This article is published in partnership with the Center for Independent Media, the Iowa Independent, and Rewire.

The national health care reform debate has been dominated by issues
like the public option, Medicare and Medicaid reimbursement rates and,
unfortunately, too many distractions and misconceptions. Of all the
open questions about moves to improve American health care, perhaps the
only fact known for sure is that changes are afoot that would likely
result in millions of uninsured Americans getting health insurance.

Expanding insurance coverage is important, experts say, but that is
only half the battle. For many Americans, particularly in rural parts
of the country, access to high quality health care services could
remain elusive.

“We have some serious challenges in Iowa as it relates to the number
of providers that we have,” said Tom Newton, executive director of the Iowa Department of Public Health.
“We do have a high percentage of our population in Iowa that is insured
at this time, and I would tell you that even some of them struggle
right now to get access to health care. You can’t just assume that by
providing people with a source of payment that you’ve provided them
with access to health care.”

As The Iowa Independent has previously reported, the Hawkeye State,
like many other rural states, is coping with a plummeting number of
health care professionals, including specialists, primary care physicians, nurses and behavioral health professionals.

While several factors such as perceived career stress and compensation issues are at the root of the decline, the problem is also being amplified by a rapidly aging health care workforce.

As a part of H1N1 flu response and vaccination plan development for
health care providers, Newton said he spoke with a public health
administrator in Van Buren County about the department’s plan to
utilize flu mist, a live-virus vaccination that is delivered through
the nose like a nasal spray. Because that vaccination contains a live
virus, its use has been restricted to certain age groups.

“Health care providers were going to be our targeted audience for
using flu mist, at least in some cases. But, in Van Buren County they
do not have any health care providers that are under the age 49,”
Newton said, noting that regulations prohibit anyone 49 and up from
using the live virus. “That presents problems for us from a vaccination
standpoint, but what does that say about health care providers in those
communities? There are probably going to be some of those folks who are
eligible to retire within five years.”

The alarming demographics and shrinking number of health care
workers in rural areas are not just limited to primary care doctors.
Other components of health care are also in short supply in much of
Iowa.

“We aren’t just talking about those people that are traditionally thought of as health care providers – it’s dentists, it’s mental health and it’s even pharmacy,” said Cheryll Jones, a southeastern Iowa pediatric nurse practitioner who serves on the board of the Iowa Rural Health Association.
“There aren’t necessarily huge numbers of pharmacies in rural areas.
So, even if you have a provider, you may have to travel a fair distance
to get your prescription filled.

“[Workforce] is a concern that we have, and not just for rural, but
especially for rural. Certainly, the need for folks to have health
insurance is important, and that is where a lot of the focus has been,
but access to insurance does not equate to access to care.”

A declining and aging workforce is probably the most publicly
visible of the challenges facing a health care system, but it is far
from the only challenge for rural areas. According to Tim Size,
executive director of the Rural Wisconsin Health Cooperative, his state, like Iowa, has maintained a relatively low uninsured rate.

“We are very used to dealing with rural health in an environment
where most people have insurance cards,” Size said. “People having
insurance cards is much better than people not having insurance cards,
but it doesn’t deal with the long, long list of issues that we have to
struggle with.”

As health care companies react to the current global economic
recession, there will be efforts to make health care services more
centralized, which isn’t always in the best interest of rural consumers
or providers.

“We need collaborative ways for rural to work with rural and for
rural to work with urban that maintains services available in the rural
areas,” Size said. “From that respect, we have to be very concerned
about the economic incentives that will come with reform. … There are a
lot of models floating around out there that have tended to be
developed in urban communities and we need to be very cautious about
those being mandated into rural communities without any demonstrating
or testing of the idea.”

When it comes to the debate over improving health care, Newton said,
“It all comes down to how you define access.” For many rural residents,
the definition is likely to remain too narrow to make much of a
difference.