Health care options in rural Iowa disappearing

[Chelsea Lensing] There definitely are some real challenges at the absolute level. But then when you look more broadly at what Iowa is doing in comparison to the rest of the country, we're actually doing pretty well. So what we found at kind of the big picture level was that there's a lot of challenges that Iowa was facing, but we're holding up pretty well in comparison to kind of what everyone is facing in the country.

[Yeager] So we're not we're not unique, but there are challenges. And I'm going to guess the challenges are there's not enough access to care for everyone and maybe, urban areas, there are more opportunities than rural areas. Does that hold up?

[Lensing] Yes. Yeah, absolutely. One whole section of the report that we looked at was the differences between urban and rural communities. You know, and there's a whole bunch of ways that you can measure access to care. So there were three primary ones that we had looked at. We looked at primary care physician rates. We looked at facility openings and closures, and then we looked at more of an intensive margin of supply when you think of hospital beds and department closures. So that first one, the primary care physician rate, so that's adjusting for the number of primary care physicians for the number of people. Right? We would expect there to be more primary care physicians in the more populated areas because there's more people. But even once we adjust on a per capita basis, we see that there are significantly more providers in these urban areas. So if you split all of the counties in Iowa into urban and rural, which the USDA has definitions of what constitutes urban, rural, 77 of our counties are considered to be rural. And if you look at trends in the number of primary care providers between these two types of counties, over the last ten years, for urban counties, we've seen about a 1% decrease in  primary care physician rate. But for the rural counties, we've seen about an 8% decrease in primary care providers. Again, this is already adjusted on a population basis. So we're seeing a much larger decrease in the rural counties. But even further than that, counties are not just urban or rural, even within the rural counties. We have 22 of those 77 counties have 100% of the population living in a rural area. So if you take those more extremely rural counties and you compare them to the counties that have, say, fewer than 20% of the population living in a rural county, there's about double the amount of care - primary care providers in those urban counties than what we see in the more extreme rural counties. So there's a really big divergence when we are looking at primary care physicians as a measure of access to health care. The higher the percentage of individuals you have that live in a rural area in a county, the lower the options are for care.

[Yeager] Is there a theme in Iowa about mental health care, rural versus urban, or does it even matter? We just have issues. 

[Lensing] Yeah. So the two ways that we were looking primarily at mental health access in Iowa is through the number of facilities and then through the number of providers. And so we'll start with facilities. And we looked at facilities that were overseen by the Iowa Department of Health and Human Services. And so it doesn't include all facilities, but it includes a lot of mental health care facilities, such as, community mental health, more like long term or rehabilitation, mental health and those types of facilities. We've seen a significant increase in the number of closures and hardly any openings over the last ten years. And so these dedicated mental health centers are closing at a concerning rate. And so that's one area in which we see a big decrease in supply for mental health. But at the same time, we're seeing an increase in the total number of mental health care providers on a per capita rate. So, for example, even in rural counties over the last ten or so years, since 2015, the number of mental health care providers per capita has doubled. And so even though it's still only about half of what we see in the urban counties, there's still a big gap between urban and rural counties. We're making a lot of progress. But again, it kind of stands in the face of all of these closures of these specific mental health care facilities. And so it really depends on the type of mental health care that individuals are seeking. and where exactly those centers are. 

[Yeager] Back to the money, always back to the money. any economics, tied to mental health and what that does to an economy. Do we know anything in those fields? 

[Lensing] Yeah, yeah. And there's a lot of evidence from an economic perspective that ties together when we're having an economic downturn. So when we're having higher unemployment, things like that, we tend to see higher rates of deaths of despair, which are also, you know, related to the mental health of, of individuals. Deaths of despair can include, you know, things like suicide, but also excess alcohol consumption, opioid or other drug consumption.  Premature death rates was something we did identify in the rural section, focus of the paper because not only are we seeing an increase in premature death across the state, it’s substationally higher for our rural communities. The absolute rates are higher and the increase  is higher for these rural counties. So even if you are just measuring our economy with the unemployment rate, that might not be telling the whole story. Right. And something else is going on here with our rates of premature death. And ag ain, we don't have the data to parse out how much of that is due to mental health, but I think it's all extremely related, right? How individuals are feeling, how they're dealing with the economy, how they're dealing with family life. 

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Contact: Paul.Yeager@Iowapbs.org