Where doctors are few and far between - medical care for rural aged population - The Elderly in Rural America

In 1986, nonmetropolitan areas had 44% fewer physicians per 100,000 population than metropolitan areas.

The pain in her leg would come and go, but had gotten so bad in the last month that she often had to find a chair quickly to sit down -- whether she was at home, in the supermarket, or on line at the bank. Her usual treatment of aches and pains was to baby the affected limb a little and to keep going. Yes, she was 85, but she had a garden to weed, several acres of grass and bushes to worry about, a house to run and cottages to rent in the small town on Cape Cod that in her late 60s had become her winter as well as her summer home.

The pain, which she suspected was connected to her arthritis, finally got bad enough for her to call the doctor--always a last resort for this very self-reliant and economical widow. He was really her heart specialist, but with so few G.P.s around, she hadn't yet found another one after her old one moved away. The heart doctor advised her to call a rheumatologist, which she did on June 10. His pleasant nurse informed her that the earliest appointment available was July 31st! Since the nurse was aware the pain was pretty severe, she said she would try to find something sooner and call back in several days.

The elderly woman knew that when her daughter, who lives 500 miles away, called during the week, the advice was likely to be, "Why don't you see a specialist in Boston?" But the 2-hour trip to Boston by bus would be tiring, and with her angina and the leg, it would be hard to get around in the city. Even if she took the senior citizen van, the service might not be door to door.

The elderly woman's hometown isn't the boondocks. It's a fast-growing, semi-rural area in Barnstable County, Massachusetts, which, in demographer's language, is a "destination retirement county." There are six types of rural countries as categorized by Department of Agriculture researchers (see chart, p. 25).

Although as a destination retirement area, Barnstable County is very different from "agricultural" or "persistent low-income" countries, the elderly in many rural and semi-rural areas face a similar and, in some cases, life-threatening problem--not enough doctors and other health professionals and long distances to travel for specialized dental and medical care.

In 1986, nonmetropolitan areas had 44% fewer physicians (M.D.s and Doctors of Osteopathy) per 100,000 population than metropolitian areas. Large metropolitan areas have 67% more hospital beds per 1,000 elders than small nonmetropolitan areas, and that gap may grow wider. The Congressional Research Service found that between 1981 and 1988, 190 rural hospitals closed.

"Frankly, the average American is relatively unaware of the inadequacy of health care faced by many rural residents and is certainly uninformed about the consequences of that situation," observes Raymond T. Coward, Ph.D., in The Future of Aging in Rural America: Proceedings of a National Symposium, 1991 (listed on p. 48).

"Although about one in four Americans lives in a small town or rural area, a proportional number of health care professionals do not practice in such areas," Coward points out. "This pattern is pervasive across the full spectrum of health care professionals--from nurses, social workers, dentists, physical therapists, and psychologists to lab technicians, X-ray technicians, pharmacists, and opticians...As yet, I do not sense the public outcry that I think will be necessary before this difficult issue is addressed.

Coward believes that it is vital to educate the American public about the maldistribution of health care providers. "It is not a trivial matter, since it has the potential to affect the lives of more than 60 million Americans."

Why has there been so little public outcry about the health care predicament in rural areas? On the most obvious level, the answer may be "out of sight, out of mind." Even when people are aware of the imbalance in the quality of health care in the city and country, the attitude of some, Coward notes, is that if people choose to live in rural areas, they must suffer the consequences "even if it's a risk to health."

As for the ability of rural residents to counter this attitude, it is difficult for them to join forces so they can be heard. Scattered throughout the country, in many different rural settings--Indian reservations, the lowlands of South Carolina, Iowa farm land, Appalachia--rural residents have not been able to exert the same kind of political pressures as their more vocal urban cousins. And like the widow in Barnstable County, many elderly rural residents were raised not to make a fuss or to demand better care.

There is a tendency to romanticize rural towns as bucolic and healthy places to live where the elderly are supported in the bosom of family, neighbors and friends. If the first myth about rural life is that the residents are healthier, the second is that family systems there are much stronger.

Conversations with service providers in out-of-the-way places indicate that the elderly are suffering--in Clayton and Tucumcari, New Mexico; Decorah, Iowa; Goochland County, Virginia; Cannon Beach, Oregon; Cookville, Tennessee; and Roundup, Montana.

M.D.s Don't Stay Long

Roundup, Montana, currently has two doctors, an unusual and fortunate situation for a small town that has often had trouble attracting M.D.s. "It's difficult to keep a doctor," explains Karen Erdie, Administrator of the Area II Area Agency on Aging, adding that frequently it's the doctors' wives who don't want to stay. "There may be basketball games in winter here, but it's not the social life the wives were used to." "Let's be nice to the wife," is the first thing residents remind each other when it's rumored a new doctor is on the way. Even when a doctor does arrive, residents still have to travel 50 miles to Billings for treatment of serious medical problems.

In some of the small towns the agency serves, Erdie claims the population might be 50 people and of those, 35 would be elderly. Typically, she says, an elderly person wants to stay in the area but begins to have difficulty managing. "The kids call and say, 'Can you find a homemaker to help my Mom?' But we can't find qualified homecare workers in these small towns," explains Erdie, "and if we get one to come from Billings, then we have to pay the mileage and righ now we don't have the kind of dollars to do this."

Erdie says the agency is sending out their Information and Referral staff "as informal case managers" to go into the home, check on the elders and help them file Medicare forms and applications for Food Stamps. Even though she says the elderly don't see themselves as poor, "We're finding some hungry folks out there."

Family Support Diminishing

Lack of in-home services in a rural area around Cookeville, Tennessee, is cited by Nadine Jones, formerly a health care planner at the Upper Cumberland Area Agency on Aging, as one of the region's biggest problems. "If you're 80 years old and have been 6 weeks in rehabilitation and come home, you need someone around to help with cooking, chores, and to monitor your ability to walk," advises Jones. She says families can't provide as much support as they used to because "people in rural areas have to have two incomes to survive, and one person's going to have to quit to take care of an elderly mother."

Independent living in assisted housing isn't an option either. Jones says she knows of only one facility in 14 surrounding countries that combines independent living, meals, and medical supervision. As for home care, she explains that Tennessee lacks a Medicaid waiver program to provide in-home services. "In Tennessee, for every 204 persons served in a nursing home under Medicaid, only 1 is served at home.

"We have a Senior Companion program, but a lot of people can't afford the average charge of $5 an hour, and there's a long waiting list for home-delivered meals," says Jones. Without help with cooking and chores or delivery of meals, "some of the elderly who really aren't so dependent end up in the position of having to go to a nursing home because of poor nutrition."

Serving Elderly on Isolated Farms

Lack of regular meals is also a problem for frail elderly people who live on farms way out in the country outside Decorah, Iowa. "A lot of people won't move off those farms," says Linda Valley, a secretary who screens requests for assistance at Area I Agency on Aging (AAA) in Decorah. "We have meal sites in 32 towns but they can't deliver outside city limits."

Valley says services "are very limited" for elderly people who have remained on the farms. She explains that some of the elderly lease their land to others to farm but continue to live in the farmhouse, often alone. "They don't drive anymore and don't have families around," observes Valley, adding that funding for the van service has been cut back substantially. She is quick to point to transportation as one of the area's biggest problems.

Valley says the AAA was "trying to get a volunteer transportation program going for months" to drive the elderly to the doctor, but the drivers' individual insurance companies refused to cover the passengers if the trips were carried out on an organized basis.

Commenting on yet another transportation solution that was foiled by red tape, Valley explains that Decorah is only one hour from Rochester, Minnesota, where more specialized medical care and sophisticated equipment is available. But she says the Northeast Regional Transit vans for senior citizens can't cross the state line "because the insurance goes way up," so elders in need of sophisticated care often have to travel 2 1/2 hours to the University of Iowa Hospital and Clinics.

Small Town Businesses Drying Up

Valley's colleague, Marion Hanson, Program Coordinator at the Decorah AAA, helps many of the rural elderly to apply for benefits from the state's Title XIX Medically Needy Program under Medicaid, even though they don't fit the definition of poor. She explains that neither their Medicare nor Medigap policies cover all of their "huge drug costs for heart, arthritis, diabetes, and some cancer medications." Medicaid, she notes, will cover prescription drugs.

Discussing other health care problems of the isolated elderly, Hanson observes that some people move from a farm to a small town so stores and services will be more accessible.

"But, you know, we had a farm crisis in Iowa in the 1980s, and small town businesses have failed." These tiny towns, she reports, "often have no supermarket, no drugstores, and no doctors. Some do have a combined gas station and grocery store--a 'Come and Go' or 'quick trip,' we call them, which will have milk, bread and maybe some fresh fruit, but their prices are horrendous." For the residents of many of these small towns, the nearest supermarket may be 30 miles away.

Hanson wishes that some of the frail elders could move to the Farmer's Home Administration (FmHA) apartments for senior citizens in the area. She says there are 8 to 12 of these individual apartments for seniors in almost all the towns where a lot of older women live. "But these units don't have a dining room, housecleaning services or help if there's medical emergency."

In ranking current problems facing Decorah area elders, Hanson--like Valley--pointed first to transportation. "We're experiencing terrific budget problems. There haven't been increases for a long time from either the federal or state levels. We had to cut the number of days the van operates and we've cut back on routes."

Reflecting on the level of Older Americans Act funding, Hanson comments: "If you take into account inflation, we recently figured that we have taken a 30 percent cut over the last 10 years. We're at our limit here now."

At least the Decorah AAA has 35 vehicles for five counties. Harding County, New Mexico, has only one van to go 60 miles to the nearest dentist and 200 miles to a family doctor. Frank White, director of the Eastern New Mexico Area Agency on Aging, says Harding, "a ranch-type county," has 987 residents, of whom 269 are senior citizens.

Joe Rey, Assistant Director for Nutrition in Harding County, reports that a nurse, available at a clinic on Tuesdays, provides the only local medical care for the residents of Mosquero, most of whom are Hispanic. He notes enthusiastically that the legislature has authorized funds to purchase another van for the area, but says the money has still not been appropriated.

Sophisticated Care Not Accessible

In some of the tiny communities east of the town of Cannon Beach on the Oregon Coast, local nurse practitioners and physicians' assistants are one solution to long distances to doctors--sometimes 40 miles round trip. Karolyn Adamson, Administrative Assistant at the local Area Agency on Aging, notes, however, that the nurse practitioners in Oregon can't prescribe certain drugs--a limitation that is being debated in the legislature.

In addition to the scarcity of local doctors, Adamson points out that elderly people in need of sophisticated cancer treatment have to travel 80 miles to Portland. "It's very difficult to find volunteers willing to go that far and wait several hours, and the van service doesn't always work if a person needs treatment every day." She says the AAA has opened discussion with local small rural hospitals about establishing a regular van service for people who need a variety of types of care from hospitals in Portland.

Like other rural AAA staff, Adamson is concerned about the loss of businesses in small towns or the regionalization of businesses and services. She says that due to the decline of the timber and fishing industries in the area, pharmacies, clinics, and other services are giving way to businesses that cater to the burgeoning tourists industry. Recently, the owner of the town drugstore sold out to the Payless Drug Company, which has a store 8 miles away. After the sale, Payless closed the local drugstore down. Now, elderly residents have to travel 14 miles round trip to the Payless store for diuretics and other prescription drugs.

About 3,000 miles away in Beaufort County, South Carolina, Corona Harrigan echoes Adamson's complaint. "For some stupid reason, most towns are putting shopping malls and services outside the central business districts." Harrigan is director of the Low Country Council of Governments Area Agency on Aging in Yemassee, South Carolina. She's unhappy about the regionalization of businesses, and like other rural service providers, sees lack of transportation as the number one problem for the area.

Finding a way to get the elderly to the stores and services that have moved away from the center of town has just added to existing transportation problems. Harrigan and other members of a transportation task force recently "mapped out a good fixed route for a van service around Walterboro--about 12 miles past the hospital, the mall, the light company--all of the things seniors would need." In the town of Beaufort, the task force has proposed a 15-mile fixed van route. "But the human services agency wants to do a study. Why we need another study, I don't know," complains Harrigan.

She says that outside the more populated areas, solutions to transportation problems for the elderly are even more difficult because of wetlands, winding rivers, and areas that are impassable. "There are a lot of lakes, a lot of rivers and streams which make it impossible to go directly from point A to point B--unless you want to do the backstroke."

Harrigan explains that many of the elderly live in extremely rural areas, down dirt roads. "I did a transportation monitoring recently when it was raining steadily and found some of the back roads washed out. There are even some main roads that are not paved that feed into these little footpaths to people's homes. These main roads need to be graded more frequently and if funds allow--paved. If a main road is washed out, you just have to hope that there is a detour road that will get you to the elderly person's home."

Stressing the need for systematic planning to improve transportation in rural areas, Harrigan says, "We're learning that the infrastructures of some of our bridges and roads are as old as our seniors and are long overdue for replacement or upgrading."

Tests and Follow-up Care Neglected

On the winding roads in the Appalachian Mountains around Franklin, West Virginia, fixed route transportation wouldn't do much good for the elderly who live way back in the hollows. Some of them may have to go 5 or 6 miles to the main road, explains Karen Howell, Regional Supervisor for the Title XIX Medicaid Waiver Program in Petersburg.

"The younger family members have had to leave to go out of the state to find employment," notes Howell, and "a lot of the elderly in the hollows live alone." She says some people live 30 or 35 miles from the nearest doctor and 90 miles from a hospital that could provide specialize care. "Pendleton County has no hospital, Hardy County has no hospital, and you have to go 30 miles to Petersburg even to our little rural hospital," Howell points out.

Discussing the most prevalent health problems, she observes that many clients are diabetics, "a really bad problem in this area because of their diets." When it comes to monitoring medications or taking tests, she says: "There's difficulties in compliance. The client just isn't able to get in to see the doctor, and follow-up can't be done. Someone who takes diuretics and has had congestive heart failure needs to go to a hospital to get lab work done. They may, for example, continue to have an electrolyte imbalance because the doctor doesn't see them."

According to Howell, most of the elderly are eligible for Supplemental Security Income and, consequently, Medicaid in-home services. "Many of the elderly were farmers or married to farmers and they never paid in to Social Security. It's not hard to make them eligible for in-home services under Medicaid Title XIX. But they live way up in the hollows and it's not so easy to find a homemaker willing to go out there--especially in winter when the roads are bad."

In addition to needing in-home assistance, the homes of many of the elderly are in need of repair. "They often need weatherization, but there's a long waiting list. I had one client who died before they got to his house, and he'd been on the waiting list for 2 years."

Also, lack of indoor plumbing isn't so rare as people might think, according to Howell. "We have one case right now where the outhouse is filled up and the Health Department won't allow another one on the property." There's no money to help the woman install indoor plumbing, "so I believe the lady is going to have to move. She's 80 years old--not bed-bound but has diverticulosis and gastritis. She doesn't have a whole lot of family. A grandson kind of looks in on her now and then. We're going to try to get her to come out of that hollow and into an apartment, but she doesn't want to."

And it's clear Howell isn't enthusiastic about making the elderly woman move either. Attachment to home and land is stil at the heart of rural America. Most service providers are trying to bring services to the homes of elderly rural residents or make it convenient for the elderly to reach the services. Winding rivers, wetlands, and mountains aren't the only barriers in the way.

COPYRIGHT 1993 U.S. Government Printing Office
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