How should we fix rural healthcare? Reckon went to the front lines of the rural health crisis in the South, talking with young doctors who live and work in communities across the region. We asked them what they think are the biggest problems facing rural healthcare in the South, and how they’d fix those problems if they had unlimited resources. Read on for their real-world solutions.
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Dr. Nola Jean Ernest, Enterprise, Ala.
Nola Jean Ernest grew up one of 10 children in rural south Louisiana. She always knew she wanted a career in which she could take care of people. She eventually earned a medical degree and has been a pediatrician in south Alabama’s wiregrass region since 2012.
Most of her patients come from families that are considered poor, with incomes below 200% of the Federal Poverty Level. Most are from rural communities near Enterprise, a southeastern Alabama city of about 26,000.
Because her patients are children, most have health insurance, thanks to ALL Kids, a government-funded health insurance program that covers Alabama kids who don’t have private insurance or Medicaid.
But many of their parents do not. Alabama is one of 12 states that has not adopted Medicaid expansion, meaning most adults do not qualify for Medicaid, even if they are low-income.
“You might wonder why a pediatrician is interested in Medicaid coverage when nearly all children in Alabama have healthcare (insurance) coverage,” Ernest said. “The reason is that the healthcare of the parent impacts the health of the child.”
If a parent is chronically ill and unable to provide enough food or stable housing, or if a parent is incarcerated because of an untreated mental illness or substance use disorder, that can have lifelong consequences for a child, she said.
“I cannot (provide the best care for a child) unless their parents have access to care,” she said. “That’s one of the most frustrating things I do. I know these experiences are going to impact that child long term and lead to that cycle of poverty that people often refer to.”
A second major problem, she said, has to do with how doctors are reimbursed for their services by Medicaid. The state’s Medicaid reimbursement rate is usually lower than most private health insurance, she said. Because of that, many doctors can’t afford to set up practices in rural communities, where a large portion of the population is covered by Medicaid.
“In a rural community, you may have to travel one or two hours to see the physician, even for a common medical problem or preventative care,” she said. In Alabama, eight rural hospitals have closed in the last decade, a problem that the Alabama Hospital Association has linked to the state’s refusal to expand Medicaid.
“People have to drive quite a distance just to get to the hospital if they have an emergency,” Ernest said. “Whether or not you have insurance, if there’s no hospital nearby, it’s difficult to access care.”
Ernest wants to see Alabama expand Medicaid coverage like most other states have done, a position echoed by many of the state’s medical and nonprofit organizations.
“There is nothing more frustrating as a child advocate than to recognize the causes of long-term health and learning and behavior problems, and not be able to fix those,” she said. “Regardless of our political beliefs about Medicaid and parents and unemployment, we cannot continue to allow children to suffer poverty, food insecurity, lack of access to healthcare.”
People who can afford preventative and primary care are “less likely to utilize hospitals and urgent cares, and if they do, the hospitals are able to get reimbursed for that,” she said.
“The second thing that I would do with unlimited resources is to make sure people who have state-sponsored insurance plans like Medicaid receive the same type of healthcare that people with private insurance plans or Medicare receive.”
To do that, she said, “You have to make sure that doctors are reimbursed the same (amount of money) for the healthcare they provide to Medicaid recipients as they provide to those with private insurance plans.”
Raising the Medicaid reimbursement rate in line with private insurance plans would “absolutely” help bring more doctors into rural areas, she said.
“I tell parents that we like to pretend the different parts of our body are separate, but they all work together,” she said. “And the same thing is true in a community as well.”