Intended for healthcare professionals

Feature Rural healthcare

What healthcare reform means for rural America

BMJ 2013; 347 doi: (Published 27 August 2013) Cite this as: BMJ 2013;347:f5093
  1. Bob Roehr, journalist
  1. 1Washington, DC
  1. BobRoehr{at}

The implications of the Affordable Care Act are very different beyond the cities, where much of it was devised. Bob Roehr investigates

All healthcare is local, to adapt a phrase made famous by the late speaker of the House of Representatives, Tip O’Neill. The local character of healthcare has become even more apparent under reforms prompted by the Affordable Care Act (ACA), particularly in rural America, where political and ideological perspectives are often not sympathetic to an expanded role for government, as envisioned in that legislation.

The problems of rural healthcare are not just a scaled down version of those seen in urban and suburban areas, says Tom Morris, associate administrator for rural health policy at the US Department of Health and Human Services. In rural areas, people are more likely to be on a low income and uninsured; they are also less likely to have employer sponsored insurance coverage.

These people also tend to be older, sicker, and have less access to specialized care. They are more dependent on federal programs and would be even more dependent if they knew they were eligible for those programs and enrolled in them.

Providers in rural areas also tend to operate on smaller profit margins, largely because of the types of services they provide—basic healthcare rather than more profitable specialized care. Patient density is insufficient to support expensive technologies and specialized skills. Healthcare reform will have to be tailored to local conditions in rural areas.

The political framework

The political environment poses challenges to expanding healthcare coverage in rural areas. This is partly because of the stigma that some attach to such programs. The belief is that they are “a handout . . . making people dependent,” says Art Kaufman, vice chancellor for community health at the University of New Mexico.

In his state, “30% …

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