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Rural Health: A New Opportunity for Behavioral Health

February 18, 2021

Despite increased emphasis recently on behavioral health care, rural residents in America still face numerous challenges to getting mental health and substance use disorder (SUD) treatment.

These services aren’t as available in rural communities as in cities. And the full continuum of services—from inpatient care to peer support--may not be offered at all. Rural first responders, often police officers, and hospital emergency room staff may have limited experience providing overdose care or lack the capacity to handle an influx of cases. As a result, individuals experiencing a behavioral health crisis can end up in jail rather than in treatment. In addition, stigma looms as a barrier since privacy is minimal, and people worry about the spread of their personal business through town.

Aggravating matters, rural regions today face a compounding challenge. Before the COVID-19 pandemic, the lack of behavioral health capacity meant the opioid crisis particularly harmed rural regions, whose death rate surpassed that of cities in 2015. Now COVID-19 is overwhelming rural healthcare systems. The share of all COVID-19 cases in nonmetro areas grew from 3.6 percent on April 1 to 15.6 percent on December 7. And opioid deaths are on the rise again. Lack of culturally appropriate behavioral health care presents yet another obstacle. Though the majority of rural residents are non-Hispanic white people, populations are changing, and racial/ethnic minorities accounted for 83% of rural population growth between 2000 and 2010.

Investments in Resilience

But ever so slowly, the pandemic is boosting efforts to roll out improvements in the rural health landscape, especially for behavioral health. The Coronavirus Aid, Relief, and Economic Security (CARES) Act includes money for rural providers and rural hospitals. The legislation can help focus attention on the health of rural populations and address not only new issues such as COVID-19, but also the behavioral health challenges that have existed for decades.

The pandemic has increased access to and use of virtual care, which may provide an unintended benefit for rural behavioral health treatment. It increases the number of behavioral health and medical providers who can meet with patients and clients on the phone or via videoconference, enabling people to see specialists without having to drive long distances.

Congress has approved nearly $1 billion in investments in telehealth since March 2020. To improve connectivity, agencies including the Department of Health and Human Services (HHS) and Federal Communications Commission have funding to improve the healthcare communication infrastructure and expand rural services. HHS also extended telemedicine waivers put in place during the COVID-19 public health emergency. The waivers enable providers to use apps such as FaceTime to meet with patients, bringing critical flexibility and virtual care access to millions of Americans. The waivers have effectively become permanent.

The Biden administration is expected to continue to expand access to behavioral health care in rural communities. Agriculture Secretary nominee Tom Vilsack has a particular interest in opioids, substance misuse, and behavioral health broadly. He is expected to support increased service delivery and access in rural and frontier communities. For Vilsak, the issue is both professional and personal. He was a small town mayor in Iowa and served two terms as governor, so he is a champion of rural America. And he is the son of a parent who had alcohol use and opioid use disorders.

Opportunities Ahead

While increasing funding for health facilities and the virtual care infrastructure is important for improving life in rural communities, the long road back for rural health will be complicated. Rural areas are diverse, ranging from the Mississippi Delta and the western frontier to border communities and rural resort communities. A one-size-fits-all approach won’t work. Communities need flexible state and federal funding to address their unique contexts and issues. Policymakers also must grapple with the complex of social determinants of health: housing, education, employment, and cultural contexts.

Yet there are reasons for optimism. We know some of the key factors in rural communities that will enable them to rebound. As Ron Manderscheid, President and CEO of the National Association of County Behavioral Health and Developmental Disability Directors and the National Association of Rural Mental Health, recently wrote: “First, each community is the source of energy for solving its own problems. Second, historically excluded groups—minorities, persons who are homeless—need to be brought into community life. Third, relationships and interactions are the basis for solving community problems.”

We need to take advantage of rural areas’ unique strengths: a strong sense of community and support for neighbors and friends; volunteerism; resourcefulness; adaptability; strong social support; entrepreneurialism; and coalitions of faith-based organizations, local businesses, hospitals, and nonprofits. Rural communities regularly collaborate to solve problems, including improving access to behavioral health treatment and recovery services to improve health and well-being. Now, thanks to the alarm COVID-19 raised, they may have the systems, technology, and funds to do it.

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