A Legislative View of Our Rural Health Care

Rural issues are no stranger to the North Carolina General Assembly. Of our 170 members, 75 legislators represent counties that are designated rural by the US Census Bureau [1]. Addressing the rural health care crisis in many ways is a natural issue in today's environment. We don't have to go further than down the street to see physician practices struggling to make ends meet or hospitals that are in financial dire straits. It is inexcusable that the Centers for Disease Control and Prevention found that our rural citizens are dying at a much higher rate than our urban citizens from the five leading causes of death [2]. With each decade, political power and capital concentrate even further in urban, metropolitan North Carolina, lessening the political will to address those issues unique to our rural brothers and sisters. This is why we must begin to address the rural health care crisis now.

Not only are people in rural North Carolina sicker than their fellow suburban or urban citizens, but they are facing fewer health care options with each passing year. As the economies of our quaint but no longer vibrant rural towns continue to decline, our health care options grow increasingly scarce. The shortage of rural health care providers is one reason why North Carolina ranks 47th in access to health care [3] and is the 18th sickest state in the nation [4] despite having an abundance of world-class urban health care providers. The population shift from rural to urban is putting the squeeze on our health care options.

House and Senate leaders are focused on these issues and have formed a committee to begin to address the root causes of this lack of access. Early on, it was apparent that the Committee on Access to Healthcare in Rural North Carolina would focus on physician training, physician retention, physician incentives, and what we called “outside the box ideas” such as telemedicine and broadband availability. The larger health care debate was too cumbersome an issue to tackle, so we began to investigate our physician pipeline, physician distribution, and concepts that could bridge this geographical divide between rural and urban North Carolina.

The committee concluded that primary care physicians should be supported throughout the pipeline [5]. Incentives should be targeted to doctors that choose to practice in rural areas. In fact, we should bolster programs like those at the Brody School of Medicine at East Carolina University or the Campbell University School of Osteopathic Medicine that make training primary care physicians a priority and succeed in placing them in rural North Carolina. Hospitals seeking to house medical residents should be free from federal government limits on residency programs established through the Balanced Budget Act of 1997, because 67% of physicians who complete medical school and their residency in North Carolina will practice in our state [6]. North Carolina should utilize its long-standing Area Health Education Center system to fund and support more residencies in rural North Carolina. The boldest idea to come out of the committee is rethinking our entire primary care system; we should pursue a direct primary care model where patients and doctors cut through the bureaucratic fee-for-service model of today's insurance system and focus on wellness through increased utilization and better management of chronic conditions.

The breadth of challenges that North Carolina faces surpasses these concepts. To those who believe we should embrace telemedicine in primary care, we agree, but say we are far from reaching many of our rural citizens due to our infant broadband infrastructure system.

We all count on primary care to be there when we get sick or have to take our kids to get an antibiotic, but our rural friends are facing a day when physicians live and practice in the far-away urban centers of North Carolina. Primary care should be accessible, affordable, and integral to our rural communities. It's going to take the realignment of our physician pipeline and the bold exploration of new ideas like telemedicine to get us there.

• ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.