Despite longstanding notions of country living as healthier and safer than life in big cities, people living in rural areas of the United States are often sicker and live shorter lives than city dwellers — dying from preventable diseases because of a shortage of providers and lack of consistent access to healthcare.
The Rural Health Transformation program funded by Congress last year will distribute $50 billion to states through 2030 to help upend grim rural-urban health disparities and offset the effects of an estimated $911 billion in Medicaid reductions over the next decade, courtesy of the One Big Beautiful Bill Act that Congress also passed last year.
But once the Rural Health Transformation program’s funding dries up, will improvements be sustainable?
That’s a driving question that informs the approaches of two different regional funders that have decades of experience funding health projects that last.
One of these two funders, the Pittsburgh-based Claude Worthington Benedum Foundation, was formed in 1944 by Sarah and Michael Benedum, drawing on an oil and gas fortune. It covers health programs in West Virginia, where its founders were born and raised.
The T.L.L. Temple Foundation, meanwhile, is based in Lufkin, Texas, and funds health programs in 23 counties in East Texas and one county in Arkansas. The founder, Georgie Temple Munz, started the foundation in 1962 in honor of her father Thomas Lewis Latané Temple, with stock from his timber business, the Southern Pine Lumber Company.
The two foundations’ approaches have a lot in common, including in their efforts to capitalize on local connections and trust to determine what works and what should be funded in rural communities. That level of local insight and networking is difficult to replicate by national grantmakers with fewer connections to rural communities, which is one reason that rural health and other rural causes remain underfunded by philanthropy as a whole. But for these foundations, proximity is paying off.
The Benedum Foundation backs community health workers in Appalachia
Kim Tieman, the vice president and program director of the Benedum Foundation, cites the foundation’s decade-plus of support for community health workers as a prime example of successful, sustainable health funding. “We haven’t paid a startup dollar in a new community health worker site in at least five years,” Tieman said. All told, this community health worker program, which was developed by Marshall University in Huntington, West Virginia, and funded initially by Benedum, now has 16 sites in West Virginia and has expanded to Kentucky and Ohio.
Working with medical practices, community health workers make home visits to patients who need extra support to manage their health. Marshall University’s community health worker program pilot focused on patients with diabetes in West Virginia’s Mingo County, part of the “diabetes belt” and “stroke belt” in Appalachia. The federal government’s Center for Medicare and Medicaid Services described the work Marshall was setting out to do with community health workers as essential chronic care management, Tieman said. “But they didn’t support financial mechanisms for it.”
Benedum stepped in to provide steady support for the launch of the program with public and other private foundation funding, and along with Marshall University, turned to Medicaid Managed Care organizations in the state to ask: “If we can prove that it works, will you pay for it?” The public payers were game, according to Tieman.
After a year of the pilot, results showed that for the 137 enrolled patients, there was a mean drop from 10.2% to 8.5% in patients’ A1C levels, a test that measures average glucose levels over a three-month period. Emergency room visits went down by 22% and hospitalizations by 30%. The public payers began paying for community health workers in 2018.
One of the reasons for the program’s success, Tieman said, is that community health workers can spot barriers to care among patients that may not be evident during a doctor’s visit. She recounts one case in which a female patient reported she was doing her insulin injections, but her glucose levels were still “off the charts.” A community health worker was asked to visit and saw that the woman, who was elderly, lacked the dexterity to hold back the cap release on the shot to get the full dose of her insulin. “We would never have found that out in the doctor’s office,” Tieman said.
For Tieman, Benedum’s health program funding is sustainable because the foundation works with and builds trust in the communities it serves. If community health workers were going to be successful in educating patients about their diabetes care, they had to be hyperlocal.
“You know that I have an accent, and I can tell you that one county below me, it doesn’t sound the same, and two counties below me, it doesn’t sound the same at all,” Tieman said. “So I couldn’t be as good of a community health worker in Mingo County as I could in Jackson County, because I can’t get through the door because they don’t know my people. It’s: Who’s your father? Who’s your mother? Where do you go to church? Where’d you go to school? Oh, I know your brother. And that’s how we get in the door!”
Also foundational to Benedum’s guiding principles, Tieman said, is the importance of equity: “Something,” she noted, “that we’re not even supposed to say today.” That can be traced back to the mid-1940s, when, amidst racial violence against Black people and segregation around the country, one of the Benedum Foundation’s first grants was to the United Negro College Fund.
This equity-focused mindset, along with the foundation’s focus on sustainability, plays into what Tieman called the “spider web” of the foundation’s work. It’s her language for how the foundation assembles different grantees to learn skills from each other and fortify systemic change.
While it initially focused on diabetes, the community health worker program has been expanded to help patients with other complex health conditions, like congestive heart failure, chronic obstructive pulmonary disorder and obesity.
Related Inside Philanthropy Resources:
For Subscribers Only
How the T.L.L. Temple Foundation supports local healthcare capacity in rural Texas
Like Benedum, the T.L.L. Temple Foundation is dedicated to what Kevin Lambing, its former senior program officer for health, describes as “equity trust.” “You can’t just roll up and roll in,” he said, recalling how, during the pandemic, a health partner that was talking to them about testing locals wanted to come to East Texas and start swabbing people for COVID.
“I said, ‘You might want to hold off on that. I’m not sure if these people are ready to accept that,’” said Lambing, who was born and raised in the area. As the foundation’s president and CEO Charlie Glover put it, “We need to be doing things with communities, not to communities.”
As is the case in many rural areas nationwide, access to healthcare in the region has been extremely challenging for many, in part because of the lack of providers.
Patient-to-provider ratios in the counties served by the foundation, for example, are on average 3,600 patients to one provider, according to Lambing. To put that in perspective, nationally — on average — rural areas have 436 more people per physician than urban areas, according to a report by Concordia University. Twenty-eight counties in Texas have no physician or physician’s assistant.
In the last three years, the foundation has supported the deployment of mobile medical units in the region, providing 5,000 primary care patient visits. A mammography medical mobile clinic has performed 8,700 mammograms and biopsies, and in the last five years, a dental care program connected to the University of Texas has provided 10,000 dental procedures to people in the region they serve.
In one instance, when a health partner from another area was looking to launch a mobile medical unit project, they sent a community health worker to work at the local food pantry. “They got their name out there, but via the food pantry,” Lambing said. From that connection, the health partner learned where to set up the mobile medical unit and what days and times would work best for community members.
One role the Temple Foundation aims to play is to act as a catalyst and build capacity among its partners and grantees. A newer project illustrates how that unfolded.
In rural Houston County (not to be confused with the city of Houston’s Harris County), where Lambing said provider patient ratios hover at 4,500 to 1, he was invited to join a community coalition seeking to come up with innovative ways to amp up the number of providers who can see patients.
During the meeting, Lambing wondered if a program he knew about might be a good fit: Texas A&M, which had set up mobile medical units run by university-affiliated nurse practitioners, was providing healthcare to schools in other rural regions of the state. He brought the university in to talk to community members. They got buy-in from the community, he said, with all of the school superintendents signing on.
It was a no brainer, they felt. “If you think about it, if you’re in a small, rural area and you have under-resourced families, and maybe the family has one car. If the child gets sick at school, someone has to take off work,” Lambing said. But with such a school-based medical unit, “the child can just simply walk out of the school and go to the mobile unit that’s there at their school and get their care.”
The Temple Foundaton also funded the project because of its potential for sustainability. The children’s visits are funded through the state’s Children’s Health Insurance Program. The teachers, who can also be seen in the mobile clinics, also are insured.
“We really don’t make a change if it’s something that the community cannot sustain,” Lambing said.
Along the same line of thinking, the foundation has set up a loan repayment program to recruit more doctors, physicians assistants and nurse practitioners to the area. It has added 16 providers in the program. In the last four years, the foundation has also funded two residency programs in the area with 39 in the program and 19 graduates.
Reflecting on Temple’s work, Lambing, who has just moved on to a new job, said, “We have a drop in the bucket of what it takes in this country to provide healthcare to the 5.9 million people that live in our region. We cannot do this alone. We have to rely on these partnerships that we have with the amazing people that also do this.”
The same mindset holds at the Benedum Foundation, according to Tieman, which also partners with other funding groups such as the Appalachia Funders Network. That and Benedum’s focus on how it interacts with grantees, she said, are key.
“You can give a grant, walk away and read about it in a year and hope it turned out,” Tieman said. ”Or you can roll your sleeves up, be present, open doors and facilitate — [you can] say, ‘OK, I’ll go to the secretary’s office with you. I’ll call and see if the governor will get us in.”
