1 The Challenge of Nebraska Health Peg Bottjen, MPA, MT(ASCP)SC Issues for Rural Health Practitioners

2 Challenge of Nebraska Health  Definition of “rural”  Who?  What?  Where?  How?  Why?

3 Definitions of Rural  Own?  Census Bureau  US Office of Management and Budget (OMB)  DHHS  Other

4 Census Bureau  Urban  Urbanized Area - Continuously built up area with a population of 50,000 or more  Urban Place - Incorporated place outside a UA of 2,500 or more  Census Designated Place – A densely settled population center of at least 2,500 people with a name and community identity and is not incorporated

5 Census Bureau  Rural – All other territories that are not urban  Farm – People living in rural areas of one acre of land or more and where $1000 or more of agricultural products were sold in last year.  Non-farm – all other people

6 US Office of Management and Budget  Metropolitan Area (MA) – by counties  One city of 50,000 people or more  CB defined urbanized area of 50,000 and a total of metropolitan area of 100,000  Counties adjacent to MA if 50% of population is included in MA or works there  Non-metropolitan – all other counties

7 US Dept. Health & Human Services  Frontier Counties – Six or fewer people per square mile.

8 Other Federal Definitions of Rural  Housing and Urban Development  Open country, not part of a city  US Adm. On Aging  Use modified census definition of rural Why is this a problem?

9 Many Definitions of Rural  Consequences  Federal funds are being allocated based on rural or urban status  Definitions used to determine health personal shortages  Research becomes inconsistent  Health policy analysis and development is affected

10 Who?  How many people live in Nebraska? a. approx. 500,000 b. approx. 1 million c. over 1.5 million d. over 2 million

11 1,758,787 Nebraskans in % live inDakota, Washington, Douglas, Sarpy, Cass, and Lancaster counties

12 Aging Population % increase 0 – 64 years old 1,409,0001,525, years old 228,000405,

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14  Race /Ethnic Origin 2004 White non-Hispanic83.8% White Hispanic6.9% Black4.3% American Indian0.9% Asian1.5% Other or 2 or more2.6%

15 Projected Increase in Population by Race/Ethnicity

16 Economic Profile Median Household Income 2004 (estimated) NE avg.$48,409 Range$33,600 (Loup Co.) $64,800 (Sarpy Co.)

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18 Poverty  Poverty is related to:  Indicators of health status  Health care access and use  Health related behaviors  Economic well-being greatly influences health and health care needs.

19 Economic Profile  Poverty NE10.6% US11.9% Range 23.0% (Thurston Co) to 3.8% (Sarpy Co.) Family SizePoverty Guideline 1$8,590 2$11,610 3$14,630 4$17,650

20 What is the health status?  General Health Status  US 83.4%excellent or good  NE 87.6% excellent or good  Non-metropolitan86%  Metropolitan91%

21 Health Status  Leading cause of death in Nebraska in Heart disease25.5% 2. Cancer22.3% 3. Cerebrovascular disease 4. Accidents (leading cause for < 45 year olds) 5. Chronic lung disease 6. Alzheimer’s

22 Rural vs Urban in U.S. RuralUrban  Heart Disease   Pulmonary Disease (men)   Accidents   Smoking, adults & young   No Mammograms (NE)  Health, United States, 2001 Urban and Rural Health Chartbook, HHS

23 Rural vs Urban in U.S. (cont.) RuralUrban  Alcohol consumption (men)   Obesity (women)   Total tooth loss   No exercise   Suicide   Homicide  Health, United States, 2001 Urban and Rural Health Chartbook, HHS

24 Rural vs Urban in U.S. (cont.) RuralUrban  Adolescents giving birth   Infant mortality   Child/Young adult mortality   Adult men mortality   High AIDS risk (NE)  Health, United States, 2001 Urban and Rural Health Chartbook, HHS

25 Health Status  Other health risksNEUS  Seatbelts68.6%76.6%  Binge Drinking17.6%14.9%  Current Smoker20.2%20.8%  No Exercise21.5%22.8%  BMI >3023.2%22.1%  Cholesterol tested69.0%72.8%

26 Where are the Health Resources?  Health Professionals  Physicians  Allied Health  Nursing  Mental  Dental  Health Facilities  CAH  Health Systems  Nursing Homes  Rural Health Clinics

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29 Federally Designated MUAs, NE

30 Active Physicians to Population Ratio, NE 30

31 Allied Health Shortages  Physician Assistant – Equal Numbers  Metropolitan (.19/1,000)  Non-metropolitan (.18/1,000)  Nursing Shortages 11-15% vacancy rate in NE  Pharmacy Shortage 21% in US  Dental Hygienists – 200 openings in NE

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34 Mental Health HPSAs, NE

35 Health Facilities  Critical Access Hospitals  Mental Health Facilities  Long Term Care  Rural Health Clinics

36 Hospitals in Nebraska                   Non-critical access hospitals Critical Access hospitals 

37 Nursing Homes in Nebraska

38 Long-term Care Beds to Population Age 65 and Over, NE

39 State Designated Shortage Areas for Rural Health Clinics, NE 2005

40 Insurance Status by Type, NE & US

41 Why does rural health care need special consideration? Cost Quality Access

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43 Access - Reasons why people were unable to obtain care. Urban Rural  Couldn’t afford48%52%  No insurance17%15%  Waiting Time12%9%  Insurance6%4%  Don’t know where to go4%4%  Inconvenient2%4%  Other11%13% NCHS, 1994

44 Quality  Right to expect local health care to meet certain basic standards.  3rd party payers want proof of quality.  Medicare asks for formalized plan of Quality Assurance.

45 Summary  Definition of rural  Who are we?  What is health status?  Where are health resources?  How do we pay for health care?  Why is this important?