Into the unknown: Rural health care in America often overlooked

Health care in rural America can be a challenge. If you need a more specialized service like mental health care or cancer treatment, be prepared to travel to find the right fit. Shortages in mental health care are on the rise in rural areas, and according to the Bipartisan Policy Center, more than 60% of non-metropolitan counties don’t have a psychiatrist and almost half of rural counties don’t have one at all.

BPC recently released a new report that provides a pathway to integrated primary care and behavioral health services in rural areas, giving patients easier access to care, improved health outcomes, and even cost savings.

Marilyn Serafini, executive director, health program at BPC, said one in seven people currently live in rural and frontier communities and increased rates of behavioral health conditions remain high in those areas. This includes things like anxiety, depression and suicide, in addition to substance abuse and overdoses.

“These rates are really troubling,” Serafini said. “But if you add to that the greater difficulties that rural Americans have in accessing care it’s an even bigger problem.”

Compounding the care shortage is the social stigma around receiving behavioral health services according to Serafini. By integrating behavioral health into already established primary care channels, patients can reduce the chance of their behavioral health falling through the cracks.

“Now, integrated care also improves patient health outcomes and is cost effective,” she said. “It allows for a dual response to both physical and behavioral health conditions.”

Tom Morris, associate administrator for rural health policy for the Health Resources and Services Administration, said it’s not a new topic and integration has been going on for quite some time. However, the lack of care emphasis has mostly been focused on urban and suburban areas, and taking a new look through a rural lens should be part of the larger policy discussion.

The real challenge, Morris said, is the actual integration.

“Can we do it successfully in rural communities in a way that really improves the experience of patients?” he said.

Rural communities have faced a healthcare workforce challenge for years, according to Morris.

“It’s harder to do the integration in rural communities if there’s no behavioral health providers to integrate services with,” he said. “What that means is that you’re either traveling greater distance for care for that behavioral health challenge or it’s going untreated. And neither of those is an ideal outcome.”

One plus that makes rural communities wonderful is the close-knit nature of how they’re set up. But by the same token it’s a downfall.

“It can also create sort of a consideration about whether people are concerned about seeking mental health services for fear of being stigmatized,” he said. “So it’s easy to talk about the value of integrated care and I can’t imagine that anyone doesn’t see the benefit but the challenge is, of course, making it happen.” 

Panel discussion

A virtual panel put together by BPC allowed listeners to learn more about the challenges in rural health care and how to deliver better care. Panelists included Dr. Matthew Duncan, MD, clinical director of integrated care, Dartmouth Hitchcock Medical Center; Dr. Octavio Martinez, MD, MPH, professor of psychiatry and behavioral services, University of Texas at Austin Dell Medical School; and Toniann Richard, chief executive officer, Health Care Collaborative of Rural Missouri. Julia Harris, associate director, Health Program, BPC moderated the panel.

“One of the unique things about rural America is really the rural economy,” Martinez said. “I think we should take that into consideration, especially because healthcare itself is also part of our economic fabric.”

Rural economies are resilient, but at times are very prone to significant factors that can impact families financially.

Richard said in rural communities, leaders are trying to figure out how to make things happen and how to get things started.

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“We know that in rural communities, we often have to get creative about how we serve people,” she said.

Allowing for different types of health care providers can be a huge first step, especially when there are special populations like those minority groups working in agriculture—migrants or VISA workers.

For Duncan in the clinical perspective, one of the biggest factors in rural America when it comes to health care is geography and distance, plus the time and resources that burdens patients. Some patients in rural parts of the country often wait for months to see a psychiatric provider—it could be a one-way trip of two hours or more for an hour-long visit.

“(There’s) time away from work, cost of transportation—because reliability of transportation is a huge factor,” he said. Another aspect Duncan believes gets magnified through the rural lens is when there is psychiatric illnesses occurring concurrently among family members, often living in the same households.

“I think that those familial and intergenerational factors, which are oftentimes very present in the rural population, just add to the intensity of some of the needs of our patients,” Duncan said.


Harris asked the panelists to shed some light on any trends they’re seeing and where there’s been any particular provider incentives that are impactful to maybe bringing more providers into rural areas.

The pandemic accelerated and expanded the need for more mental health services and substance use services by specialists like psychiatrists, but it’s definitely leaning on primary care providers.

Richard also believes mental health is becoming a really comfortable word.

“Ten years ago, we didn’t even say mental health. We didn’t talk about it. It was kind of hush-hush and now, the pandemic I definitely think brought that to the forefront of some conversations because it was so visible within our communities,” she said. “So we’re talking about it.”

People are having really hard conversations around things like generational depression, PTSD, even postpartum depression.

“I think the more that we can encourage mental health services to become mainstream in our conversations with our friends and our family, you will see some of that come to be important to our young people,” she said.

For more information or to read the report visit

Kylene Scott can be reached at 620-227-1804 or [email protected].