With covid-19 raging through many rural areas and health-care systems, it’s easy to not notice that another killer has been silently growing in deadliness there: chronic diseases of the heart and lungs.
As for chronic lung disease, the fourth most common cause of death in the United States, we found in a more recent study that rural Americans had a 61 percent higher chance of dying from the disease than Americans living in large metropolitan areas. The greatest increases in deaths were among middle-aged Whites.
Preexisting heart and lung disease are two of the most potent risk factors for suffering a severe case of covid-19, requiring a ventilator or leading to death.
The rising toll of chronic disease in rural America is not a failure of medical technology — it is a failure of social and economic policy that makes it difficult for many people to access quality health care.
Being able to afford and easily get to doctors, clinics and hospitals may be more critical for patients with chronic disease than any other group: Studies have shown that having insurance is associated with fewer deaths in people with heart disease, diabetes and hypertension, but no such reduction is seen for people who don’t have these conditions.
The greatest toll of chronic disease is seen in Southern states. Unfortunately, the states of that region almost uniformly rejected the Medicaid expansion offered in the Affordable Care Act, which was adopted in 2010.
Expanding that program could be the most effective short-term means to provide access to appropriate medical care for many rural Americans. Medicaid expansion also presents a lifeline to struggling rural hospitals. According to news accounts, 73 percent of rural hospital closures have occurred in states that didn’t expand Medicaid.
But Medicaid expansion is no panacea, given the damage to rural health care that has already occurred.
Rural hospital closures grab all the headlines and perhaps rightfully so. From 2010 until today, some 134 rural hospitals have closed, and a report released last spring, before the pandemic had hit many rural areas, showed a quarter of surviving rural hospitals in dire financial straits. Cancellation of routine medical care necessitated by the novel coronavirus, which causes covid-19, has pushed more hospitals off the cliff.
Yet, building more brick-and-mortar hospitals might do little to ease heart disease’s tightening vice. Heart and lung disease often evolve slowly over decades before becoming serious conditions. The factors that lead them to slowly worsen — smoking, high blood pressure and cholesterol, diabetes, obesity and a sedentary lifestyle — are all more common in rural America. By the time people go to the hospital after a heart attack or a flare up of their chronic obstructive pulmonary disease, it is often too late. As health professionals who deal with many patients with these chronic and debilitating conditions, it is clear that the focus must shift to providing higher-quality upstream preventive care in the outpatient setting.
Improving chronic disease management in rural areas will be impossible without addressing the serious physician shortage that these areas face. But relying on physicians alone cannot meet in time the stark needs of remote areas to reverse these disturbing trends. Overcoming chronic disease in rural areas will require an all-hands-on-deck approach involving every member of the health-care ecosystem.
Pharmacists, for example, can have a sizable impact on health by assuring that people have access to the many effective preventive treatments. Pharmacist-led management of high blood pressure has been shown to be successful. Studies have found that nurse practitioners and physician assistants, with appropriate physician supervision, can manage patients with stable heart disease.
Community health workers have been shown to be particularly effective in reducing people’s risk of heart disease by helping make their lifestyles healthier while providing critically needed jobs in rural areas.
Health-care workers who can provide high-quality outpatient care cannot turn the tide of chronic disease in isolation, however. They need to work with efficient emergency services that manage acute conditions and swiftly refer higher acuity patients to larger hospitals. Rural care should be regionalized, as advocated by the American Heart Association and the American Stroke Association in a recent call to action.
To survive, rural medicine care might need a metamorphosis. The backbone of a regionalized rural health system will be telemedicine. But telemedicine will have a limited impact if it is not accompanied by the widespread provision of broadband Internet to allow access for people living in rural areas. Furthermore, any growth in telemedicine should be coupled with an effort to encourage large health systems to get qualified workers in rural areas, rather than concentrating in urban centers.
Immigrant physicians have been more likely to work in rural areas; making immigration by doctors as seamless as possible seems a no-brainer as we look to improve rural health care. The same goes with rewarding U.S.-trained physicians who practice in areas of need by wiping away some of the their medical loans.
In addition, changing payment models to focus on improved health and clinical outcomes for the population served, rather than high volumes of procedures performed, would be an important step toward improving care.
Covid-19 could land a fatal blow on patients and health-care systems already dealing with chronic heart and lung diseases. Rural Americans have been struggling for many years, and their poor health also has widespread economic and political fallout that needs to be address urgently.
Haider Warraich is a cardiologist at VA Boston Healthcare System, Brigham and Women’s Hospital and Harvard Medical School. Robert Califf, a cardiologist, is the head of Medical Strategy and Policy at Verily Life Sciences, and a former commissioner of the Food and Drug Administration. Sarah Cross is a social worker with extensive experience in palliative care, and a PhD candidate at the Sanford School of Public Policy at Duke University.