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Southernmost Illinois

Minority Health Disparities in Rural Areas

Mike BularzFall 2012

Public Health 330Dr. Richard Barret

3

Southernmost Illinois:Health Disparities in Minority Populations

If you ever get a chance to beeline South through Illinois from Chicago, you will probably experience vast expanses of the great plains of America’s heartland, interspersed with single-intersection towns, a few aging rustbelt cities, and the college towns. Follow this path for upwards of 5 to 6 hours, and the view will start to change as you arrive in the rockier and forested landscape of the southern tip of Illinois. Here exists a paradox between the North and the South in a few contexts: The area, referred to as Little Egypt because of the fertile plains fed by the confluence of the Mississippi and Ohio rivers,1 was originally staked out to be the central hub of Illinois, Checagou2 was just a distant and impenetrable swamp at this time. The unexpected also emerges from the environmental geography of the region: great expanses of plains end to yield rock formations and hilly landscapes, this is due to the geological history of the shaping of Illinois: the flattening of the entire state by glaciers during the ice age didn’t reach out this far, and receded to leave the flat majority of the state, and more interesting topology in Southern and far Northwestern Illinois. 3 The last contradiction arises in terms of demography in the area: several urbanized towns boast heavy African-American and Hispanic populations, and are encumbered with poor socioeconomic status across several indicators: income, uninsured, teen pregnancies, and a prevalence of several chronic diseases.

Interestingly enough, the distribution of these two minority populations does not exactly mirror the distributions found in more urbanized northern counterparts. The spatial patterns of the populations differ somewhat in rural towns: African – Americans are further from city center, Hispanics further than African-Americans, and Whites at the center and far out in the country. The origins of these populations and their concentrations are the outcome of different economic factors transplanting or attracting different minority populations over time, and are the subject of speculation based on history. The causes of the population distributions are speculated in this paper, but it is imperative to first give an overall account of Illinois settlement patterns.

1 Musgrave, John. “Egypt.” Egypt. American Weekend, 13 July 1996. Web. 12 Dec. 2012.2 Original Native-American term, meaning “stinking onion”. It referred to the odorous and muddy landscape where the city was founded, and was eventually changed to “Chicago”. 3 Testa, Adam. “Our History: How Southern Illinois Came to Be.” Thesouthern.com. The Southern, 13 Oct. 2011. Web. 12 Dec. 2012.

Remnants of Un-derground Railroad

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Early Illinois Settlement Patterns

Exploration

The earliest settlement of Illinois (not including Native Americans) was by French explorers and fur and hide traders. The confluence of the Ohio and Mississippi rivers made the area an ideal trading post, and the French king even staked out a large buffalo hide tanning operation in the area between Grand Chain and Mound City. Settlement also occurred in Kaskasia, but the area was eventually wiped out by a flooding of the river which wiped out the town.4 Cairo, founded at

the southernmost tip of Illinois on a peninsula shaped like a crescent, was strategic for trade and future military operations.5 The War of 1812 established the port for takeover by English settlers, and the Civil War boosted the economy at the strategic location by providing medical services on the Red Rover hospital ship.6

Shift in Transportation and Rise of Industry

Hubs came and went in Illinois, the southern tip at Cairo being essentially the first in relation to others: St. Louis and Chicago overtook the spotlight as a canal was dredged through the muddy banks of Chicago, and was primed to be the new center of the Midwest. This all changed with the advent of rail, and boosters and speculators investing in Chicago, such as William B. Ogden, who purchased development rights door to door, and secured rail transport from Galena to Chicago.7 The industrial boon in Galena was mining for materials needed for Chicago’s construction, and similar economies thrived in Southern and Central Illinois, and were eventually connected with the Illinois Central Railroad. Southern Illinois enjoyed industries around coal, mining, and salt mines such as the one in Equality, IL.8

Settlement by Race, Early and Industrial Era Illinois

The majority of white settlement occurred from land speculators at this time traveling westward, as well as Appalachian whites who migrated from Kentucky and Virginia.9 Cairo and Equality garnered a large black population from the underground railroad routes by which slaves from the south traversed north to Chicago and Canada,10 the former being a safe rest-stop and the latter being a capture point by night hunters re-capturing escaped slaves to work in Equality’s salt mines.11 Urbanized areas attracted populations to work, including minority populations, as industrial processes demanded labor. This was particularly true in what is deemed the “Great Migration” of blacks in the 1950’s during the war, when mostly whites were abroad fighting, and the war itself generated a demand for

4 Keller, Fred. “Cairo-Kaskaskia - Southernmost Illinois History.” Southernmost Illinois History. N.p., n.d. Web. 12 Dec. 2012.5 Keller, Fred. “Cairo History - Southernmost Illinois History.” Southernmost Illinois History. N.p., n.d. Web. 12 Dec. 2012.6 Keller, Fred. “Red Rover Hospital Ship - Southernmost Illinois History.” Southernmost Illinois History. N.p., n.d. Web. 12 Dec. 2012.7 History of Chicago – William B ogden, St. Louis Canal8 Musgrave, John. “Black Kidnappings in Southeastern Illinois.” Black Kidnappings in Southeastern Illinois. N.p., Apr. 1996. Web. 12 Dec. 20129 Harris, Jesse W. “Dialect of Appalachia in Southern Illinois.” JSTOR. N.p., n.d. Web. 12 Dec. 2012.10 ”The Underground Railroad in Illinois, Freedom Trails: 2 Legacies of Hope.” The Underground Railroad in Illinois, Freedom Trails: 2 Legacies of Hope. N.p., n.d. Web. 12 Dec. 2012.11 Taylor, Troy. “The Old Slave House.” The Old Slave House. N.p., 2008. Web. 12 Dec. 2012.

Early River Barge

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labor as outputs increased.12

Modern Settlement Patterns by Race Hispanics

Research by the USDA – ERS (Economic Research Service) reveals a growing trend in Hispanic migrants settling in rural areas of the country, as opposed to the traditional migration pattern of Hispanics into southwestern states. Currently, more than half of Hispanics are settling in non-metro areas.13 The Carsey Institute attributes this trend to new migrants being recruited to work in rural meat-processing plants and other agricultural operations.14 Research into Central Illinois distributions of Hispanics further assesses barriers of integrating into existing communities, discrimination, language barriers, and access to schools and health care.15

12 Great Migration – History of Chicago13 Kandel, Willam, and John Cromartie. New Patterns of Hispanic Settlement in Rural America. Rep. no. 99. N.p.: United States Department of Agriculture - Economic Research Service, 2010. Print.14 Jensen, Leif. New Immigration Settlements in Rural America: Problems, Prospects, Policies. Rep. Durham, New Hamspshire: Carsey Institute, 2006. Print.15 Rafaelli, Marcella. “Challenges and Strengths of Immigrant Latino Families in the Rural Midwest.” Journal of Family Issues (2012): n. pag. Print.

0

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15

20

25

30

35

40

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pre 1 965 65-6 9 70-74 75-7 9 80-84 85-8 9 90-94 95-2000

Figure 8

Year of U.S. arrival for all foreign-born HispanicsPercent

Source: Calculated by ERS using data from Census 2000, SF3 �les.

High-growth Hispanic

Established Hispanic

Other nonmetro

Metro

Salt Mining

6

12New Patterns of Hispanic Settlement in Rural America/RDRR-99

Economic Research Service/USDA

Hispanic share of total county population, 1990Figure 4a

Source: Calculated by ERS using data from the U.S. Census Bureau.

Less than 1 percent

Metro

10 percent or higher

1-9 percent

Hispanic share of total county population, 2000Figure 4b

Source: Calculated by ERS using data from the U.S. Census Bureau.

Less than 1 percent

Metro

10 percent or higher

1-9 percent

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Blacks

There is increasing evidence of of what is deemed “black flight” of African-Americans from northern to southern states, and from urban to more rural and suburban areas. A few trends are speculated to contribute to this pattern of migration: 1) Decrease of industry and jobs in urban areas making it less attractive to live in cities for the urban poor is speculated to be causing blacks and other minorities to seek out jobs in rural areas and processing plants.16 2) Increasing gentrification of areas within cities is pushing the urban poor and minorities out into suburban and rural areas, and suburban areas are abundant in cheap housing options as property owners scramble to sell or attract tenants after the housing crisis.17 3) On a positive note, blacks are seeing an increase in social mobility with higher educational attainment and are populating the farther suburbs of cities, such as Chicago’s southern suburbs.18 4) Decreased racial tensions in urban areas in the southern states are attracting more blacks than whites.19 These several factors, whether contributing to lower-class African-Americans or higher class, are in general perceived to be causing a reversal of the Great Migration.

16 Godfrey Ukpong, Onoyom. Yankee Migration: Causes and Reverse Trends in Urbanization. Rep. Louisiana: Southern University, n.d. Print.17 Greene, Richard P., Mark Jansen. Bouman, and Dennis Grammenos. Chicago’s Geographies: Metropolis for the 21st Century. Washington D.C.: AAG, Association of American Geographers, 2006. Print.18Greene, Richard P., Mark Jansen. Bouman, and Dennis Grammenos. Chicago’s Geographies: Metropolis for the 21st Century. Washington D.C.: AAG, Association of American Geographers, 2006. Print.19 Frey, William H. The New Great Migration: Black Americans’ Return to the South. Rep. Washington D.C.: Brookings Institute, 2004. Print.

Figure 1. Black Net Migration, U.S. Regions, 1965–2000

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-200,000

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0

100,000

200,000

300,000

400,000

1995–20001985–901975–801965–70

WestMidwestNortheastSouth

Source: Author’s analysis of 1970, 1980, 1990 and 2000 decennial censuses.

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Physical Health Disparities in Rural Areas in AmericaFocus Area - Nutrition and Physical Health

The focus of this work is the physical health – and inficators manifested in prevalence of chronic diseases such as Obesity, Diabetes, and diseases of the heart, incidence of deaths from stroke, complications from diabetes or obesity, as well as hospitalizations attributed to these diseases. I also examine southern Illinois in terms of indicators linked as contributors to these chronic diseases. Indicators, referred to as “risk factors”, examined at the level of individuals and populations include the availability of healthy food sources and level of physical activity and exercise. Community and environment-level factors examined include availability of preventive, emergency, and supplemental (government-sponsored community health centers) care, as well as broader socio-economic status and indicators by race categories, such as income, poverty, insurance coverage, and ability to drive.

Differences between Urban and Rural Health

The health problems of rural minorities often mirror the problem of those of urban areas, but are not necessarily of the same causation. For example, poor nutritional environment is may not be because of an abundance of cheaper, high calorie “meals” like in urban areas, but more likely caused by general dearth of grocery outlets and options in less-densely populated areas. Examining the issue in southern Illinois requires understanding rural health disparity patterns, as well as urban ones as there are both, urban and rural areas in this

part of the state.

Prevalence of Chronic DiseasesIn general, health disparities are markedly higher in rural areas than in urban areas. African-Americans have higher prevalence of self reported fair or poor health (determined through National Health

Interview Survey asking to rank themselves as on average, very good health, good, fair, poor), and hispanics rank the highest.

Diabetes in Rural America

Certain chronic disease categories has significant variation by race in rural and urban areas. Diabetes affected African-Americans significantly higher than Whites, Hispanics, and Asians as a percentage of population. The number was significantly higher in areas classified “small-adjacent rural” meaning rural areas adjacent to an urban area; 12.6% of urban blacks had diabetes, while 15.1% of all rural blacks had diabetes. Within the rural category, 17.2% or “small adjacent rural” blacks had diabetes. Probable cause for this pattern may be the settlement of blacks near urban centers or micropolitan areas as opposed to far rural areas.20

20 Van Nostrand, Joan, DPA. Health Disparities: A Rural-Urban Chartbook. Rep. Columbia, SC: South Carolina Rural Health Research Center, 2010. Print.

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Obesity in Rural America

A similar distribution occurred for blacks and hispanics in the distribution of obesity rates among rural versus urban classifications, with some minor differences. Overall, blacks were more obese than Whites and Hispanics, and obesity was higher in rural America in general. Hispanics had higher obesity rates within the micropolitan rural and small-adjacent rural areas. This was true for blacks as well, but obesity among blacks increased out into remote rural areas as well, whereas remote rural hispanics were significantly less obese.21

Access to Care and Quality of CareAvailability and Quality of Care Facilities

The base economics of low density population hamper rural access to various necessary care facilities: Doctors need density of patients, Hospitals need patients and a labor force, and it is difficult to blanket large regions with community health centers and preventive services as well. Further, it is challenging to maintain a high standard of care with limited training and resources.22

Barriers from the Individual’s End

To complicate things, most rural residents don’t have insurance, as well as money or time to seek proper health care.23 Barriers exist in the larger community as well, as individuals’ inner and outer circles, as well as broader community do not promote proper health.24 Contributing factors to health disparity exist in the built environment as well, with limited availability of quality produce, and oversaturation with convenient and unhealthy meal options (“food swamps”).

Environment, Community, and CultureNutrition in Rural America

Surprisingly, rural residents have poor food choices like their urban counterparts. This is particularly true in micropolitan areas and small-adjacent rural areas, where there are significant low-income populations either not attracting healthy food options due to financial constraint or healthy food options are limited due to particular cultural choices.25 USDA - Economic Research Service mapping of income and distance to grocery stores posits that

21 Van Nostrand, Joan, DPA. Health Disparities: A Rural-Urban Chartbook. Rep. Columbia, SC: South Carolina Rural Health Research Center, 2010. Print.22 Maripuri, Saugar, and Martin MacDowell. Addressing Rural Health Disparities in Illinois. Rep. N.p.: University of Illinois at Rockford, n.d. Print.23 Ziller, Erika, and Jennifer Lenardson. Rural-Urban Differences in Health Care Access Vary Across Measures. Rep. N.p.: Maine Rural Health Research Center, n.d. Print.24 Reardon, Kenneth M. “Enhancing the Capacity of Community-Based Organizations in East St. Louis.” Enhancing the Capacity of Community-Based Organizations in East St. Louis. N.p., n.d. Web. 12 Dec. 2012.25 Smith, Chery, and Lois W. Morton. “Rural Food Deserts: Low-income Perspectives on Food Access

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the distribution of food deserts (defined by census tracts with 33% low income bracket individuals with less than 5 grocery stores within driving distance of 5 miles) are not primarily urban, contrary to popular belief and the focus of most studies. Although I was not able to calculate percentage Urban Vs. Rural populations for the U.S., for Illinois, 89% of the population living in food desert tracts is Urban, whereas 11% is Rural. This indicates that, although food deserts are located mostly in urban areas, there is still more than 1/10 of the population in food deserts is rural, in Illinois. (See Illinois Health section)

Exercise & Fitness in Rural America

Rural populations face similar disparities in terms of exercise and physical fitness26, it is likely that the near-urban and rural environments require a car to get to around in general, and the ability to walk places, accompanied by availability of parks and recreation opportunities is limited. Studies show that a portion of rural and near-urban work is shifting to less labor-intensive jobs,27 but the connection between labor intensive jobs and fitness is not necessarily comparable, in fact, many would argue that labor intensive jobs are a cause of poor health.28 Rural populations have very close numbers to urban populations in terms of general exercise: 45% of Urban Residents met moderate or vigorous exercise guidelines, while 44 % of rural did the same.29 Hispanics in urban adjacent areas showed higher activity than Hispanics in other categories, while Blacks showed higher in far-rural areas.

Access to Care

A key obstacle for good health in rural residents is access to adequate medical care. Many rural residents do not produce enough of a draw to attract hospitals, doctors, and other wellness / preventive services. Often, rural residents will need to rely on social safety nets – nonprofit and government sponsored community health centers. The locations of these are often not sufficient to meet the needs of rural and near-urban residents, as the centers are located primarily in urbanized areas.30

in Minnesota and Iowa.” Journal of Nutrition Education and Behavior 41.3 (2009): 176-87. Print.26 Van Nostrand, Joan, DPA. Health Disparities: A Rural-Urban Chartbook. Rep. Columbia, SC: South Carolina Rural Health Research Center, 2010. Print.27 ibid 28 “Labor Intensive Industry.” EconoWatch. N.p., June 2010. Web. 12 Dec. 2012.29 Van Nostrand, Joan, DPA. Health Disparities: A Rural-Urban Chartbook. Rep. Columbia, SC: South Carolina Rural Health Research Center, 2010. Print.v30 Removing Barriers to Care: Community Health Centers in Rural Areas. Rep. N.p.: National Association of Community Health Centers, 2011. Print

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Illinois “Southern Seven” Diabetes Risk Factors:Indirect Contributing Factors

Direct Contributing Factor Poor school lunch programs Limited availability of fruits /

vegetables Low income neighborhoods

Lack of Farmer’s Markets in all counties Indirect Contributing Factors

Direct Contributing Factor Cultural / Family norms

High fat diet Abundant Fast Food Restaurants

Risk Factor Low income level Poor Diet Indirect Contributing Factors

Direct Contributing Factor Large serving sizes at restaurants

Portion Sizes Lack of education

Cultural / Family norms Indirect Contributing Factors

High soda intake

Excessive intake of simple sugars / caffeine Cultural / Family norms / High poverty

Abundant fast food restaurants Indirect Contributing Factors

Direct Contributing Factor Lack of self motivation

Sedentary lifestyle Lack of time / resources

Nature of employment/physical limitationsIndirect Contributing Factors

Obesity / Diabetes Type II

Risk Factor Direct Contributing Factor Community Finances

Lack of Physical Activity

Walking Routes / Safety / other venues

City Council leaders without health focus

Crime in the community

Direct Contributing Factor Indirect Contributing Factors Inadequate / Lack of incentives

Lack of Motivation / Time Lack of understanding / education Indirect Contributing Factors

Direct Contributing Factor Incomplete records

Lack of Family History Knowledge Lack of communication

Lack of genetic testing Indirect Contributing Factors

Direct Contributing Factor Chemical exposures

Genetic Mutation Radiation exposures

Risk Factor

Direct Contributing Factor

Genetics Indirect Contributing Factors

Parents

Indirect Contributing Factors

Direct Contributing Factor Race / Ethnicity

12

Illinois Health Disparity PatternsPrevalence of Chronic DiseasesObesity

Obesity and Nurtition disparities are significant in Illinois, especially when examining rural communities. Illinois ranks at 61.7% obese (gauged by BMI) as compared to the national average of 61.1%. Obesity rates (percentage or population obese) are actually higher in rural communities than urban ones.31 The highest obesity rates are in southern counties, and counties by the St. Louis / East St. Louis metro area.

Obesity and the Environment in Illinois

The distribution of obesity patterns in Illinois is somewhat correlated with risk factors such as availability of healthy food outlets, consumption of fruits and vegetables, and physical activity / inactivity, this is especially true when comparing in terms of North vs. West vs. South.

Other risk factors include access to healthy food. The USDA Food Desert locator highlights a majority of food deserts around St. Louis metro area, far southern Illinois, and parts of Chicago and Rockford.

A further complication is the ability for residents to drive in these areas. Examining data from the American Community Survey, there are pockets where people walk to work. This could indicate inability to afford a car.

Diabetes

Diabetes distributions in Illinois seem to mirror the patterns seen in Obesity and Nutrition distributions. This isn’t surprising as the Diabetes is often associated with poor diet habits. Diabetes can be closely tied to most of the same risk factors: Physical Inactivity, Poor Diet (Limited Furits and Vegetables, High-fat Diets), Genetics, as well as contributing factors (ex. Crime and a neighborhood’s walkability, and the amount of physical activity of individuals. See Figure on Next page). Diabetes, and diabetes risk factors are concentrated in Southern and Southwestern Illinois similarly to obesity.

31 Arnold, Damon T. Illinois Strategic Plan: Promoting Healthy Eating and Physical Activity to Prevent and Control Obesity 2007 – 2013. Rep. Springfield, IL: Illinois Department of Public Health, 2012. Print.

Puerto Rican

White Population Black Population

Cuban

MexicanHispanic - All RacesAsians

American Indian or Alaskan Native Single Mothers New Single Mothers 2011(Under Poverty Line)

13

Fair Poor Health 2007

Fair or Poor Health, 2002 Fair or Poor Health, 2003

Fair or Poor Health, 2008

Fair or Poor Health, 2006Fair or Poor Health, 2005Fair or Poor Health, 2004

Fair or Poor Health, 2009 Fair or Poor Health, 2010 Fair or Poor Health, 2004 to 2010

Overall Illinois Health: National Health Interview Survey participants were asked: On an average day, is you health Very good, Good, Fair, or Poor? Maps show fair or poor health

White Diabetes

All Obese Hospitalizations White Obese

Hisp Diabetes

All Diabetes HospitalizationsBlack ObeseHispanic Obese

Uninsured, All Uninsured,Under Poverty Line

Incidences of Hospitalizations from Diabetes or Obesity Compli-cations, by Race or Ethnicity

14Obesity Prevalence, NHIS:

Figure 11: Percentage of Adults Reporting Cardiovascular Disease Risk Factors, Illinois, 2003 and 2004

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Figure 6: 2006 Illinois Adult Weight Prevalence by Region

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Data Source: Illinois Behavioral Risk Factor Surveillance System, 2006

Risk Factors to Health

There are several risk factors to consider in assessing risk and prevalence of populations for Obesity, Diabetes, and Heart Disease. Several of these risk factors are prevalent in Illinois rural areas, particularly south and southwest: BMI and overweight rates are higher in rural areas, poor nutrition is higher in rural areas and rural adjacent to small urban.

Food Deserts

Another risk factor to consider is access to food; the USDA Economic Research Service publishes data from their “Food Desert Locator”, which tracks areas in the US which have low income populations that are far away from a healthy food source such as a grocery store. This data, combined with the ability to drive to a store (car ownership) highlights the issue further - residents in southern and western Illinois need to drive to the majority of destinations, but cannot do so because they don’t own a vehicle and public transportation is often limited, if an option at all.

Urban 89%

Rural 11%

Urban

Rural

Rurality of Illinoisans living in Food Deserts:

11% Rural89% Urban

15

Illinois Food Deserts, with darker values representing percentage of population under poverty with no vehicle. Southern Illinois and the St. Louis metro have the highest number of people with difficulty accessing healthy food options.

16

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Access to Rural Health Centers

Key potential for attacking the issue of disparities lies in strengthening the effectiveness of our Rural Health Centers. The current distribution of health centers is primarily in urban areas. An analysis of populations within 5, 10, 15, and 20 mile driving distances revealed the following:

• Almost no populations under the poverty level live within 5 miles of a community health center

• The majority of the poverty population was within the 15 and 20 mile range

• Poor Blacks lived primarily within 15 mile, and 20 mile driving distances, whereas Hispanics live in further reaches (20 miles or more)

It is evident that siting health centers in small municipalities may be convenient for running the centers, but is highly incovenient for the rural populations needing the most care. Offering a shuttle service, or working with the public transportation system may offer a solution other than siting centers in more rural areas. Looking for clusters of low-income individuals may be an option for siting satellite offices, or small scale health centers.

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Alton

Pekin

Dekalb

Ottawa

Normal

Urbana

HerrinMarion

Quincy

MortonCanton

Peoria

Macomb

Pontiac

Bradley

Rantoul

Decatur

Mattoon

Godfrey

Lincoln

Kewanee

Sycamore

Kankakee

Danville

Sterling

Champaign

Effingham

Centralia

Galesburg

Charleston

Carbondale

Bourbonnais

Bloomington

Glen Carbon

Taylorville

Springfield

East Peoria

Mount Vernon

Collinsville

Jacksonville

Percent Minoritywithin 20 Miles

! 0.000011 - 1.013780

! 1.013781 - 2.407460

! 2.407461 - 4.353350

! 4.353351 - 7.076070

! 7.076071 - 12.015400

! 12.015401 - 21.952801

! 21.952802 - 53.849602

Alton

Pekin

Dekalb

Ottawa

Normal

Urbana

HerrinMarion

Quincy

MortonCanton

Peoria

Macomb

Pontiac

Bradley

Rantoul

Decatur

Mattoon

Godfrey

Lincoln

Kewanee

Sycamore

Kankakee

Danville

Sterling

Champaign

Effingham

Centralia

Galesburg

Charleston

Carbondale

Bourbonnais

Bloomington

Glen Carbon

Taylorville

Springfield

East Peoria

Mount Vernon

Collinsville

Jacksonville

Poverty population by closestRural health Center

Population in Poverty

Black, up to 20 Miles

Hispanic, up to 20 Miles

White, up to 20 Miles

18

ILLINOIS AND THE PPACA (Patient Protection and Afforable Care Act)

Health Insurance Exhanges

The Future of Public Health Policy, especially for Southern Illinoisans, is due to change. WIth the passage of the Patient Protection and Affordable Care Act (PPACA)a few years ago, there are two things that will be occuring in the next three or so years: Illinois will set up centers referred to as Health Insurance Exchanges (HIE’s) where private insurance companies will pool resources to provide coverage for many residents who cannot currently afford health insurance, are uninsured, or have pre-existing conditions. These new centers will give residents options for purchasing insurance. HIE purchasing for rural ans small-urban periphery blacks, as well as rural Hispanics will greatly decrease the disease disparities faced by these two minority groups in rural southern Illinois.

Increased Community Health Centers

Implementation of final stages of PPACA will create more community health centers as demand for services grows. These centers, if placed optimally in rural areas, will ensure that populations in poverty with low access to current centers receive better coverage. Increasing the amount of centers, as well as existing center capacity will allow more preventative care and decrease mortality rates for diseases.

Percent Unin-sured, Under Poverty

White Unin-sured, Under Poverty

Black Unin-sured, Under Poverty

19

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