Rural Hospitals Closures in the United States 1 : Theoretical Impact Analysis on African Americans Health Care Disparity in the South 2

This paper examines the impact of rural hospitals closures in the United States on African Americans health care access with focus on the South region (Black Belt). Specifically, the paper argues that rising rural hospital closures has disproportionate impact on African Americans and has exacerbated the health disparity between African Americans and Whites. In addition, the paper will examine the underlying socioeconomic factors influencing African Americans health outcomes in the South. Furthermore, the paper will add to the body of knowledge and literature on the subject of African Americans health disparity in the United States, with implications for public policy. African Americans health disparity in the United States is a long-standing problem. The rising closures of rural hospitals that provide critical care to historically underserved populations including Blacks has made the situation worse. The closures has made it more difficult for African Americans to obtain basic health care services and has resulted to diminishing access to care and persistent gaps in health quality for African Americans. The health disparity problem will be analyzed in the context of four underlying factors: race, discrimination, costs, and poverty. Methodically, the study is a narrative literature review and data analysis of previous and current works using Boolean search technique. The study finds and further re-affirm that race, discrimination, costs, and poverty contribute to African American health disparity in the United States. Based on the findings, the study concludes that rural hospital closures has disproportionate impact on African Americans health compared to Whites. To address the inequity, the study recommends better funding and resources for rural hospitals, Medicaid expansion, enhanced reimbursement incentives for health providers who practice in rural communities, strengthening federal health programs that support rural residents, such as, Essential Communities Providers (ECP), Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), Health Professional Shortage Area (HPSA). In this paper, the terms “Black (s),” “Black Americans,” and “African Americans” are used interchangeably.


I. Introduction
The aim of this paper is to examine the impact of rural hospitals closures (Table 2) on African Americans health care access in the United States, particularly, in the South. Specifically, the paper argues that rural hospitals closures have disproportionate impact on African Americans and have further widened health disparity between Blacks and Whites. In addition, the paper will examine the underlying socioeconomic factors influencing African Americans health outcomes in the South with implications for public policy thereof. Before going further, it will be in order to define health disparity in the United States. According to the U. S. National Institutes of Health (NIH, 2014), "Health disparities are differences that exist among specific population groups in the United States in the attainment of full health potential that can be measured by differences in incidence, prevalence, mortality, burden of disease, and other adverse health conditions." The examination of the impact of rural hospitals closures on the African American population in the South region is necessary for three reasons. First, majority of African Americans in the United States live in the South. 3 As such, the research findings can be generalized as representative of Black health care inadequacy problem in the general U.S. population. Second, the South has the highest percentage of people living in poverty and without health insurance in the United States, with Black poverty and health inequity in particular disproportionately higher than that of whites. As Brookings Institution scholars, Shambaugh, Nunn, and Anderson (2019) observed, "…poverty in the Deep South tend to be much higher in counties with high black populations." Third, the South has historical resistance to African American equity including health care access (Dent, 1949;Daniel, 1970;Beardsley, 1986 andSmith, 1998Smith, , 1999Smith, , 2005aSmith, , 2005bReynolds, 1997a) and the rural hospitals closures has aggravated the problem, calling for urgent and necessary policy measures to address the disparity.

Figure 1: Census Regions of the United States
Source: Adapted from U.S. Census Bureau https://gisportal.data.census.gov/arcgis/apps/MapSeries/index.html?appid=7a41374f6b03456e9d138cb014711e01  adaptation to stressors (Taylor, 2019;McEwen, 1998) for adults aged 18-64 years. African Americans were found to have higher allostatic load scores than Whites as a result of "living in a race-conscious society" (Geronimus et al., 2006, p. 826). Inextricably linked to racial bias is "distrust from a legacy of discrimination" (Frakt, 2020) and concomitant "effect of segregation on disparities" (Smith, 2005b), which as Richard Kahlenberg (2020) of the Century Foundation noted, "segregation is the fundamental social architecture that has supported white dehumanization of black people."

B. Discrimination
Frakt (2020) "racial discrimination has shaped so many American institutions that perhaps it should be no surprise that health care is among them. Put simply, people of color receive less care -and often worse care -than white Americans." Frakt is not alone. The literature indicate that because of racial discrimination African Americans tend to receive low quality of care for basic hospital services (Ayanian, 1999;Noonan, Velasco-Mondragon, and Wagner, 2016;Scott and Wilson, 2011;Gerend and Pai, 2008;Hostetter and Klein, 2018). Also, national data show that African Americans not only have worse health outcomes (compared to whites), but also, they are more likely than whites to die from preventable and treatable health conditions, such as, cardiovascular disease, diabetes, asthma, cancer and HIV/AIDS (Betancourt and Main, 2004;Bloche, 2004;Peterson, et al. 2018;Clements, et al. 2020;Zachary, et al, 2020). Also, Black Americans and low income areas are more likely to have unnecessary limb amputations and suffer medical malpractice than whites (Frakt, 2020;Stapleton et al., 2018;Stevens, et al. 2014;Feinglass et al., 2008;Goodney et al., 2014;Presser, 2020).
There are high levels of medical distrust linked to bad experiences and low quality of life among Blacks in the United States (Kinlock, et al., 2017;Alsan, Garrick, and Graziani, 2018;Gaston and Alleyne-Green, 2013). The infamous "Tuskegee Experiment," 1 perhaps, represent the most egregious example of the reasons why African Americans distrust the American health care system. Byrd and Clayton (1992, p. 196) called the Tuskegee experiment "unethical experimentation on blacks." The Tuskegee Experiment was organized by the U.S. Public Health Service in Tuskegee, Alabama, from 1932 to 1972. It conducted a study of the effects of untreated syphilis on 399 African American men with latent syphilis and 201 African American men without syphilis in the control group (U. S. Centers for Disease Control and Prevention, n.d.), for the purpose to "better understand the natural course of the disease" (Frakt, 2020). To achieve this aim and track the disease's progression, the study participants were "promised free medical care," "lied to about the study and provided sham treatments" (Frakt, 2020). Consequently, many of the subjects died, infected family members, went blind or insane or experienced other severe health problems due to their untreated syphilis (Frakt, 2020;Nix, 2019). "As a result of the Tuskegee Experiment," wrote Nix (2019) "many African Americans developed a lingering, deep mistrust of public health officials" in the United States. In a 1997 apology to the study survivors and their families, then President Clinton called the Tuskegee study "America's shameful past," adding, "What was done cannot be undone…We can look at you in the eye and finally say on behalf of the American people, what the United States government did was shameful, and I am sorry" (The White House, 1997).

C. Cost
The cost of health care has long been a concern in the U.S., on both a national and a personal level (Hamel et al., 2016). The United States health care system is the most expensive in the world (Davis et. al., 2014), and cost remains the major impediment to health coverage in the United States (Nwagbara and Ejigiri, 2018). A brief overview of the cost problem will be in order. In the United States, nearly one in every six dollars spent goes to health care, yet, almost one in every six American lack coverage that would ensure access to medical care (Brauchli, 2010). A recent report indicated that 45% of uninsured adults said that they tried to get coverage but did not because it was too expensive (Tolbert, Orgera, and Singer, 2019), while 53% had problems paying household medical bills in the past year (Hamel, et al., 2016). Overall, 70% of Americans who have faced medical bill problems report that they cut back spending on food, clothing, and basic household items (Hamel et al., 2016.) At the same time, medical expenses have become a leading cause of personal bankruptcy in America (Kutilek, 2016).
A 2007 Harvard university seminal study found that medical expenses contributed to 62% of all bankruptcies in the United States, up 50% from 2001 (Himmelstein, Thorne, Warren, and Woolhandler, 2007). In addition, healthcare costs continued to grow faster than the economy and has maintained upward trend (Torio and Andrews, 2013). To put it in historical perspective, U.S. health spending as a share of the Gross Domestic Product (GDP) was 5. 3% in 19603% in , 5.9% in 19653% in , 7.4% in 19703% in , 13.8% in 20003% in (Rushefsky, 2013, reaching 17.7% in 2018 (Centers for Medicare & Medicaid Services (CMS) and National Health Expenditure Accounts (NHEA) n.d.). Latest report show that the United States spent $3.6 trillion (17.7% GDP) on health care in 2018, or $11,172 per person (CMS and NHEA, n.d., Hartman, et al. 2019), up 54% from $7,269 in 2007 (Keehan, et al., 2016). America's health care portion of the GDP of 17.7% is twice the average (8.9%) among developed nations ISSN 2224-5731(Paper) ISSN 2225-0972(Online) Vol.10, No.7, 2020 60 (Organization for Economic Cooperation and Development, 2016), and it is expected to rise to 20.1% in 2025 (Keehan, et al., 2016). Figures 7 and 8 show where America's health dollars come from and where they go. The health care cost problem is highest in the African American community (Williams et al., 2010;Sohn, 2017;Taylor, 2019).  high cost of health insurance means that access to affordable health care is still a challenge for many Americansparticularly African Americans (Taylor, 2019). According to County Health Rankings & Roadmaps, a collaborative program between the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation (health philanthropy), "Poverty and financial insecurity can have profound negative effects on mental and physical health outcomes. When families cannot access financial resources, the choices they can make about housing, food, medical care, and other key factors in living a long and healthy life are limited. Across and within counties, there are stark differences in these opportunities and the barriers to them disproportionately impact communities of color" (n.d.). Recent research (Figure 9) show that in 2018, the percentage of persons who were in families having problems paying medical bills was highest among non-Hispanic black persons (20.6%), followed by Hispanic (15.6%), non-Hispanic white (13.0%), and non-Hispanic Asian (7.1%) persons (Cha and Cohen 2020). By region, "The Burden of Medical Debt" report from the Kaiser Family Foundation and The New York Times found that people in the South [majority African Americans] have the highest difficulty paying medical bills (32%), while those in the Northeast [mostly whites] have the lowest (18%). And because African Americans tend to be poorer than other demographic groups on average (Taylor, 2019), even when health insurance is available, the coverage for them can be limited for a number of factors, including rising deductibles and costsharing, out-of-network charges, and insufficient financial assets to cover medical expenses (Hamel, et al., 2016). Closely tied to the cost problem is the "South's stubborn approach to Medicaid Expansion" (Taylor, 2019) which have disproportionate impact on Black health coverage because majority of African Americans live in the South.  Under the Affordable Car Act (ACA) protocol, Medicaid 1 eligibility was expanded for adults with incomes at or below 138 percent of the federal poverty level (FPL) ($12,760 for an individual in 2020) (USDHH, HHS Poverty Guidelines, 2020). Given that African Americans are disproportionately poor compared to other demographic groups, public health insurance programs such as Medicaid go a long way to address their health care needs (Taylor, 2029). In states that have not expanded Medicaid eligibility under the ACA (as of May 2020, 14 states had not expanded their programs) (Kaiser Family Foundation, 2020), African Americans and other people of color are more likely to fall into a "coverage gap"-meaning they earn too much to qualify for the traditional Medicaid program, yet not enough to be eligible for health coverage premium tax credits under marketplace plans Public Policy and Administration Research www.iiste.org ISSN 2224-5731(Paper) ISSN 2225-0972(Online) Vol.10, No.7, 2020 (Taylor, 2019;Garfield, Orgera, and Damico, 2020). The majority (9 out of 14) of states that have not adopted Medicaid expansion eligibility are located in the South (Figure 10). As a result, nine in ten people in the coverage gap reside in the South (Garfield, Orgera, and Damico, 2020). Put another way, "due to the failure to expand Medicaid, the South is now home to the nation's sickest people, and is where health disparities between whites and people of color are the most pronounced" (Taylor, 2019). The cost problem is made worse by poverty.

D. Poverty
African Americans are one of the most economically disadvantaged populations in the United States (Bloome, 2014;Chetty et al. 2014;Hardy, Logan, and Parman, 2018;Fausset and Rojas, 2020). A 2019 study (Probst and Ajmal, 2019) from the University of South Carolina's Rural and Minority Health Research Center found that rural African Americans are much more likely to live in counties with persistent poverty (41.3%), and in persistent child poverty counties (63.9%) than are white rural residents (8.9% and 20.9%, respectively), and more likely to live in regions that the federal government has designated as Health Professional Shortage Areas. Another study from the North Carolina Rural Health Research Program (NCRHRP) found that rural hospitals considered to be at high risk of financial distress serve communities that have statistically significant percentages of non-Whites and Blacks in particular; higher rates of unemployment, premature deaths, and worse health status (Thomas, Pink, and Reither, 2019), pointing to economic disadvantage and poor health. Due to structural and systematic barriers, African Americans are more likely to be poor than white Americans (Taylor, 2019), more likely to be unemployed ( Figure 11) (U.S. Bureau of Labor Statistics, 2020; Weller, 2019) and more likely to earn less than Whites ( Figure 12) (Weller, 2019), pointing to unequal pay as a contributing factor in the gap in household income. Also, according to a recent key "Economic Well-Being of U.S. Households" report by the U.S. Federal Reserve (Central Bank), African Americans are more likely (19%) to suffer income volatility, meaning, unpredictable incomes and low savings than Whites (11%); African Americans were less likely to get a raise than Whites regardless of educational attainment. Furthermore, African Americans were more likely to encounter adverse credit application outcomes and negative perceptions (44%) compared to Whites (18%); African Americans are more likely (36%) than Whites (21%) to have no retirement savings, and are less likely (25%) to view their retirement savings as being on track compared to Whites (42%). Further perpetuating African American disproportionate poverty is the spatial distribution of Black population.
Studies indicate predominant African Americans regions and areas (e.g. South and urban counties and large metropolitan areas - Figure 13) are more likely to experience economic distress and low level of economic mobility compared to White neighborhoods in smaller metropolitan areas and in rural counties (Chetty et al. 2014;Hardy, Logan, and Parman, 2018). In addition, black neighborhoods are more likely to experience pollution and environmental risks than White's, as in the Mississippi Delta with predominant African American population, where Black health suffer consequential of "densest concentration of petrochemical plants in the country" (Denne, 2020), leading to feared "Cancer Alley" phenomenon. As Shambaugh, Nunn, and Anderson (2019) suggested "this Public Policy and Administration Research www.iiste.org ISSN 2224-5731(Paper) ISSN 2225-0972(Online) Vol.10, No.7, 2020 63 concentration of African-American population is not accidental," influences include "slavery, Reconstruction, Jim Crow, discrimination and intimidation, lender behavior, white flight from cities, public policies, e.g. redlining or highway construction" (Hardy, Logan, and Parman, 2018;Berger, 2018).   (2018). "The Historical Role of Race and Policy for Regional Inequality." The Hamilton Project. Brookings Institution. http://www.hamiltonproject.org/assets/files/PBP_HardyLoganParman_1009.pdf. Across economic indicators, vast disparities exist between African Americans and whites that reflect the proportions noticed in health disparities (Taylor, 2019). Gap in household incomes between African Americans and Whites brings the disadvantage to sharp focus. And since household "income is a major factor in a family's ability to access health care, it can constitute a significant share of household spending in terms of insurance premium costs and out-of-pocket costs" (Taylor, 2019). Income is central to most people's economic well-being (U. S. Federal Reserve Board, 2019, p. 11). While "a large majority (Figure 14) of individuals report that, financially, they are doing okay or living comfortably, the gaps in economic well-being by race and ethnicity persist, even as overall well-being has improved" (U. S. Federal Reserve Board, 2019, p. 1). According to the U.S. Census Bureau in 2018 (latest), the average Black median household income was $41,361 in comparison to $70,642 for White households (Semega, Kollar, Creamer, and Mohanty, 2019, p. 2). (Figure 15). By region, median incomes were highest in the Northeast ($70,113) and the West ($69,520), followed by the Midwest ($64,069) and the South ($57,299) (Semega, Kollar, Creamer, and Mohanty, 2019, p. 2).  (Semega, Kollar, Creamer, and Mohanty, 2019, p. 13). (Figure 16). That is, African American poverty rate was higher than for any other ethnic or racial group in the United States, and more than double that of Whites. By region, poverty was highest in the South (13.6%) followed by West (11.2%), Midwest (10.4%), and Northeast (10.3%) (Semega, Kollar, Creamer, and Mohanty, 2019, p. 13). In 2018, according to the U.S. Census Bureau, 55.4% of Blacks in comparison to 69.3% of Whites used private 1 health insurance (Berchick, Barnett, and Upton, 2019, p.14). Also in 2018, 41.2% of Blacks compared to 33.8% of Whites were enrolled in public 2 health insurance or Medicaid. During the same period, 9.7% of Blacks in comparison to 5.4% of non-Hispanic Whites were uninsured 3 (Berchick, Barnett, and Upton, 2019, p.14). The five states (Texas, Oklahoma, Mississippi, Georgia, and Florida) in the United Sates with the highest percentage (12 percent or more) of people without health insurance coverage are located in the South, consequently, the South has the majority of the uninsured, and is where health gap between African Americans and Whites are most glaring (Figure 17). Linked to poverty is the wealth gap between African Americans and Whites.
1 Private health insurance includes coverage provided through an employer or union, coverage purchased directly, or TRICARE (Berchick, Barnett, and Upton, 2019, p.14). 2 Public health insurance coverage includes Medicaid and Children's Health Insurance Program (CHIP), Medicare, CHAMPVA (Civilian Health and Medical Program of the Department of Veteran Affairs) and care provided by the Department of Veteran Affairs and the military (Berchick, Barnett, and Upton, 2019, p.14). 3 Individuals are considered to be uninsured if they do not have health insurance coverage for the entire calendar year (Berchick, Barnett, and Upton, 2019, p.14).   Wealth is the measure of an individual's or family's financial net worth and it provides several opportunities for American families (Hanks, Solomon, and Weller, 2018). However, for African Americans, their wealth accumulation and worth pale enormously in comparison to Whites -in 2016 the median wealth of White families ($142,180) was ten times more that of African American families ($13,460). (Table 2). This gap has widened in Public Policy and Administration Research www.iiste.org ISSN 2224-5731(Paper) ISSN 2225-0972(Online) Vol.10, No.7, 2020 recent years especially since the Great Recession. Black families lost more wealth during and after the financial and economic crisis of 2007 to 2009. (Figure 18). This resulted in a widening racial wealth gap over the past decade. In addition, research indicate that the wealth gap impacts African Americans across the income and education spectrum, making it harder for them to own homes or build retirement savings (Hanks, Solomon, and Weller, 2018;Weller, 2019;Taylor, 2019). Moreover, while African Americans on average have less total debt than whites, the wealth gap means they are more likely to have costly, high-interest debt obligations (Taylor, 2019). High health care costs and unexpected medical bills can adversely affect a Black family's ability to reduce or eliminate debt, and ultimately the ability to create wealth-which could affect a family for generations (Taylor, 2019).