Rural North Carolinians Face Disproportionately Long Travel Distances to Health Care

Workers' and families' need for paid family and medical leave is a topic of growing discussion in North Carolina. Governor Roy Cooper signed an executive order providing paid parental leave to state workers when he took office, and more than a dozen cities and counties also provide paid parental leave or broader paid family and medical leave to public employees. But for private sector workers in the Tarheel State, paid leave access is entirely dependent on an employers' decisions whether to provide leave to new parents and to workers addressing their own health condition or caring for a loved one.

For North Carolinians in rural areas — about 19 percent of the state's population, spread across 80 of the state's 100 counties — there is a unique need for paid leave. Demographic and economic factors, including lower rural per capita household incomes relative to urban areas, disparities between rural white and Black, Latine and Native American median household incomes, and higher poverty rates in rural areas of the state mean rural households are more likely to struggle if a worker must take leave without pay or loses their job. An aging rural population means rural communities must also simultaneously attract enough workers to fill jobs and ensure that older adults are able to get the family-provided care they need.

The longer distances that people in rural communities must travel to get to hospital-based care, relative to people in metropolitan areas of the state, only exacerbates the challenges that rural North Carolinians have accessing care. For rural communities, where long distances to hospitals and lack of paid leave together have significant implications, guaranteed access to comprehensive paid family and medical leave is a necessary intervention.

Access to Paid Leave

Overall, less than one-quarter of private-sector workers nationwide (24 percent) — and just 22 percent of workers in the South Atlantic region, which includes North Carolina — have paid family leave through their jobs, according to the Bureau of Labor Statistics. In North Carolina, even job-protected unpaid leave is available and estimated to be affordable for 12 weeks to only 35 percent of workers overall and just 34 percent of parents with children under 18, according to researchers from Brandeis University; even smaller shares of Black workers (29 percent), Latine non-immigrant workers (27 percent), and Latine immigrants (16 percent) in North Carolina have both job protection and the ability to afford an unpaid leave for 12 weeks.

Rural workers have even less access to both employer-provided paid family leave and paid sick leave than workers in metropolitan areas because the types of jobs that are most prevalent in rural communities are less likely than others to offer paid leave benefits. Rural workers also have reduced access to job-protected, unpaid leave through the Family and Medical Leave Act of 1993 (FMLA) because they tend to work for smaller employers and are more likely to work part-time. All of this is true for North Carolina: In the state's rural counties, 70 percent of businesses have 10 or fewer workers, which makes the provision of employer-based paid leave very unlikely. The industries that are most prevalent — manufacturing, retail, food service and accommodations, health care, and construction — also tend not to provide paid leave to workers.

Lack of access to paid leave can force impossible choices between keeping a job, feeding a family, and getting or helping a loved one to get the health care they need.

Distances to Hospital-Based Health Care Services

In 2022, the Better Life Lab at New America — supported by new, commissioned analysis conducted by researchers from the University of North Carolina — released a report, Health, Work, and Care in Rural America, tying together new analysis of rural disparities in access to paid leave and new calculations demonstrating the long and disparate distances that rural people must travel to seek six specific types of hospital-based health care services: obstetrics care, NICU care, pediatric care, cardiac care, cancer screening, and cancer treatment. [1]

New state data analysis augments our national findings: Rural North Carolinians must travel more than twice as far as urban residents for NICU, pediatric, cardiac and cancer treatment, and they must travel further for obstetrics and cancer screening services as well.

In North Carolina, NICUs are an average of 32 miles from rural communities, but just under 14 miles from metropolitan areas; hospital-based pediatric care is 30 miles from rural communities and 14 from metropolitan areas. For rural communities that are furthest from hospitals, people must travel 42 miles or more to reach NICU and pediatric hospital-based care.

Hospital-based obstetrics care is also further for rural residents — an average of 21 miles, compared to 12 miles — which may disproportionally affect Black and Native women, for whom maternal health risks are greater. For rural people furthest from hospitals, an obstetrics department may be 25 miles away or more.

Workers with serious health issues and their caregivers also face significant distance disparities: Cancer treatment and cardiology care are more than 21 and 23 miles away from rural communities, but just 10 and 12 miles, respectively from metropolitan ones. For people in more remote rural communities, distances to these services can be 30 miles away or more.

Cancer screening is also further for rural residents — an average of 20 miles, compared to 12 miles — which may disproportionally affect people of color, for whom health risks are greater and screening rates are lower, in part because of workplace leave-related challenges.

Implications: Comprehensive Paid Leave Will Strengthen Rural North Carolina

Hospital distances and lack of paid leave together have significant implications, especially for people in rural communities where labor force participation rates are already lower than in other communities, where measures of good health are lower, and where caregiving needs are higher. For example, research cited in our main national report shows that rural cancer patients are better able to return to work when they have paid leave and workplace flexibility, that hospitalized children recover more quickly when a parent can be at the hospital with them, and that cancer treatment recommendations are followed more closely when patients and caregivers have and use paid leave. Additional research shows that paid leave contributes to workforce retention for new parents and caregivers and higher earnings for mothers; positive impacts for businesses; and, as a result, improves the potential for economic growth.

North Carolina's policymakers should evaluate the evidence, the needs of all geographic areas of the state, and key demographic, business and economic trends, and they should consider joining 11 states and the District of Columbia in passing a comprehensive, inclusive statewide paid leave program. Paid leave is an family, health and labor force issue, and for rural communities in particular, it's a factor to consider in economic development as well.

Hannah Friedman, a doctoral candidate in the Department of Health Policy and Management at the Gillings School of Global Public Health and The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, provided the North Carolina hospital-distance data analysis used in this blog. Dr. Erin Kent at the UNC Sheps Center advised on the project and conducted some additional analyses.

[1] Distances to hospital-based health care services are measured from the middle of each census tract. Census tracts are classified as rural or metropolitan using RUCA codes. Data on hospital services is from the American Hospital Association Survey. Files used for mapping are from the National Historical Geographic Information System. For more information on our methodology, please see descriptions in Health, Work, and Care in Rural America.