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.

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When Iowa Department of Public Health officials planned their health provider flu vaccinations, they learned that many Iowa providers were above the recommended age requirements to receive the live virus H1N1 vaccination. In fact, no providers in Van Buren County were below the cut off age of 49.

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.