Integrated Primary Care in Rural America Is Urgently Needed

Authors: Jeff Brown, Elizabeth Lerner Papautsky, & Emily S. Patterson (Jeff Brown & Emily S. Patterson are guest authors)

Caleb is a 26-year-old living in rural United States. He was diagnosed with schizophrenia as a teen, is unable to hold down a job, and is often in need of a place to stay. Although Caleb has Medicaid coverage, it pays little for the services he desperately needs. Thus, he lacks access to health and social services to help manage his illness and to keep a job and a place to live. The medications he is prescribed cause dental decay, weight gain, and diabetes. Pain from abscessed teeth has periodically landed Caleb in the emergency department at the nearest Critical Access Hospital. Medicaid pays for a couple of tooth extractions a year, but little for preventative care. Caleb has been denied coverage for dentures, twice. He drinks heavily and has developed heart disease and kidney failure. Caleb is in urgent need of tailored and continued support—his mental and physical health are in significant decline. It hurts to even move. Caleb has lost hope that he can ever get right.

Caleb’s story is not unique. It is an amalgam of stories of normalized harm shared by primary care and social services professionals during a study of health disparities in Washington County, Maine as the COVID-19 pandemic deepened in 2020, carried out by a multi-disciplinary team that includes social and behavioral scientists. It speaks to the damage to individuals and communities of disjointed treatment under a transactional health care financial model that has cost control as its foremost concern, not a focus on the coordinated care and well-being of the whole person.

Washington County exemplifies the inequity that comes with a rural zip code in the United States. It is remote, with large tracts of unorganized territory, and its population of 32,000 consistently has the worst health rankings in the state, and a poverty rate of 19.6% as of 2019, well above the rest of Maine (11.1%) and the U.S. (10.5%). There is no large hospital system with direct accountability for providing health services in the county, where there are two standalone Critical Access Hospitals. One of these hospitals is in bankruptcy and hopes to sell its assets to the other. The combination of a small, low-income population and facilities whose survival hinges on fee for service not only jeopardizes the continuation of rural hospitals, but primary care services of all stripes—medical, behavioral, dental, social services and more. Federally Qualified Health Centers, Tribal Health Centers, Rural Health Clinics, Behavioral Health Clinics, and myriad community groups wage a daily crusade to care for members of their communities, working around the systemic dysfunction wrought by the business model of health care. And the compassionate, ever-dwindling rural health care workforce is burning out.

The recently released National Academy of Science, Engineering and Medicine (NASEM) Consensus Study Report (Implementing High-Quality Primary Care | National Academies) makes five recommendations for immediate action to counter the grotesque health inequity by making primary care available to all residents of the United States—whether in rural or urban settings. These are quoted below:

1. “Pay for primary care teams to care for people, not doctors to deliver services.”
2. “Ensure that high-quality primary care is available to every individual and family in every community.”
3. “Train primary care teams where people live and work.”
4. “Design information technology that serves the patient, family, and the interprofessional care team.”
5. “Ensure that high-quality primary care is implemented in the United States.”

These recommendations are strikingly consistent with the recommendations of patients, providers, and community groups in Washington County, Maine, and the NASEM study’s statement that “primary care is a common good” resonates strongly with the perspective of study participants. The five actions to achieve high quality, equitable primary care are much-needed and reasonable solutions to alleviating the preventable suffering caused by the misguided application of a business mentality to a fundamental human right—and to inform the design of a health care system that accounts for the health and welfare of its biggest stakeholders: all of us. States have the opportunity to support the implementation of NASEM recommendations by using the American Rescue Plan (ARP) funds to begin correcting these injustices in rural and other vulnerable, marginalized communities. Our rural health care professionals and the people they serve need our support to make this happen.

We strongly encourage everyone to use their voice and platform to learn more and pursue these recommendations. One action to take today is to call your Senate and congressional representatives and tell them that infrastructure funds for mental health and prevention and treatment of substance use disorder can be directed to these priorities to invest in primary care, particularly in rural communities.