“We don’t have time to wait for the ambulance to get here. We’ll just take her ourselves.”
The nine-year-old, curled into a fetal position on the table, didn’t care which vehicle would be transporting her to the nearest trauma center. She just wanted the pain in her abdomen to go away, so she could go back to school and keep learning cursive. She couldn’t understand why her parents were panicking; after all, they were doctors. They’d seen plenty of pediatric patients with stomach pain before. However, the image that hung on the x-ray viewer behind her would have unsettled most seasoned physicians: an unidentifiable mass overtook her abdominal cavity and compressed the vital organs within. Every second counted. In the frightened parents’ minds, there wasn’t time to wait for a pediatric helicopter to fly over 200 miles when they could drive their daughter themselves. Their Chevy Suburban broke a few speed limits that day, but what’s a speeding ticket compared to the life of your child? That little girl was me, and the choice my parents faced that day is only one example of the many ways that the rural healthcare crisis continues to affect people across the country.
Sixty million Americans live in an area classified as “rural”; this comprises a little less than 20% of the American population. Only nine percent of American physicians practice in rural communities. In the last 10 years, many of these rural Americans have faced the closure of local hospitals, 119 in total; at that rate, 25% of all rural hospitals will close within the decade (1). These closures are primarily due to financial circumstances unique to rural areas: diminishing populations are too small to support the existence of high-profit specialty departments and are less likely to have high-paying insurances, while Medicare’s Disproportionate Share Hospital (DSH) policy disadvantages rural hospitals compared to urban ones. For Beverly Rollings of Sedalia, Missouri (population of 22,000), the rural location of her co-owned architecture firm directly impacts the kind of insurance options she’s able to offer her employees: “In Pettis county…, if you purchase through the Affordable Care Act, you have one option.” The limited network of this insurance option doesn’t include providers in Kansas City, the nearest metropolitan area. One such employee and his wife, after learning that their unborn child had polycystic kidney disease, were forced to consider moving their entire family to either Kansas City or St. Louis in order to have some kind of insurance coverage for the treatment. After the insurance company assured them that an exception could be made in their case, the couple chose to have a C-section in Kansas City. Their child, Simon, only lived for 12 hours after birth. Following his death, they received a bill for $50,000 in the mail, as their insurance had refused to cover the costs of their procedure after all. The harsh realities of this situation may be shocking to some, but to inhabitants of rural areas, it’s only another anecdote highlighting the deficits within the rural healthcare system.
Of the hospitals that remain open, 47% spend more money on a monthly basis than is brought in, leaving the future existence of these hospitals in jeopardy. Hospital closures cripple local economies, lead to disinvestment in the area and negatively impact a community’s ability to attract other healthcare providers to the area. For citizens that already face a significant commute to reach a healthcare facility, these closures further limit the ability of rural Americans to access both emergency and preventative care. In emergent cases, waiting an additional 20 minutes for EMS to arrive might mean the difference between life and death. For farmers, ranchers and other rural workers, driving to a healthcare provider may mean taking off work, which delays the treatment of conditions that otherwise might have been preventable. Driving long distances both delays the treatment of these conditions and disincentivizes people from consulting specialists. Hospital closings have only increased the distance people must travel to gain access to basic medical care. Dr. Roy Elfrink, a general surgeon who’s worked in Marshall, Missouri (population of 13,000) for over 25 years, notes that low socioeconomic status and rural culture both play a role in these disparities.
“Rural life is hard,” he notes. “Rural people seem to be more accepting of illness and death and take responsibility for their less than ‘standard of care’ healthcare decisions, often leading to poorer outcomes.”
These circumstances manifest as increased death rates in rural communities due to “heart disease, cancer, unintentional injury (including vehicle accidents and opioid overdoses), chronic lower respiratory disease, and stroke” (5). Deaths due to modifiable behaviors and a lack of preventative care, like tobacco and drug use, and cervical and colorectal cancer, are also higher in rural areas (6). Needless to say, the limited access to healthcare faced by rural Americans leads to higher incidences of preventable disease and poorer outcomes.
The limited number of hospitals means that rural Americans are reliant on primary care physicians, including family practice, OB/GYN, and internal medicine physicians to treat both chronic and acute conditions. These providers must often work outside of their scope of practice to treat patients that cannot afford to take time off to travel to see specialists (7).
Carol Platt, of Union, Missouri (population of 12,000), notes that, in urban areas, “your regular physician passes you off to other doctors in the city for special procedures, but family physicians here do it all.”
The shortage of rural primary care providers has been documented for nearly 85 years, (8) and shows little indication of reversing anytime soon. According to Roger Rosenblatt, co-investigator of the Washington, Wyoming, Alaska, Montana, and Idaho Rural Health Research Center, (9) one of the major contributors to this issue is the prioritization of specialization in medical education. Specialists tend to generate more income than do primary-care physicians, giving medical students more incentive to specialize early in their education. The more specialized a physician becomes, the more likely they are to be located in an urban area, leaving rural Americans with no choice but to drive to the nearest metropolitan area for initial, primary, and follow-up specialist visits or forgo seeing a specialist at all.
Given that rural healthcare disparities affect a large portion of the American population, systematic changes are being studied and implemented to varying degrees to try to address this issue. Medical education has the widest-reaching effect on the physician population as every practicing physician must attend medical school, so many efforts that focus on increasing the number of rural physicians are centered in that field. Federal programs like the Area Health Education Centers (AHECs), Federally Qualified Health Centers (FQHCs) and the National Health Service Corps (NHSC) offer competitive loan repayment options for recent graduates who practice in rural areas (10). Similar statewide programs exist, as do medical school-specific initiatives. For example, at the University of Missouri School of Medicine, the Bryant Scholars Pre-Admission Program is part of a rural track pipeline program that recruits high-achieving students from rural Missouri communities as undergraduates. As a part of this program, I was offered a place in the School of Medicine and have been given opportunities as an undergraduate to learn how to best serve rural communities and cope with the unique challenges such communities present. So far, the program has been deemed successful: 61 percent of Bryant Scholars practice in a rural location and 70 percent stay in Missouri (11).
Telemedicine is also an incredibly promising practice that may mitigate the effects of geographic distribution of both patients and healthcare providers. Telemedicine refers to the practice of caring for patients remotely via telecommunications technology. The option to meet with a specialist or primary care provider via video conference or another medium would drastically improve healthcare accessibility. Telemedicine appointments could be substituted for initial and follow-up appointments, and in cases where a hospital is accessible but the specialist is not, vitals and other testing documentation could be collected on-site and directly transmitted to the healthcare provider. The remote reading of EEGs is one example of telemedicine that is actively in practice in some hospitals; dermatology consults have also utilized this technology. Despite their promising future, current telemedicine efforts are “uncoordinated, expensive, inaccessible, and at times even illegal” (12). Initiatives to reconcile these issues would foremost involve resolving professional licensure regulations so that urban physicians are legally allowed to remotely practice medicine across state lines. In addition, a unified infrastructure is absolutely necessary to reduce operating costs and allow patients to communicate with multiple providers over the same network (13). The development of telemedical legislation also offers an opportunity to secure reasonable third-party rates for telecommunication services provided. The existence of a cohesive telemedical option in rural areas would likely serve to decrease preventable deaths and increase the utilization of medical services.
As harmful as the spread of COVID-19 has been to healthcare systems nationwide, it has served to highlight the critical healthcare disparities rural Americans already face on a daily basis and the impact of these disparities outside of rural areas. For example, in Saline county, Missouri, a lack of financial resources and preparedness led to only two boxes of N95 masks being stockpiled at the healthcare department in case of emergencies. While COVID-19 was not active in the town at the time, other rural areas faced similar shortages while combating the spread of the disease in their community. If rural hospitals were politically prioritized and legislation passed to strengthen their infrastructure, the nation as a whole would have been better prepared to combat community transmission. In addition, the financial impact of the COVID-19 crisis will affect rural hospitals and healthcare providers for years to come. Rural hospitals tend to operate in the red in the best of times, but the cancellation of non-essential medical services and the increasing costs of PPE means that operating costs will become unsustainable. When urban hospitals run out of room for COVID-19 patients, rural hospitals will likely be called upon to pick up the slack and may serve as recovery centers if they lack formidable critical care departments.
As for my story, the immediate action taken by my parents, other local doctors and the physicians at Children’s Mercy saved my life. I was in a privileged position to be surrounded by medical experts and to have a rural hospital in my hometown; other patients in rural areas are not so lucky. Stories like these, as well as the continued spread of COVID-19, highlight the need to invest in rural infrastructure and consider policy changes to address the primary-care disparity present in these communities for the good of both rural populations and the rest of the country.
Written by: Rachel Ulbrich
Edited by: Daniel Berkovich
Illustrated by: Jennifer Broza