A former grocery clerk, Tenorio's been scraping by on
disability benefits for more than a decade. The 60-year-old, and many of
her neighbors, are skeptical health care overhauls pending in Congress
will change much in
Colorado
's rural
San Juan
Valley
.
"I would tell Congress, they need to get out here to
Huerfano
County
and see how bad it is, see what we're living with," said Tenorio, who
suffered a neck injury in 1979 and hasn't worked since 1996.
In rural
America
, many like Tenorio are too poor to afford basic care. People who can
afford doctors often can't find them. The lack of health care in small
towns like Walsenburg is a problem Congress is just beginning to address.
Many folks in
Huerfano
County
, population 7,900, depend on a low-cost outreach clinic for care. There's
no eye doctor, no full-time dentist. The clinic relies on nurse
practitioners, midwives and medical assistants to provide basic exams, but
most sick patients are referred to a bigger town about 30 minutes away.
"I don't have any way to get up there to the doctor," said
Tenorio, who doesn't drive. "Sometimes I can't even get out of bed
because of the pain."
The 25 percent of Americans who live in rural areas are poorer, older,
fatter and sicker than their city neighbors. They live farther from
doctors and have a harder time getting to appointments, many depending on
neighbors or church volunteers if public transportation doesn't exist.
Small towns often lack specialists and rely on family physicians. But even
incentives such as covering student debt for new doctors haven't worked.
Many small towns look to nurse practitioners for general care or seek
foreign doctors using J-1 visa waivers.
According to the Washington, D.C.-based National Rural Health Association,
only about 10 percent of
U.S.
physicians practice in rural areas. The problem: Medical students know
they can make more money, and work shorter hours, in a specialty practice
in a city.
At
Spanish Peaks
Regional
Health
Center
in
Huerfano
County
, administrators have long offered loan forgiveness to entice doctors
fresh out of medical school, but have been unable to recruit a single
doctor.
"They just don't have a desire to come out here, the young
ones," said Bill Bolt, clinical manager at
Spanish Peaks
.
When small towns do find doctors, their patients are less likely to be
able to afford treatment. About 23 percent of residents in
U.S.
communities smaller than 2,500 people have no health insurance, compared
to 19 percent in urban areas, according to the NRHA.
Those covered by Medicare or Medicaid aren't always better off. Because
federal reimbursement rates are routinely tied to volume, rural doctors
are paid less for the same services and as a result sometimes won't treat
those patients.
"If I'm a young physician, I want most of my patients to have
insurance, maybe some of them on Medicare. I'm not even touching the
Medicaid," said Dr. David Zehring of La Veta,
Colo.
, a plastic surgeon who practiced in
Seattle
and retired to
Huerfano
County
.
The proposals in Congress do address some rural disparities.
A Senate bill would roughly double funding — an extra $1.1 billion by
2015 — for the National Health Service Corps, which pays student debt
for health providers in underserved areas. Bills pending in both the House
and Senate would address disparities in Medicaid and Medicare
reimbursement rates.
But some advocates say those measures aren't enough to crack the
urban-rural divide. And besides, Congress has yet to smooth disagreements
about an overhaul that aims to cover more than 46 million uninsured
Americans.
First, rural health advocates say, reforms must get doctors into rural
areas, then worry about insurance coverage.
"We keep hearing about universal coverage. From a rural perspective,
that solves nothing," said Lou Ann Wilroy, executive director of the
Colorado
Rural
Health
Center
in suburban
Denver
. "You can have an insurance card in your wallet, and that doesn't
mean you're going to have care."
One solution is to start before doctors are licensed.
Dr. Allen Perkins, president of the Alabama Rural Health Association, says
Congress must address medical education. Medical schools are typically in
cities, Perkins says, where they have access to advanced lab equipment and
specialists. Their students train in big-city hospitals, where young
doctors return to practice.
The result is a shortage of doctors who understand small-town medicine,
even if they're willing to take a pay cut to work there.
"If we want to change the lack of doctors in rural
America
, we've got to look at the pipeline of doctors coming in," said
Perkins, who is professor of family medicine at the University of South
Alabama College of Medicine in
Mobile
,
Ala.
The NRHA is pushing for any overhaul to include incentives for medical
schools to recruit rural students and encourage them to return to small
towns. "We really need to have a pipeline program to have people come
home and treat the people they grew up with," said Maggie Elehewany,
NRHA's vice president of government affairs.
In the interim, rural health providers say, Congress should dramatically
increase funding for low-cost clinics that provide basic health
screenings.
Sylvia Martinez, a 68-year-old breast cancer survivor living in
Walsenburg, said she doubts Congress will improve rural access in her
lifetime. But she's says she'll consider any movement a victory.
"I'm sick of hearing them say, 'Oh, it's not going to work.' We have
to start somewhere!"
Martinez
exclaimed, pounding the table at a senior lunch at the Walsenburg
community center.
"So what if it's not perfect? We need to do to do something. Out
here, we need to do something bad."
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