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• Working on Wellness: The Rural Health and Employment Link

Transcript

Tim Sablik: My guests today are Surekha Carpenter and Bethany Greene. Surekha is a senior research analyst and Bethany is a regional economist, both at the Richmond Fed. Surekha and Bethany, welcome back to the show.

Surekha Carpenter: It's great to be back.

Bethany Greene: Thanks for having us.

Sablik: Our topic for today is an Econ Focus article you both wrote alongside your colleague, Stephanie Norris. The article explores the link between health and employment, with a particular focus on rural places.

To start off, how do health and employment interact with one another?

Greene: Basically, health impacts employment and employment impacts health. A person's health status — whether it be having a chronic condition like arthritis, having a physical injury, or having a mental health condition like depression or anxiety — can impact their ability to perform their job. It can impact their productivity and the number of hours they are able to work. It can also determine whether a person is able to participate in the labor force at all.

Employment also impacts health, right, often in ways people that don't always think about. It is a key social determinant of health. Having a job provides income, which is crucial for accessing health care — whether that's paying for a doctor's visit, medication, or treatment. Employment also provides financial stability and that can reduce stress — there is less anxiety about making ends meet, paying rent, putting food on the table. Of course, a lot of jobs come with employer-sponsored health insurance — that can be the difference between getting preventive care or letting health problems go untreated.

Since there is this two-way relationship, there can be a feedback loop that can spiral in a negative direction. Think about the fact that poor health can lead to job loss. That can lead to reduced income, loss of health insurance. That can then lead to financial stress, which can make health even worse. And then that worse health can make it more difficult to work, and the cycle continues.

Carpenter: When we were writing this article, I found it helpful to think about this bidirectional link through examples.

Take a factory line worker. The job requires standing for long periods [and] the physical ability to interact with the manufactured product on the line. Obviously, health is very important to this individual's ability to perform the tasks of the job. Without being able to stand and stay on their feet or reach comfortably across the line, for example, keeping this job would be hard or impossible.

If the factory line worker happens to sustain an injury — perhaps a hand injury — and they can no longer perform the duties of the job, they may be out of a paycheck while they take time off to recover. If that injury lingers, they could face job loss, as Bethany was describing. In that scenario, they risk losing employer-provided health insurance. Income loss or health insurance loss may mean that this person's ability to access health care takes a hit, hindering their recovery. If there are chronic conditions that arise from that scenario — lasting physical pain or, as Bethany was mentioning, anxiety or depression about not being able to work — that could continue to impact the individual's ability to stay employed or regain employment.

Of course, we have Social Security Disability Insurance to help mitigate those negative effects. But just as an example, it's clear how intertwined employment and health can be.

Sablik: I mentioned at the beginning that your article focuses particularly on rural places. Turning to those geographical differences, Surekha, how does the rural employment picture compare to urban employment?

Carpenter: There are a couple of differences that we could discuss. Those have to do with things like employment participation, demographics, or the types of employment available across those different geographies.

Generally, there tend to be poorer employment outcomes in rural counties across the Fifth District. Let's take the employment-to-population ratio to start. The employment-population ratio measures the proportion of the working-age population that is employed, expressed as a percentage. We routinely see that our urban counties have a larger percentage compared to our rural counties.

However, this ratio doesn't show the clearest picture of employment due to two factors. First, this counts working-age individuals — so, those age 16 years and older with no age cap. It also only captures individuals that are employed, not those that are seeking employment.

We can get more specific by looking at the labor force participation rate of just prime-age working individuals. Labor force participation captures those employed and also those actively looking for work, and prime-age individuals are those age 25 to 54. This is a useful metric because rural areas tend to be older. But even for this metric, using 2023 estimates, labor force participation rates in our most rural counties were still nearly 20 percentage points lower than our most urban counties. Therefore, we are still seeing a consistent underutilization of labor in our district's rural areas.

Another notable difference between urban and rural places is the type of jobs that are available. Jobs in rural places tend to be more physical, more physically demanding. And, there generally are fewer professional services and administrative roles compared to urban areas.

Sablik: Yeah, we'll get into why those differences in occupations matter in a moment. But that sort of covers the employment differences between rural and urban. How about health? How do rural health outcomes compare to urban ones?

Carpenter: A good baseline of overall health is life expectancy at birth. Across our Fifth District states, the median life expectancy is three to four years higher in urban counties compared to rural ones.

The University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation have built out a national county health ranking. They have complied a comprehensive list of uniform health measures so that we can compare the outcomes across geographies.

One measure they report and that we included in the District Digest article is average number of physically and/or mentally unhealthy days. Now this metric is self-reported but, as we discussed in the article, that can be insightful as to how individuals gauge their own wellbeing. Observing trends across geographies showed us that, consistent with other measures, individuals from rural counties reported more unhealthy days than their urban counterparts.

Similarly, self-reported disability rates provide a window into how populations feel about their own health and capabilities. When we looked at self-reported disability rates across the rural-urban continuum, we again observed higher rates in rural places. Cutting self-reported disability rates by age, we found that the rate doubled for individuals between 35 and 64 in our most rural counties compared to our most urban ones. That suggests that there are significant differences in rural health outcomes.

Sablik: Yeah, let's dig into what could be driving some of those differences. Bethany, what specific challenges may contribute to worse health outcomes in rural places?

Greene: First off, rural areas in our district are very diverse. So, by no means am I suggesting that living in a rural area automatically translates to worse health outcomes.

But there are some features common to many rural areas that can create real barriers, both to health and healthcare access. Understanding these features helps explain why we see some of the patterns that we do like Surekha mentioned before.

One of the most fundamental characteristics of rural areas is low population density — people are simply spread out over larger distances. And when you're living in a sparsely populated area, that often means you're traveling much longer to access essential services, and healthcare is a big one.

We're not talking about a five- or 10-minute drive to the doctor. For some rural residents, it might be 30 minutes, an hour, or even longer to get to the nearest clinic or hospital. That places a much greater burden on rural residents compared to their urban counterparts. And, in the event of an emergency — for example, a heart attack, a stroke, a serious accident — those extra minutes or hours of travel time can be absolutely critical. They may not receive the healthcare that they need in time.

It's not just about emergencies. Distance creates barriers to routine care as well. If someone has to take half a day off work just to drive to and from a doctor's appointment, they may be much less inclined to go, especially if they're paid hourly and losing that time means losing income they can't afford to lose.

Also, travel distances impact someone's ability to engage in certain health behaviors. In a rural area, a grocery store with fresh fruits and vegetables may be further away than a convenience store that may not have as many healthy options. Or, think about access to gyms, recreational facilities, or even safe places to exercise outdoors. These things can be much harder to access in rural communities.

Also, there are the social determinants of health that tend to be worse in rural areas. Rural areas, on average, have higher poverty rates. Someone with fewer financial resources may not be able to access adequate care, or they may delay care due to costs. There are really difficult trade-offs a person may have to make — whether they seek that health care out or they pay their rent or pay for their groceries.

Also, educational attainment and health literacy is lower. That may lead to more risky health behaviors and more difficulty understanding when to seek care or how to manage health conditions, or difficulty advocating for yourself while navigating the health care system.  

Sablik: Does the health care infrastructure in rural places also play a role in health outcomes?

Greene: Since 2005, there have been over 20 hospital closures in the Fifth District. These closures point to the unique financial challenges that exist in the rural hospital space. First, they have lower patient volumes — there are simply fewer people in the area to serve — so they don't have the same economies of scale that a large urban hospital might have. Second, a higher share of their patients are using Medicare or Medicaid, which have lower reimbursement rates than private insurance. Or, patients may be uninsured altogether, which means the hospital may not get paid for all the care they provide.

Because of these financial pressures, even hospitals that manage to stay open sometimes have to make really difficult decisions about cutting services. A common story is rural hospitals cutting their labor and delivery units. The same thing can happen with emergency services, surgical units, specialty care. These are critical services that are gradually disappearing from rural communities.

Sablik: Surekha mentioned that the composition of jobs in rural places tends to be different from urban places. How do the characteristics of the rural labor market intensify the interaction between health and work that we've been talking about?

Greene: Compared to urban areas, rural areas in the Fifth District have very different industry and occupational compositions. That can influence someone's ability to find a new job if they leave a previous job due to a medical event.

Rural areas tend to have higher concentrations of manufacturing, mining employment, and agriculture employment. These are industries we typically associate with higher levels of physical exertion. In the article, we find that in non-metro areas, more people are employed in occupations that require a high level of physical activity. For example, there may be fewer people working as web developers and more people working in, say, on-site construction.

In rural job markets, it may be more likely that a person who cannot stand for long periods of time or is easily fatigued may not find a job that accommodates their condition, like a desk job. So, their decision to leave the labor force may also be a reflection of a labor market that is not accommodative to their specific health condition.

Now, I also want to say not every work-inhibiting medical condition limits a person physically. Mental health conditions also can determine the type of job someone is able to perform.

Sablik: What are some ways that rural communities in the Fifth District are working to address health gaps and, as we've been discussing, also improve employment outcomes?

Carpenter: Communities, states, nonprofits, and schools are all doing their part to improve rural health gaps. Generally, there are two ways to approach bridging those gaps: by either increasing immediate access to health care or by addressing those underlying causes of poor health outcomes, the social determinants of health. Many communities are tackling these challenges from both sides.

With regards to improving access to health care, we see many innovative approaches to meeting people where they are. We highlight mobile clinics in the District Digest — this is a model that closes the distance between health care and patient, potentially easing transportation challenges. Additionally, many of these clinics are run by universities (who, by the way, are training the next generation of health care professionals) or nonprofits. In those cases, the university, community college, or nonprofit will often provide care for free or reduced cost, making critical services like dental or eye exams, or treatment of chronic conditions accessible to low-income or uninsured individuals.

Another model of increasing access to care is employer-based initiatives, where an employer brings health care service on site for a period of time or, in some cases, offers clinic services to employees on a permanent basis. Employees benefit greatly from those reduced travel times to care, like Bethany mentioned, since they need to report to work anyway.

When it comes to solutions on improving the social determinants of health, many communities are taking a wholistic approach. They recognize that there is a whole ecosystem of factors that influence poor health.

Take, for example, stable, affordable, quality housing. Without access to good housing options, individuals will have a harder time with stability in their wellbeing, their health, and employment. There are many factors like this that will influence people's wellbeing: access to childcare, access to fair credit and banking services, proximity to anchor institutions in their communities, feeling a sense of community within a town. These are all things that we heard about from economic developers or state health associations that we spoke to, and they can all be part of solutions.

Sablik: Do you have an example of these types of solutions in action in our district?

Carpenter: We had a conversation with the South Carolina Office of Rural Health, which is a non-profit organization that has a mission to close that gap in health status and life expectancy between their urban and rural communities in their state. They brought up this concept of "pride in place." The idea is that throughout rural revitalization and redevelopment or development, they aim to strengthen both the physical and social environment. Basically, they are aiming to make rural places fulfilling places to be, where residents can feel connected to their neighbors and community, to feel a sense of purpose and shed feelings of isolation that can occur in rural settings.

This type of development can be achieved through design — for example, providing walkable Main Streets with spaces for people to gather or just be around their neighbors in their community. Or, it can be achieved through the type of revitalization or development that the community prioritizes, like quality affordable housing or community centers.

We know that there are other similar models. Some of them are national, some of them are just grassroots and occurring in our district's communities.

Sablik: Surekha and Bethany, thank you so much for joining me today.