HHS' annual snapshot of the nation's health paints a grim picture of the care provided to inner-city and rural residents compared with that given to suburbanites.
The report, issued last month, also notes a sharp drop in home health visits to those age 65 or older since the passage of the Balanced Budget Act of 1997.
"Access to care (in rural areas) has been one of our largest concerns, along with quality of care and hiring staff," says Alan Morgan, Washington-based vice president of governmental affairs and policy for the National Rural Health Association, Kansas City, Mo.
Although the report underlines calls by rural advocates for payment increases, Morgan says, the reality of lobbying Congress after the Sept. 11 terrorist attacks has changed the strategy.
"I certainly expect that Congress will still address the rural disparities in healthcare in some form this year. To what extent they do is another issue," Morgan says. "Certainly, on the regulatory front, there's much that can be done."
The association provided its ideas in a four-page letter to HHS Secretary Tommy Thompson and an HHS task force that will review all 12 of the agency's divisions to find ways to better serve rural areas. The letter urges the elimination of urban and rural designations in both Medicare and Medicaid payments, changes in the hospital wage index that would increase payments to rural providers and an increase in rural residency positions. The letter also calls for more money to widen access to eye, oral and podiatric health services in rural areas.
According to the HHS report, residents under age 65 of counties bordering large metropolitan counties, otherwise known as fringe metro counties, were the most likely to have private insurance, at 80.2%. By comparison, 65.9% of residents of large metro counties and 66.4% of residents of the "most rural" counties had private insurance. The most rural counties are those that lack a city with a population of 10,000 or more.
Overall, 71.2% of the under-65 population had private insurance in 1998, and 17% of the under-65 population had neither public nor private insurance in 1999, the latest years, respectively, for which those figures are available.
Fringe metro counties also posted the lowest mortality rates for infants, children and young adults (ages 1 to 24) and working-age adults (ages 25 to 64) and had the lowest teen birth rate. Based on self-reported surveys, adults in the suburban regions were the least likely to smoke, the least likely to be obese and the least likely to be physically inactive.
In a written statement, Thompson said the report can help public officials determine "where the most rural and urban communities can target public health efforts to close the gaps" with the wealthier suburban regions.
As for home healthcare, in 1996, 547 out of 10,000 elderly people received such services, but the rate fell to 381 per 10,000 elderly by 1998, a drop of 30.3%. The decline in use was a direct result of the budget-cutting interim home health payment system in use for Medicare from October 1997 to October 2000, the report said.
The figures surprised no one in the home health business, because the report covers a period marked by sharp Medicare cuts under the interim system, says Julie Phillips, communications director of the American Association for Homecare.
The report's findings should bolster the case the trade group has been making in Congress to repeal a 15% cut in Medicare home health reimbursements scheduled to take effect Oct. 1, 2002, Phillips says. "Of course, everyone is not necessarily focused on healthcare and Medicare right now, but we're going to try," she says. "It's really too soon to say." She adds that about 60 members of the House of Representatives have signed on in support of a repeal bill.
The report also reinforced some longstanding trends in how care is being delivered. In 1999, 62% of surgeries were performed on outpatients, up from 35% in 1990 and 16% in 1980. The hospital discharge rate-the number of hospital discharges per 1,000 population-declined by 22% from 1985 to 1999, and the average length of stay fell to five days from 6.6 days during that period, according to the report.