This report seeks to identify what healthcare access means to the communities served by the IU Center for Rural Engagement. Informed by community members, experts in the field, and the latest research, this report also aims to outline potential next steps to improve access to care for rural Hoosiers

Pope, Katherine

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Access to Healthcare in Rural Indiana 
A report by Katherine J. Pope, RN, MPH, IU Center for Rural Engagement 
August 2020 
 
Every day, Hoosiers struggle with their health. From obesity to substance use, lack of prenatal care to 
anxiety and depression, Indiana ranks near the bottom of the United States1 in health outcomes and health 
behaviors. And despite the fact that healthcare providers, professionals, and individuals are motivated to 
address these health disparities and improve Hoosier health, no treatment measure can be effective if 
the recipient cannot access the treatment itself. 
 
Healthcare access is an issue of utmost importance, affecting the lives of rural Hoosiers in a myriad of ways. 
Not only does lack of access affect the physical and mental health of rural residents, but it also renders 
businesses and new industries less likely to relocate to an area where there is not adequate healthcare.2 
This exacerbates the social determinants of health affected by the economy such as better access to 
resources and jobs. 
 
This report seeks to identify what healthcare access means to the communities served by the IU Center 
for Rural Engagement. Informed by community members, experts in the field, and the latest research, this 
report also aims to outline potential next steps to improve access to care for rural Hoosiers. 
Defining the problem 
Access to healthcare is defined as the “timely use of personal 
health services to achieve the best possible health outcomes.”3 
However, there is often not one specific reason that blocks an 
individual from accessing care in a timely manner. Experts define 
healthcare access in differing ways, rendering it difficult to 
pinpoint the exact cause. 
 
The lack of health insurance is a significant barrier to healthcare 
access. Physical distance– that is, not having geographic area – 
or lack of transportation to get to an appointment are also cited 
as common barriers, which becomes even more obvious and 
problematic in rural settings. Some research suggests that the 
Common causes of lack of 
healthcare access 
__________________________________ 
• Health insurance 
• Language barriers 
• Geographic or transportation-
related barriers 
• Shortage of healthcare providers 
and clinics 
further that patients have to travel, the less likely they are to seek healthcare services.4  Rural areas also 
suffer from a shortage of primary care providers.5 Language-related barriers, disabilities or fear of provider 
stigma (related to weight, sexual orientation, race, etc.) are also identified as reasons that patients do not 
seek healthcare.6 Lack as access can also be exemplified by the inability to take time off work to attend 
appointments. 
  
If a resident doesn’t have access to care, they are less likely to receive preventive care, primary care, dental 
care, chronic disease management, and behavioral health counseling, all of which impact health 
improvement priorities in rural counties, the state of Indiana, and nationally. 
 
Without insurance, patients are often diagnosed at later, less treatable disease states and overall, have 
worse health outcomes, lower quality of life, and higher mortality rates.7,8 
Healthcare Access in Indiana 
Indiana struggles with access to care, which is why it is 
listed as one of the top priorities in the Indiana State 
Health Improvement Plan.7 While the uninsured rate in 
Indiana is decreasing, thanks to the Healthy Indiana 
Plan that expanded insurance options, the rate is still 
high: 8.1 percent of Hoosiers were uninsured in 2016.7 
With such a high rate of uninsured residents, many 
Hoosiers will have trouble getting and affording the 
healthcare they need. 
 
While lacking insurance strongly affects our ability to 
access care, even when residents have insurance, 
there might not be an appropriate provider in their 
community, requiring them to travel to the nearest 
urban area to seek care. Most Hoosiers live in counties 
that are designated as Health Professional Shortage 
Areas9 and we lag behind the rest of the United States 
and the Midwest in physicians per capita. Indiana has 
230.8 active physicians per 100,000 people 
(compared to the median of the United States of 
263.8 physicians per 100,000 people). In the Midwest, 
Iowa is the only state with a lower per capita rate than 
Indiana.10 
 
Lack of access to behavioral health represents a large gap in the healthcare system in Indiana. In 2017, 
according to the Indiana Physician Licensure Data Report, more than half of Hoosier counties lack enough 
access to mental health providers like psychiatrists, psychologists, addiction counselors, and marriage and 
family therapists.11 
  
It can be difficult to pinpoint why so many counties don’t have an adequate number of providers, but one 
can project that it has to do with the difficulty of operating a clinic in a rural setting as well as personal 
preference. Working in an independent practice can be difficult for providers when their overhead costs 
(administration, rent, etc.) aren’t covered. Providers are also more likely to be on call and do not have the 
peer support that their urban counterparts have.12 In addition, providers often prefer a setting where there 
is more entertainment, arts, and culture. Collectively, this choice has a downstream effect. When young 
professionals do not choose to relocate to rural areas, a decrease in education and income can reflect that, 
linking the level of education and income with access to care. Counties with a higher rate of residents that 
had a high school or college degree reported having a lower provider-to-patient ratio. In addition, there was 
a $5,000 per capita income difference between counties with high versus low provider ratios, where 
counties with a higher income reported much better access to care.2 
 
Rural counties themselves identify the lack of access to care as one of their top health priorities. When 
analyzing community health needs assessments (an extensive report required for all tax- exempt hospitals 
every three years that requires significant input from communities13), almost all rural Hoosier counties 
ranked access to care as a top priority. (Only substance use, mental health, and chronic diseases were 
ranked as priorities more frequently.)14 Upon examining the Indiana Uplands, an 11-county region in 
southwest central Indiana, access to care was ranked even higher (with only substance use and chronic 
disease listed as priorities more often).14  
 
 
Rural counties did not only identify access to care as an issue in community health needs assessments, but 
in their Regional Opportunity Initiatives (ROI) Quality of Place and Workforce Attraction plans as well. 
Greene, Martin, Orange, and Owen counties all identified healthcare access as a priority. Each county aimed 
to improve it with a different strategy, some of which included increasing provider-to-patient ratio, 
improving transportation, or increasing number of clinics.15 In addition, a community needs assessment 
performed in Crawford County found that 80 percent of people surveyed identified “access to care” as a 
very important health issue that merited more funding and resources.16 As exemplified in these reports, 
the Indiana Uplands region identifies access to care as one of their largest issues and is motivated to 
improve it. 
  
Expert opinion also explains additional reasons why Hoosiers do not have adequate access to care, even if 
they happen to live in an area with enough providers and have insurance. In particular, Hoosiers struggling 
with substance use disorder (SUD) present a unique situation. SUD treatments have evolved in recent 
years and insurance reimbursement does not always cover the most up-to-date treatment regimen. 
Patients are also wary of provider stigma associated with drug use and its treatment. Thus, patients are 
often less likely to seek care and if they do, the most evidence-based treatments might not be used.17 One 
study, done in conjunction with the Indiana Minority Health Coalition, sought to understand why African- 
American and/or LGBTQ men did not seek healthcare. Their barriers included not wanting to see providers 
who “didn’t look like them,” providers who might come from the same home town as they did, or concern 
that their treatment would show up on an insurance bill that would “out them.”6 In short, the barriers 
symbolized a lack of trust between patient and provider. 
 
There are a wide variety of causes of the healthcare access problem that affects Indiana. From a high rate of 
uninsured residents, lack of providers, lack of transportation, to lack of trust, it has been identified as a top 
priority by communities, experts, and healthcare leaders around the state. 
 
Next Steps 
Solving this problem requires a change in mindset about healthcare treatment: instead of the status quo of 
people travelling to treatment, we must shift to care that travels to the patient.18 We must also create an 
environment of trust where patients feel comfortable and safe seeking care).6 
 
Resources must be expanded and shared. For example, when Medicaid Expansion occurred in 2015, 
approximately 500,000 people became newly insured and better able to access care. There are now over 
240 managed care organizations that provide Medicare and Medicaid that are linking their clients with 
healthcare resources.17 IU Health is attempting to raise awareness and share a resource—Aunt Bertha—
that will allow clients to access free and reduced cost services 
related to medical care, food, job training, and more. They have 
funded and are providing support for auntbertha.com where 
anyone can search and identify those appropriate resources. 
They have also removed the IU Health branding so that rural 
communities feel more comfortable sharing it on their websites 
and beyond.  
  
Indiana University School of Medicine (IUSOM) identifies the key 
barrier to access to care as a physician shortage and is taking 
strong measures to counteract that. They aim to expand local 
expertise through expanded physician residency programs, 
specialty provider training, and tele-medicine support. For 
example, they have launched the Rural Medical Education 
Program at the Terre Haute campus for medical students where 
clinical experiences are the priority and where possible, a rural 
emphasis is included.11 The Bowen Center, as part of IUSOM, 
continues to track health care workforce shortages by developing 
data tools and improving how it tracks provider availability and 
engagement. In this way, it can better inform solutions to the 
provider shortage. 
 
Project ECHO, sponsored by the IUPUI Fairbanks School of Public Health, is also an excellent resource that 
links specialists in urban areas with difficult cases in communities. It is free to use and provides case-based 
learning for anyone who joins. It successfully leverages expertise and resources, especially in areas with few 
providers.19 Project ECHO has also been able to quickly respond to the COVID-19 pandemic, providing 
statewide data, best practices, and updates to providers across the state, many of whom hail from rural 
communities. 
 
It is necessary to further incentivize caregivers to provide healthcare in underserved areas. Several grant 
and scholarship programs exist to help with tuition reimbursement for nurses, physicians, mental health 
providers, and more.20  Clinicians who do not want to work full-time in an underserved area could also be 
incentivized to work for part of the week in a rural area and for part of the week in their home community.2 
Another strategy is to increase rural health clinics. These institutions are certified by the state and must be 
located in a rural, underserved areas. By increasing the number of clinics or extending the number of 
services (such as ambulance services), patients would have a more robust experience and be better able to 
access these clinics that are often their first point of contact.2 
 
Many efforts at Indiana University are focused on improving access to care. For example, the IU Center for 
Rural Engagement, IU School of Nursing, and IU School of Social Work have partnered to create a clinical 
experience for nursing and social work students in rural areas. As more clinicians rotate through rural, 
underserved areas, they will become more confident and comfortable with the experience. Ideally, this will 
translate into higher numbers of healthcare graduates choosing to locate to these rural areas. In addition, 
Prevention Insights at IU has recently partnered with a large health system to integrate medication-assisted 
treatment for substance use disorder into their hospitals, providing more effective treatment in a more 
convenient location to increase substance use treatment access. 
 
There are a wide variety of different solutions to ameliorate the problem of healthcare access in Indiana. It is 
important to understand the issue on different levels—acknowledging that the cause of poor healthcare 
access isn’t simply transportation or health insurance. It can also be due to social determinants of health 
such as income and education, language or disabilities, or lack of providers themselves. When addressing 
this health issue, it will be critically important to understand that there is no silver bullet to fix access to 
care. However, with greater awareness and understanding, each initiative that acknowledges this important 
issue and addresses at least one of its causes will begin to ensure that all residents of rural Indiana are 
able to easily access and receive the healthcare they need and deserve. 
  
Proposed solutions in Indiana 
__________________________________ 
• Increase insurance coverage 
• Aunt Bertha 
• Rural residencies for healthcare 
professionals 
• Telehealth and telemedicine 
• Better incentivize healthcare 
professionals to work in rural areas 
• Increase the number of rural health 
clinics 
References 
1 United Health Foundation. (2019, December). America’s Health Rankings 2019 Annual Report. United Health 
Foundation. https://www.americashealthrankings.org/learn/reports/2019-annual-report 
2 Purdue Center for Regional Development. (2008). Healthcare Access in Indiana. Research Paper PCRD-R-5. 
3 Milliman M. (1993). Access to health care in America. Institute of Medicine (US) Committee on Monitoring Access to 
Personal Health Care. Washington (DC): National Academies Press (US). 
4 Perry, P. and Gesler, W. (2000). Physical Access to Primary Healthcare in Andean Bolivia. Social Science and 
Medicine. 50: 1177-1188. 
5 Healthy People 2020. (n.d.) Washington, D.C: U.S. Department of Health and Human Resources, Office of Disease 
Prevention and Health Promotion. Cited April 23, 2020. Available from: 
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions- 
resources/access-to-primary. 
6 Carter, G. (2020, February 18). Personal interview. 
7 Indiana State Department of Health. (2018). Indiana State Health Assessment and Improvement Plan. Retrieved from 
https://www.in.gov/isdh/files/Indiana_State_Health_Plan_I-SHIP.pdf 
8 Clancy C, M. W. (2013). 2012 National healthcare quality report. Agency for Healthcare Research and Quality 
(AHRQ). 
9 Bowen Center for Health Workforce Research and Policy. (2017). Indiana Primary Care Health Professional Shortage 
Area (MHPSA). Map Gallery: Primary Care Physicians. Retrieved from 
https://bowenportal.org/index.php/hpsa-stoplight-pcp/ 
10 Association of American Medical Colleges. (2019). 2019 State Physician Workforce Data Report. Washington, DC: 
AAMC. Retrieved from https://store.aamc.org/downloadable/download/sample/sample_id/305/ 
11 Indiana University School of Medicine. (n.d.) Access to Care. Expertise in Indiana Health. Retrieved from 
https://medicine.iu.edu/expertise/indiana-health/access-to-care 
12 Reising, D. (2020, May 26). Personal correspondence. 
13 Internal Revenue Service. (2019). Community Health Needs Assessment for Charitable Hospital Organizations – 
Section 501(r)(3). Charities and Nonprofits. Retrieved from https://www.irs.gov/charities-non-
profits/community- health-needs-assessment-for-charitable-hospital-organizations-section-501r3 
14 Indiana University Center for Rural Engagement and School of Public Health. (2020). Community Health Priorities: 
Rural Indiana. 
15 Regional Opportunity Initiatives. (n.d.) Quality of Place and Workforce Attraction Plans. Quality of Place Initiatives. 
Retrieved from https://regionalopportunityinc.org/ready-communities/plans/ 
16 Barnes, P. and Mauzerolle, K. (2020). Crawford County Community Health Assessment: Status Report. (Completed 
report pending.) 
17 Simon, K. (2020, February 18). Personal Interview. 
18 Docherty, C. (2020, January 28). Personal Interview. 
19 IUPUI Richard M. Fairbanks School of Public Health. (n.d.) Project ECHO. Research and Centers. Retrieved from 
https://fsph.iupui.edu/research-centers/centers/public-health-practice/ECHO/index.html 
20 Grangaard, Laura. (2014) Programs for Loan Repayment and Forgiveness: A list for Rural Providers. Rural Monitor – 
Rural Health Info Hub. Retrieved from https://www.ruralhealthinfo.org/rural-monitor/loan-repayment-and-
forgiveness/ 
  
 
 
 
 
 
 
 
 
 
 


Access to Healthcare in Rural Indiana

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Access to Healthcare in Rural Indiana

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