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Rural Areas Are Not Just Small Urban Enclaves
"Some populations of American children are receiving greater attention in our outreach efforts due to higher rates of poverty and lower rates of insurance, specific barriers that make mainstream outreach efforts less effective, and disenfranchisement from the health care system in general. Rural and frontier populations are often left out of conversations of specially targeted populations. rural children are more likely to be uninsured than their urban counter part--21% of rural children are without insurance, versus 14% of children in urban areas."
"Rural areas are not just small
urban enclaves in which mainstream outreach efforts can be
ownsized and effectively implemented without translation.
The rural context, while containing
some of the same elements as the urban context, is
different and warrants focused attention.
While rural areas are extremely diverse, there are
some generalizations that can be made about
rural demographics and infrastructure that help to
place outreach in rural areas in the
appropriate context."
"Rural areas have higher rates of
poverty than urban areas. In 1997, non-metro counties had a
15.9% poverty rate compared to 12.6% for metro counties.
This higher rate of poverty can
partially be attributed to a higher reliance on minimum
wage jobs and service sector
employment in rural areas."
"While rural economies are no longer
exclusively dependent on farming, rural areas still have a
higher percentage of small business economies than
urban areas. Low wages and smaller
business size in rural areas also mean that rural
residents have lower rates of employer
sponsored health insurance coverage. 51.7% of rural
employees are covered by employer
health plans compared to 60.4% coverage in urban
areas. Lower rates of employee sponsored
insurance contributes greatly to the lower rate of
insurance for rural children. Therefore,
partnering with small rural businesses may prove
an effective outreach strategy."
"The characteristics of rural communities
also may suggest subtle differences in outreach
strategies. For example, rural welfare recipients
are more likely to be employed and married than
urban recipients. Rural communities are smaller communities
in which residents are more
familiar with each other than in urban areas. This
familiarity is often coupled with a distrust of
outsiders and newcomers. Many rural communities also
have strong religious values and have
strong connections with their local churches. Rural
areas also have a large elderly population.
These respected elders provide much of the childcare
in rural areas, and may serve as a special
target for rural outreach."
Enrolling Rural Children for Health Insurance
"It is this rural context that outreach
efforts need to focus on reaching rural children. A United
States General Accounting Office report in March
1998 discussed general reasons why
children may not be enrolled in Medicaid or CHIP.
The working poor may not realize they are
eligible. The delinking of Medicaid and cash assistance
also has created confusion for families
and service providers. Outreach efforts will also
have to deal with cultural misunderstanding,
language barriers, and the negative perception of
dependency. Efforts will also have to be
made to simplify and explain the cumbersome enrollment
process and health system."
"These factors, compounded by sparse
rural populations and less health infrastructure,
suggest that outreach efforts in rural areas may
require more effort, more time, and a higher
initial investment. While it is too early in the
CHIP implementation process for a complete
evaluation of rural outreach efforts, there are lessons
that can be learned from 'rural' states that
have had some success in reaching children. We also
can learn from efforts in Medicaid
outreach that proceeded CHIP. There are also lessons
from CHIP outreach success stories in
rural communities."
"In Balsam Lake, Wisconsin, ABC
for Health Inc. developed an outreach model that has been
successful in increasing Medicaid enrollment. Since
1988, the project has used family health
benefit counselors at local health departments to
assist clients in enrolling in public assistance
on a family-by-family basis. In 1998, the project
began to focus on children's health insurance
programs, and has since expanded to 17 counties in
northwestern Wisconsin. The counties
share information on available programs, rules, and
regulations. These counselors do not just
enroll children; they also review applications, assist
clients when they have been denied
coverage, and provide guidance for hearings and appeals.
Public health nurses refer families to
the counselors, and a small team of public interest
lawyers and law students provides technical
assistance to the counselors and families."
"The program's success is linked
to the dedication of resources by health clinics and health
departments. Health clinics have found that the program
is only beneficial when they can
dedicate enough staff support to the effort. After
eighteen months, one clinic found a 46%
increase in third-party payment. Project Director
Michael Rust says 'the clinic administrators
told us that we gave them a new outlook on working
with the community.' They said 'We'll do
anything we can because we discovered it's to the
family's benefit and it's to the clinic's
financial benefit.' "
"Rural communities often have few
choices when it comes to primary care providers. For the
enrollment of children in CHIP and Medicaid to lead
to improved health outcomes, the health
professionals that currently reside in rural areas
will need to participate. With many states
turning to managed care as a way of increasing eligibility,
it is important that these managed
care programs include rural providers. It will not
help a child to be insured if the only doctor
that can treat him or her is 50 miles away."
"Rural families will also need help
accessing the health care system. Basic assumptions made
by the health care system may not be true in some
rural areas. For example, some poor rural
families do not have phones. Transportation problems
in rural areas are severe because of a
lack of public transportation and farther distances
to travel to get to a medical facility. Training
outreach workers in rural communities that can help
families enroll children in programs, and
then work with families to help them access the system,
can help to alleviate some of these
problems."
"Although a strong case can be made
for the need to focus on rural communities, the rural
context is not completely unique and distinct from
the urban setting. To the contrary, the
similarities between the two settings are striking
and a lot will be gained by sharing experiences
between both settings. Rural areas and urban areas
face many of the same problems, but many
times rural communities experience these problems
in different degrees or with a different
spin."
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