Introduction
The United States has a unique health landscape where healthcare spending accounts for 19.7% of the nation’s Gross Domestic Product, but this high spending does not equate to improved outcomes, quality, or access, especially in rural parts of the country. One of the most common sources of medical services is from primary care physicians, but in a rural county or state, there is often a stark disparity not only in the amount of primary care physicians available, but also in the number of hospitals that populate these areas. Due to the lack of PCPs in a rural area, many residents would visit their local emergency department, creating a large influx of people using these services, often for non-emergency situations.
In a response to this culmination of a lack of primary care physicians, an influx of ED patients, as well as over 400 rural hospital closures in the early 1990s, Congress created the Critical Access Hospital designation in an effort to improve healthcare for these at risk rural communities. A Critical Access Hospital is often located in a rural county as the facility must have 25 inpatient beds or less, be located more than 35 miles from another hospital, and provide 24/7 emergency care services. Indiana has 35 of these Critical Access Hospitals. However, when looking at how many rural counties there are in Indiana, there are 42 rural counties, but only 35 hospitals; creating another disparity in the rural healthcare landscape, such that was seen with primary care physicians. Investigating how the presence of these hospitals impacts the mortality rates of their counties is one aspect of my study.
Another important aspect of my study is looking at how unemployment rates affect mortality rates, because ever since the end of World War II, employers have offered health insurance to employees as an incentive to come and work for them. This has become a staple in the United States now, with employment being connected to health insurance, which in turn is then connected to access medical services and receiving treatment. Poverty and unemployment often go together, and those living in rural areas are often victims of poverty, with rates increasing more than ever. Past studies have found there to be direct relationships between unemployment and mortality, where if one increases, then the other will increases. This study also concluded that the effects are not immediate and would need to be studied over longer period of times in larger groups to determine any effects between the two.
Research Question
Looking at the combination of research of rural counties, access to healthcare, Critical Access Hospitals, mortality rates, and unemployment rates led me to asking my research question:
Do Critical Access Hospitals affect mortality rates in rural Indiana counties?
From this, I came up with two hypotheses that I would look at while finding an answer to my question. My first hypothesis was that counties with a Critical Access Hospital will have lower mortality rates than counties that do not have one of these facilities. The second hypothesis was that rural Indiana counties that have high average annual unemployment rates with also experience high mortality rates.
Data Methods
Using data collected from the CDC, I looked at both crude and age-adjusted mortality rates for all 92 Indiana counties over the course of 20 years, from 1999-2019. Crude rates account for all deaths in a population whereas age-adjusted mortality rates are used more often by the CDC for comparative metrics.
In the above graphs, we see the differences in the county’s crude vs age-adjusted mortality rate, with numerous outliers and high mortality rates being include in the crude rate, whereas the age-adjusted has now become much more condensed. A very similar effect is seen when looking at the mortality rates of counties with Critical Access Hospitals, as well as looking at unemployment rates vs mortality rates for all Indiana counties, as seen in the figures below.
Results
When looking at the results and determining what impact a Critical Access Hospital had on a county’s mortality rates, it was found that when a county had a CAH, that county’s crude mortality rate would be 18.4 per 100,000 deaths higher than a county without a CAH, so it appears that having the hospital in the county led to more deaths…
However, when a county had a CAH, that county’s age-adjusted mortality rate would be -0.0771 per 100,000 deaths lower than a county without a CAH; almost no change! And, to add to this, these results are not statistically significant to solely attribute the presence of a hospital to an increased or decreased death rate. Thus, my first hypothesis was not supported.
When looking at the results and determining what impact unemployment rate had on a county’s mortality rates, it was found that an increase in a county’s unemployment rate would see a -1.221 per 100,000 deaths decrease in their crude mortality rate. So it would appear that being unemployed leads to you living longer, and that working seems to kill you…?
Additionally, when a county sees an increase in their unemployment rate, they see a -2.366 per 100,000 deaths decrease in their age-adjusted mortality rate. However, again, these results are not statistically significant to solely attribute increases or decreases to the relationship between unemployment and mortality. Thus, my second hypothesis was also not supported.
Implications
From all of these results and the data analysis, a few conclusions can be made about rural healthcare, Critical Access Hospitals, mortality rates, and unemployment rates in the United States.
Critical Access Hospitals are still important, as it seems that the locations of the facilities are not random but are rather strategically placed in rural areas where there is a greater need for healthcare. Additionally, they do more than just inpatient and outpatient services and can serve as community health centers that provide preventive screenings, education and training, attract other providers and patients to the area and much more. In turn, they do affect mortality rates more than just by treating patients with medical services or surgeries.
Despite all of the benefits that a CAH provides, rural healthcare is still behind even based off of the map of rural counties and hospitals seen in Indiana. Some hospitals are standalone when the current trend has been to join a network to take advantage of economies of scale, improved quality, and evidence-based medicine.
It appears that working may lead to a higher risk of dying, where being unemployed leads to a slightly decreased risk of dying and lower mortality rates, however some of those deaths from the crude mortality rates are from the Medicare 65+ population who may be retired and do not count towards the unemployment rate. This is an odd dynamic because of the pairing of unemployment and lack of health insurance with access to medical services. This may be because Critical Access Hospitals are doing more and providing free services, again affecting mortality rates in more than one way.
Nicholas Stevens is a senior at the Indiana University O’Neill School of Public and Environmental Affairs studying Healthcare Management & Policy.
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