Appalachia is falling behind the rest of the United States in key health metrics. Financial instability in the region’s health care industry, a devastating opioid crisis that still is unfolding, and ongoing socioeconomic challenges mean that the disparity will likely get worse before it gets better.

A study published this week in the journal Health Affairs found that health-outcome gaps between those in Appalachia and the national average have increased since the early 1990s, with infant mortality 16 percent higher in Appalachia from 2009 to 2013, and life expectancy increasing from 0.6 years below the national average from 1990 to 1992 to 2.4 years from 2009 to 2013.

The study blames the usual mix of personal health behaviors— smoking, drug abuse and obesity—but also financial problems in the network of hospitals, clinics and other facilities that deliver healthcare to rural areas. Economic, social and cultural factors are converging to make it more difficult to treat Appalachia’s most vulnerable populations, driving a  growing disparity between this region and the rest of the nation.

Last month, West Virginia’s third-largest private employer announced significant cuts. Two health systems that serve a broad range of patients in Appalachian Kentucky, North Carolina, Tennessee and Virginia are planning to merge in September, prompting concerns that a monopoly may result in higher prices and fewer services.

Those challenges—along with broader ones such as availability of higher education, social services and economic development—mean that the disparity in infant mortality and life expectancy between Appalachia and the rest of the country will likely continue into the future, said Gopal Singh, a senior health equity adviser at the federal Health Resources and Services Administration and a co-author of the study.

“I would not expect patterns or trends to change that much,” Singh said. “For example, drug overdoses played only a 6.3 percent role in terms of contribution to a decrease in life expectancy. That percentage will go up. Drug overdoses will become a bigger factor in driving disparities.”

The factors that can be attributed to unhealthy behavior, such as drug use and obesity, can’t be addressed without a robust healthcare system. Other factors, such as car wrecks and population trends of  younger, healthier people moving out of the region, are also linked to more complex challenges that will take much more to address than a commitment to give up cigarettes or lose weight.

Given the gaps in socioeconomic conditions between Appalachia and other parts of the U.S., the study says solutions would require “a new commitment to investment, at various levels of government, in human and physical capital; infrastructure developments, particularly in higher education; and increased access to high-quality affordable health care.”

A “new commitment to investment” looks unlikely, however, both at the state and federal levels. West Virginia’s budget, for example, cuts higher education, and President Donald Trump’s proposed national budget significantly slashes rural investment. The Affordable Care Act wasn’t implemented until after the study period, but it too may have a muted effect, given that seven out of 13 Appalachian states chose not to expand Medicaid.

While Appalachia is falling behind the rest of the United States in terms of infant mortality and life expectancy, many healthcare providers and facilities that could play a role in erasing that disparity are struggling financially, making treating patients in the region more challenging.

When Charleston Area Medical Center president and CEO Dave Ramsey said the non-profit was on track to lose $40 million and would have to cut programs and 300 positions by the end of the year, he cited West Virginia’s declining economy, rising drug prices, and the nursing shortage for the financial challenges. He said that CAMC sees a high number of people on government insurance like PEIA, Medicare and Medicaid, which reimburse below the cost of treatment. The CAMC program cuts included a pharmacy, pulmonary rehabilitation, a childcare facility and a heart disease unit that emphasized lifestyle changes.

Two large health systems that serve eastern Tennessee and southwest Virginia are planning a merger that would sidestep federal oversight through the use of a loophole in the laws of the two states. Officials from Mountain States Health Alliance and Wellmont Health System, the two parties to the proposed merger, say the plan would cut redundancies and provide better quality of care.

“There is a huge amount of linkage between the proposed merger and health outcomes and health disparities in our corner of Appalachia,” said Teresa Hicks, spokeswoman for Mountain States. “Those health outcomes and health disparities are exactly what we are hoping to be able to redress. If we have to keep directing resources toward duplicative costs dictated by competition, we can’t put those resources into things that are going to make an impact on population health.”

But some medical professionals, as well as officials at the Federal Trade Commission, are wary of what may be a monopolization that could allow price hikes and cuts to service.

One of the partners in the proposed merger, Mountain States, has been working with a multi-member authority in Lee County, located at the southwest tip of Virginia, to reopen a community hospital that was closed in 2013. Mountain States told the authority it would take $4 million annually to subsidize the hospital. The county can’t afford that, so instead the authority is working with Americore Health on a new plan that would transform the building from a traditional community hospital to a smaller facility subsidized by other health care companies located in the same building. 

The latest version of the plan, said Ronnie Montgomery, vice chairman of the Lee County Hospital Authority, would involve running the facility as a critical-access hospital with up to 25 beds, where patients can stay for up to 96 hours before they go home or are transferred to another facility.

“Lee County starts just a mile or so west of Big Stone Gap and goes for 70 miles down to Cumberland Gap,” Montgomery said. “It’s a big geographical county. Taking patients across the county to Big Stone Gap is putting stress on the emergency vehicles.”

Appalachia’s devastating opioid crisis makes the disparities between health in Appalachia and the rest of the U.S. more glaring. The Health Affairs study showed drug overdoses accounted for 6 percent of the life expectancy gap between 2009 and 2013. The opioid crisis has only become more severe since 2013, so its full impact has yet to be studied. 

“We’re a poor county, one of the poorest in the state,” Montgomery said. “We’ve got a lot of people on Medicaid, a lot on Medicare, and some people don’t have anything. This is the third year we have not had an active coal mine working in Lee County. We used to grow a lot of burley tobacco, and that’s gone. We’ve got a big drug opioid problem.”

Lee County’s problems are a microcosm of Appalachia’s. Singh said that many poorer, more rural areas lack access to family doctors, and improving its health gap will require a multifaceted response. “In terms personal choice, yes, you can reduce inequalities in those areas through reductions in smoking and obesity. Access to care is more of a systemic level factor that drives up some of the differences you see in cost and access disparities.”