hypertension on a higher per capita basis than their urban counterparts. Rural residents are more likely to die following heart attacks than urban dwellers. Oh, and that notion that the slower pace of country living is safer? National Rural Health also had this: “Although only one-third of all motor vehicle accidents occur in rural areas, two-thirds of the deaths attributed to these accidents occur on rural roads.”
So much for the simple life.
Texas legislators have taken steps to increase the number of physicians in rural areas that appear to be working. The Legislature approved increased funding for a program that helps doctors repay student loans in exchange for at least four years practice in areas where physicians are in short supply. Legislators appropriated $33.8 million for 2014-15. The program made $5.7 million available in the 2012-13 budget — an amount that quickly evaporated. The Texas Higher Education Coordinating Board had been unable to accept new applications since 2011.
Legislators also authorized nurse practitioners more latitude and authority in providing health care.
But, the Legislature — following Gov. Rick Perry’s lead — refused to expand Medicaid assistance to low income people, which will aggravate problems in obtaining health care, especially in rural areas.
There is also the ongoing dilemma posed by nursing home care, regulation and availability. Nursing home owners have been pleading for years for increased reimbursements. This year, they got some relief, but a funding gap persists. “Of the more than $350 million in biennial (general revenue) we were seeking to ensure Texas seniors’ nursing home care is funded at the level actually deemed necessary by state health officials, the Legislature ultimately approved nearly $100 million — a needed step forward as we work to continue narrowing this funding gap,” said Tim Graves, President of the Texas Health Care Association, the nursing home lobby.
The quality and availability of rural health care deserves increasing focus because some of those rural problems will become urban ones — and sooner than we think.