Health, Aging Disability
Social factors, such as educational and occupational opportunities, access to quality healthcare, in addition to individual behaviors, are determinants of the health of a community.1 Across Virginia's counties, population health varies. Rural areas, such as Rockbridge, typically fare worse on common indicators of community health, compared to suburban or urban areas.2 For example, a significant number of children in the County are at risk for obesity because of a lack of physical activity and access to nutrient-dense foods.3
The ratio of patients to primary care providers is higher in the County and Buena Vista than the national benchmark as of 2016.4 Due to the concentration of goods and services in the cities, residents of the County may have to travel up to thirty minutes to reach medical care in Lexington. This extended travel time is a burden, particularly for low-income households who might also have limited access to transportation.
When the 95 counties plus the 38 independent cities of Virginia are ranked according to their health outcomes and health factors, those having the high ranks (1 or 2) are estimated to be the healthiest.5 Health outcomes are measured by an average of the incidence of disease and death rates, while health factors are measured by, "weighted scores for health behaviors, clinical care, social and economic factors, and physical environment."6 Although the entire Rockbridge area has fairly average health factors and outcomes, the results in Figure 7 indicate that Buena Vista is the area facing the most significant challenges.7 Additionally, high blood pressure is a persistent problem in the Rockbridge area, affecting 27% of adults in Buena Vista, 32% in Lexington, and 30% in the County.8 Lexington City's high percentage number exceeds the statewide percentage of 30% adults diagnosed.9 More positively, Buena Vista has a lower percentage of adults diagnosed with high blood pressure than the state of Virginia.10
Healthcare Providers and Services
In the Rockbridge Area, there are multiple sources of care for residents, including health departments, a hospital, health centers, pharmacies, and private providers.
The Health Departments of both Buena Vista and Lexington provide access to immunizations, family planning, prenatal care, the Women, Infants and Children (WIC) program, environmental health services, and dental care.12
The Carilion Stonewall Jackson Hospital is part of the Critical Access Hospital federal program, which helps rural communities maintain their health care facilities. Consequently, the financial viability of this small hospital is strengthened through enhanced reimbursements. The hospital provides 24-hour emergency care services and maintains access to primary care. However, it has no more than 25 inpatient beds and the length of patient stays average no more than four days. Patients who need more intensive or longer-term care are generally transferred to another facility outside of the Rockbridge area. An urgent care clinic was established at the hospital in 2016.
Carilion Stonewall Jackson Hospital13
As of 2012, there are ten private primary care practices in the area. Though eight of these practices accepted new patients, only two practices accepted new Medicaid clients.14
The Rockbridge Area Free Clinic became the Rockbridge Area Health Center (RAHC) after receiving recognition as a federally qualified health center. Such health centers receive grant money from the Public Health Service Act and qualify for Medicaid and Medicare reimbursement.15 This non-profit community-directed provider is open to all residents, regardless of ability to pay or insurance status. Along with providing comprehensive health care services, the health center provides assistance that help its patients access care, such as transportation, translation, and case management. In addition, the Health Center is cost-effective, reducing expensive emergency, hospital, and specialty care. The former Development Director of the RAHC speaks positively about the impact of the Health Center in providing care in the community:
Although there are several local health care providers, these resources are often least accessible to those who need them most. The federal government designates certain geographic areas, population groups, or healthcare facilities as having a shortage of health professionals (primary, dental, mental health), deeming them Health Professional Shortage Areas (HPSAs). Of these, the Rockbridge Area has the following designations as specified in the 2015 Rockbridge Area Community Health Needs Assessment:
- Low-income residents of Buena Vista, Lexington, and Rockbridge County are a Medically Underserved Population;
- Low-income residents of Buena Vista, Lexington, and Rockbridge County live in a Primary Care Health Professional Shortage Area and a Dental Health Professional Shortage Area; and
- The entire Rockbridge service area is labeled as a Mental Health Professional Shortage Area.17
Locally, there are twelve private mental health providers, only two of which accept Medicaid and Virginia's public insurance program for pregnant women and children.18 Rockbridge Area Community Services (RACS) provides mental health and substance abuse services, including emergency services to low- income children and adults. However, with an approximate three-month wait for psychiatric services and no inpatient mental health facilities in the whole Rockbridge area, mental healthcare is limited.19
Maternal and Prenatal Care
Although teen pregnancy rates in the County (107.7 per 1,000) are higher than the state (89 per 1,000),20 there is no labor and delivery unit in the Rockbridge area. Therefore, expecting mothers must deliver at Augusta Health in Fishersville, Virginia. Though full prenatal care is available through the Lexington Health Department, 18.80% to 27.20% of Rockbridge area women enter into prenatal care late after the first trimester. This rate of late access is a significantly higher than the state's average of 17%.21 Late access to prenatal care, combined with other social risk factors, lead to poor prenatal and perinatal health indicators in the area, including high infant mortality (19.5 per 1,000 births) in the County, which is 3 times higher than the State (6.2 per 1,000 births).22
Insurance Coverage and the Affordable Care Act
In the 2015 Rockbridge Area Community Health Needs Assessment, 47.2% of respondents reported that cost prevents them from receiving needed healthcare.23 Medicaid is a public health insurance program for low-income people, with different eligibility requirements determined by states. In Virginia, eligibility for Medicaid is very restrictive, as applicants must meet certain criteria based on income and assets. Although some people living below the FPL are eligible for Medicaid (pregnant women, children and their parents, the elderly, and disabled people); childless adults are not.
Under the Affordable Care Act, thirty-one states plus the District of Columbia have chosen to expand Medicaid coverage.24 Virginia did not. Without the Medicaid expansion, 191,000 uninsured adults remain in the so-called "coverage gap," meaning their incomes are above Medicaid eligibility levels but too low to be eligible for Marketplace subsidies (generally 138% FPL).25 These subsidies decrease the cost of purchasing private health insurance on the federal exchange.26 Even for those with higher incomes who might qualify for Marketplace subsidies, enrollment is open only for three months of the year, compared to the year-round enrollment period for Medicaid and Children's Health Insurance Program.27 In Virginia, the uninsured rate decreased from 13.3% in 2013 to 13% in 2014.28 However, community health centers report a 20% increase in uninsured patients over the past two years.29
Although aging is a natural part of life, the elderly population is at greater risk for poverty-related problems as personal savings diminish with time and medical complications and expenditures rise. In addition to needing more medical and social services, the size of Rockbridge County, coupled with limited access to transportation, increases social disconnection and isolation among area seniors. Jeri Schaff, Executive Director of the Valley Program for Aging Services, explains that due to this sense of seclusion, simply talking to someone can make their entire week.
Figure 8 shows that compared to Virginia and the nation, Rockbridge County has a significantly greater proportion of people 65 and older.32
Several local assisted-living facilities, although expensive, provide elderly people with personal care in a safe and social environment. Those with moderate to low incomes are often unable to pay for these services and rely on family and community resources.
Under the Americans with Disabilities Act, individuals are disabled if they have, "a physical or mental impairment that substantially limits one or more major life activities. This includes people who have a record of such an impairment, even if they do not currently have a disability."33 People with disabilities often face additional struggles that inhibit their ability to support themselves or their families. Employment, transportation, and healthcare challenges are further compounded by the correlation between disability and poverty.
In 2014 those with a disability made up a larger share of the U.S. population in poverty (29%) than those without a disability (12%).34 In other words, the disabled make up a greater portion of the U.S. population in poverty than they do the overall population. The percentages of individuals with disabilities residing in Buena Vista or Rockbridge County are significantly higher than the state and national percentages,35 as seen in Figure 9.
|Locality||Percent Persons in Poverty|
12016 County Health Rankings and Roadmaps: Virginia, (University of Wisconsin Population Health Institute, 2013), 1, accessed July 12, 2016, http://www.countyhealthrankings.org/app/virginia/2016/downloads.
2“The Virginia Health Care Landscape,” (The Henry J. Kaiser Family Foundation, May 20, 2014), accessed July 22, 2015, http://kff.org/medicaid/fact-sheet/the-virginia-health-care-landscape/.
3 Simpson, Rockbridge Area Community Health Needs Assessment, 26.
4 See in Table: Ranked Measure Data, "2016 Virginia Data," (University of Wisconsin Population Health Institute, 2016), accessed August 2, 2016, http://www.countyhealthrankings.org/app/virginia/2016/downloads.
52016 County Health Rankings and Roadmaps, 3, 5.
8Rockbridge Area Community Health Needs Assessment: Final Report, 131
11 [2016 County Health Rankings and Roadmaps, 3, 5.
12 "Carilion Stonewall Jackson Hospital," (GJ Hopkins), accessed November 5, 2015, http://www.gjhopkins.com/project/carilion-stonewall-jackson-hospital/.
13'Carilion Stonewall Jackson Hospital,' (GJ Hopkins), accessed November 5, 2015, http://www.gjhopkins.com/project/carilion-stonewall-jackson-hospital/.
14Simpson, Rockbridge Area Community Health Needs Assessment, 44.
15 What are Federally Qualified Health Centers (FQHCs)?" (U.S. Department of Health and Human Services), accessed October 27, 2015, http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/qualified.html.
16Katy Datz (former Development Director of the RAHC) in discussion with Jennifer Borman and Daniela Leon, June 4, 2015.
17 Rockbridge Area Community Health Needs Assessment: Final Report, 112.
18Simpson, Rockbridge Area Community Health Needs Assessment, 47.
20 "Virginia Indicators: Health," (Annie E. Casey Foundation), accessed August 20, 2015, http://datacenter.kidscount.org/data#VA/5/27/28,29,30,32,33.
21 Rockbridge Area Community Health Needs Assessment: Final Report, 136.
22"Virginia Indicators: Health."
23Rockbridge Area Community Health Needs Assessment: Final Report, 51.
24 "A 50- State Look at Medicaid Expansion," (Families USA), accessed November 4, 2015, http://familiesusa.org/product/50-state-look-medicaid-expansion.
25 "The Virginia Health Care Landscape."
27 "Open Enrollment Has Begun!," News, (Cover Virginia: Connecting Virginians to Affordable Health Insurance), accessed November 4, 2015, http://www.coverva.org/main_news.cfm.
28 "Five Years Later: How the Affordable Care Act is Working for Virginia," (United States Department of Health and Human Services, 2015), accessed July 14, 2015, http://www.hhs.gov/healthcare/facts/bystate/va.html.
29 "The Virginia Health Care Landscape."
30 Jeri Schaff (Executive Director at the Valley Program for Aging Services) in discussion with Jennifer Borman and Daniela Leon, June 6, 2015.
31See in table: Age and Sex, QuickFacts Beta, (United States Census Bureau), accessed July 22, 2015, http://www.census.gov/quickfacts/table/PST045214/00.
32 See in table: Age and Sex, "QuickFacts Beta."
33"What is the Definition of Disability under the ADA?" (Americans with Disabilities Act National Network), accessed July 5, 2015, https://adata.org/faq/what-definition-disability-under-ada.
34"How is Poverty Status Related to Disability?" (University of California Davis Center for Poverty Research), accessed July 5, 2015, http://poverty.ucdavis.edu/faq/how-poverty-status-related-disability.
35 See in table: Health, "QuickFacts Beta," (United States Census Bureau), accessed June 22, 2016, http://www.census.gov/quickfacts/table/PST045214/00.