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Urban-rural health disparities should prompt state-level healthcare reform

BY DI EDITORIAL BOARD | JULY 21, 2011 7:20 AM

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Rural Iowans face greater increases in health-care costs than urban Iowans and are more likely to be uninsured.

On July 15, a study by the University of Iowa College of Public Health was released to the public. The report, titled "Iowans Speak Out on Their Health — the Rural-Urban Divide," addresses problems in Iowa's health-care and health-insurance systems. The report reveals that Iowans living in rural areas pay an increasingly larger amount for health-insurance premiums, deductibles, copayments, and out-of-pocket maximums. These results should prompt immediate responses from Iowa citizens and legislative members to act in their respective roles in order to accomplish state health-insurance reform.

The study, and others similar to it, suggest that insurance-market factors play a large role in the disparity; because we believe that health care is a right, not a privilege, Iowa should investigate a single-payer option to alleviate the market-generated inequity.

Last week's study was conducted by compiling years of health-care and health-insurance data, interviewing stakeholders, conducting focus-group studies, and employing two separate surveys: the 2010 Real Iowans Health Survey and the 2004-2010 Iowa Employer Benefits Study.

The first survey, composed of more than 1,600 registered Iowan voters, found that "significantly more rural employees (89 percent) reported having a primary-care doctor than urban employees (85 percent), and a higher portion of rural employees had seen their doctor in the last 12 months."

Given these findings, one would assume that the rural respondents were receiving better and/or cheaper health-care insurance. However, the opposite seems to have been found by data and the survey responses. "Nearly three-quarters of rural employees reported they paid increasing rates for health insurance … Only one in seven urban employees reported the same."

Combined with data and reports from the second survey, rural Iowans are paying more for all aspects of their health care — and it's a result of differences in insurance acquisition. The second survey found that, "Virtually all Iowa employers with more than 50 employees offer health-insurance coverage, compared with about 60 percent of organizations with two to nine employees [mostly in rural areas]."

Dr. James Merchant, a coauthor of the study report, told the DI Editorial Board that "the size of employers and distribution of employees affects health-care insurance rates. Due to more smaller employers being located in rural areas, their rates are significantly higher."

This disparity in access to affordable health care has been noted before. A 2009 NPR investigation found that many rural Iowans purchase high premiums with large deductibles, in part because they are forced to buy it individually because small businesses — which hire most people in rural areas — are unable to buy care for their employees.

The federal-level Patient Protection and Affordable Care Act may make health care more affordable through its system of subsidies and exchanges, but the individual mandate will do little to address the fundamental inequity between rural and urban insurance costs.

Luckily, Iowa can learn from other states' attempts to address the same problem. Vermont has a marked difference in access to care between mountainous, sparsely populated areas and more urban communities; in 2009, the Vermont Department of Health issued a plan for improving health care for rural populations.

Many of the plan's provisions focus on increased monitoring and efforts to improve access to care. Iowa doesn't have a similar problem with access — here, the problem is affordability, and the differences in cost between rural and urban areas. But Vermont's effort to improve health care focused on keeping expenditures in the local economy and also resulted this year in its becoming the first state to have a single-payer health-care system.

The difficulty of finding affordable insurance for rural Iowans, who are more frequently uninsured or underinsured, is a strong argument for at least exploring the possibility of single-payer health insurance. While the demon of "socialized medicine" still lingers after the entrenched battle over health-care reform, a single-payer system would go a long way toward evening Iowa's health-care inequity.

Whether Iowans support single-payer or not — we unequivocally do, although it's doubtful whether the Republican House and executive will agree — the data should prompt state efforts to concoct its own health-care reform, one suited for the specific needs of Iowa's population. Iowans, too, should demand greater equality in health-care costs; people forced to purchase individual insurance by sheer accident of birth or profession should not also be forced to pay more for their care.

Sadly, it is now considered radical to state that health care is a human right. But if we're given the rights to life and the pursuit of happiness, affordable access to that which sustains life should follow. Medical treatment shouldn't cost rural Iowans disproportionately more, and legislators should prioritize making health care affordable for all.


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