A Silent Struggle: The Rural Healthcare Crisis
By Sarah Mirkin
Marcelo Leal on Unsplash
The mountain wind whips through my hair as my bike picks up speed. My eyes scan the trail in front of me as I navigate the rocks and branches jutting up from the ground. I stand up slightly, my knees bent to absorb the sharp bumps. I let off the brakes a little more, determined to show my little brother I can keep up. He may be good at mountain biking, but I’m not quite ready to admit he’s better than me. I watch him disappear around the next hairpin turn and adjust my speed to take it myself. Suddenly the sound of the rushing wind and forest birds are silenced by the crashing of metal and the thud of a body hitting the packed dirt. My breath stops in my throat. I skid to a halt. Time stands still for a moment. The silence is broken when my brother cries out in pain grabbing his arm, his face a picture of agony. I spend the next hour trying to keep him calm as we walk slowly to the bottom of the mountain. From our campsite, it’s three hours in the car to the nearest hospital and an hour wait before he sees the doctor. All the while his arm swells bigger and bigger turning a deep shade of purple. In the end, it’s five hours before he feels any relief.
In the mountains of the Methow Valley in Washington State, help is not close by. In recent years smaller clinics throughout Eastern Washington have downsized or closed forcing many people in the area to drive between two and four hours to the nearest hospital for any medical issues that require more than a standard check-up. At the end of the day my brother was okay. He did break his arm and it really hurt, but it was not life-threatening. Unfortunately, this isn’t always the case, and for people who live permanently in rural Washington, the lack of healthcare options within a reasonable distance can be deadly.
This, however, is not a problem unique to rural Washington, as Robin Warshaw, a writer on medical, healthcare, and social issues wrote in the Association of American Medical Colleges, “Rural Americans—who make up at least 15 to 20% of the U.S. population—face inequities that result in worse health care than that of urban and suburban residents.” These inequities stem from a variety of factors unique to rural areas such as having lower median household incomes, a higher percentage of children living in poverty, fewer adults with postsecondary educations, more uninsured residents under age 65, and higher rates of mortality (North Carolina Rural Health Research Program). To make matters worse, the healthcare gap has only been widening in recent years as more physicians are working in urban areas and the federal budgets provided to rural hospitals get smaller. The onset of COVID 19 also amplified this issue, pushing many rural hospitals to the brink of closure. All in all, people living in rural and non-urban areas do not have access to the healthcare they need to live full and healthy lives. To me, this is a huge problem. I have seen how this issue affects my friends and family who live in rural Washington and I know it affects the millions of people who live in rural areas all over the country. In order to do something, however, we need to understand how we got here. How did the rural healthcare crisis become so extreme? How is this affecting rural communities? And most importantly how can we begin to close this gap?
One of the main causes of the rural healthcare crisis is a lack of resources. There is an overarching lack of money, lack of physicians, and lack of clinics that leave rural residents without access to care. An article from the University of Washington Center for Health Innovation and Policy Science states that in a recent analysis one in five rural hospitals in the United States are at risk of closing unless their financial situation improves. Specifically in Washington State this study found six rural hospitals at risk of closure, two of which are “essential to the community” because of their trauma care status, service to vulnerable populations, geographic isolation, and economic impact (Firth). The thought of more hospitals in rural Washington closing is terrifying. Family friends I know who live in Mazama, Washington already drive three and a half hours to the nearest hospital. They simply can’t afford the time and money to travel further than that to receive basic medical care.
Additionally, an extreme shortage of physicians in rural areas is contributing to this healthcare gap. Experts are predicting a national shortage of 200,000 physicians in the coming decade. If that becomes a reality, 84 million patients will be without a doctor’s care. These shortages exist in radiology, cardiology, and neurology, but the greatest shortages persistently have been in primary care (US Government Committee on Health, Education, Labor and Pensions 2). It is hard when reading these statistics to wrap my mind around the number of people impacted by this healthcare crisis. 84 million is simply too large a number for us to understand, yet we have to remember that these are millions of individual people with families, jobs, hobbies, and full lives whose wellbeing will be threatened by limited access to care. Senator Lisa Murkowski of Alaska describes the severity of this issue in a field hearing stating, “The shortage of primary care physicians in rural areas of the United States represents one of the most intractable health policy problems of the past century (CHELP 5).
The physician shortage has come about due to a variety of factors of different magnitudes. A large percentage of physicians are reaching the age of retirement and medical schools are keeping enrollment flat, so there are not enough graduating medical students making up for this loss. Additionally, physicians are leaving their practices out of frustration. Low Medicaid and Medicare reimbursement rates limit the number of patients physicians are able to take on and as complex regulations and paperwork continue to increase they are increasingly angered by the practice of medicine as it stands today (CHELP 7). Decreasing Medicaid and Medicare reimbursement rates is especially problematic for those in rural areas as people in rural areas are more likely than their urban counterparts to be on some form of Medicaid or Medicare. If doctors are not going to be reimbursed, they are often unable, as much as they may want to, to take on these patients. A woman from Anchorage, Alaska voiced her experience with the physician shortage saying, “During the past year, I’ve tried to find a doctor that accepts Medicare. I used the Anchorage Yellow Pages and called over 100 doctors, only to be told that they won’t accept any more Medicare patients. I’ll tell you ahead of time, we’ll be going to the hospital emergency rooms to receive even the basic medical care for colds and flu and other basic needs” (CHELP 6). You can hear the frustration in this woman's voice and I can only imagine the despair she would feel calling dozens of people and hearing over and over again they wouldn’t be able to provide her with even basic medical care.
The final piece of the physician shortage crisis deals with specialty care. While primary care is most essential to providing general healthcare to those in rural communities, the extreme lack of any sort of specialized care is equally as problematic as a lack of primary care physicians. Rural communities have only 30 specialists per 100,000 people compared to 263 specialists per 100,000 urban residents (National Rural Health Association). That means there are almost nine times the number of specialists in urban areas. This issue is highlighted in obstetric care. A 2017 study found that 54% of rural counties didn’t have hospitals with obstetric services and depending on where you live you may have to drive 200 miles to see an OB/GYN (Hung). Many problems that may arise with pregnancy and childbirth require immediate medical attention, and yet, if a woman lives in a rural area, that likely means she doesn’t live in an area that can provide that medical attention.
It is quite clear that there is a significant lack of healthcare resources in rural communities; what makes the lack of resources such an issue, however, is the effect that has on residents living in these communities. Rural communities end up experiencing more chronic conditions, higher mortality, and lower life expectancies than their urban counterparts partially due to the rural healthcare gap (Firth). People living in rural communities with less access to clinics and healthcare providers end up with illnesses and diseases that go unidentified for longer periods of time and thus become more deadly and harder to treat. For example, cancer incidence is higher in rural areas because if a person identifies a warning sign of cancer they will often go a long time before getting checked out due to how far they would have to travel to see a provider. This in turn results in more cancer-related deaths. In a study on rural cancer incidence, mortality, and funding, Blaker found that, “Cancer mortality rates were 166 per 100,000 in metropolitan counties and 182 per 100,000 in nonmetropolitan counties.” In addition to diseases like cancer, rural areas also have higher rates of mental, behavioral, and developmental disorders in children, and youth and veterans have higher rates of suicide than their urban peers (Warshaw). A significant lack of mental healthcare providers in rural communities is a leading cause of this higher rate. All in all, those living in rural areas are experiencing the deadly effects of the healthcare gap in their daily lives. The fact that there is less funding, clinics, and physicians in rural areas is not without consequence. People’s loved ones, children, grandparents, friends, and co-workers are being diagnosed with severe illnesses at younger ages, experiencing more intense mental health issues, and they aren’t getting help dealing with these problems.
Fortunately, there are many things that can be done to close the rural-urban healthcare gap and increase the quality of life for those living in rural communities. One emerging idea includes global budgeting. Global budgeting is the idea that you pay hospitals based on value as opposed to volume. This is significant because rural hospitals do not get very many inpatients (people who need long-term hospitalization) per day; however, they treat many outpatients (people who only need a one-time appointment) per day. The ability to pay rural hospitals, not based on the number of inpatients receiving long-term care, but the value they bring in treating a large population of people over time is much more accurate to the role they are actually performing. Specifically, “a global budget is a fixed amount of funding for a set period of time for a set population. This is different from typical funding which is based on individual services or cases” (Firth). Global budgeting will help rural hospitals because it creates income stability, allows them to allocate resources in ways that specifically benefit their region, and it allows for easier administration. Because of global budgeting's recent emergence as a solution to the healthcare crisis, it is important that people in both rural and urban communities do their research on different funding options and push policymakers towards newer, more effective approaches to hospital funding. The global budgeting approach is largely implemented by policymakers at the state level so it is something that can be pushed for on a somewhat smaller scale than something that requires nationwide backing. Global budgeting is just one new way of creating budgets that allow for rural hospitals and clinics to stay open and available to people in rural communities.
Telehealth is another emerging idea to close the rural healthcare gap. Telehealth specifically addresses the issue of the large distances many people must travel to see providers, especially specialists. Dr. Carole Myers, who works in public health at the University of Tennessee with a focus on healthcare disparities and rural health, writes about the potential of Telehealth saying, “It has the potential to address mental healthcare gaps and health status disparities.” She goes on to discuss how telehealth can improve patient outcomes by assisting in chronic disease management, mental health disorders, and the provision of mental health services. Furthermore, implementing telehealth is really just as easy as setting people and communities up with the basic technology needed for these online visits and ensuring that they have access to mobile data and internet. Because there is very little policy change that needs to take place for telehealth to be used, it is a great solution to integrate into communities sooner rather than later. Telehealth has become even more prevalent since the onset of COVID and in this day and age, it is a fairly easy and cost-effective way to get more people in touch with providers and receive quality medical care that they have not been able to receive to that point.
Finally, in order to close the healthcare gap, many steps are being taken to bring more healthcare providers to rural areas. Medical schools are creating rural healthcare tracks specifically designed to graduate doctors who will practice in underserved areas and these have begun, in recent years, to show significant success. At the University of Minnesota Medical school 2 out of 3 graduates in their rural track have gone on to practice in that state, and 40% of them practice in rural locations. Additionally, of the 127 doctors who have graduated from the University of Colorado Medical School’s rural track since it began in 2005, 35% are practicing in communities that are considered rural or frontier (Jaret). Furthermore, there has been an increase in loan forgiveness and more scholarships given to those who commit to practicing in underserved areas. If we can continue to push for these changes to be made and implemented, rural communities will begin to receive better care. If hospitals can stay open and treat more patients, if there is greater access to specialty physicians and primary care providers alike, and if people are more educated about the rural healthcare crisis the rural-urban healthcare gap will begin to close.
With enough people dedicated to fixing this issue and spreading awareness, the woman from Alaska will not have to be turned away from dozens of care providers and instead she will be able to find a primary care provider located in an area that she is comfortable getting to. With enough resources and funding towards rural hospitals, when my brother breaks his arm in the middle of nowhere he will be able to get help in half the time it took when he crashed two years ago. What we must remember is that 20% of the population lives in rural areas of the United States. This rural healthcare crisis is a problem affecting a huge group of people and yet it is rarely talked about. We must be aware of the healthcare inequities present in our communities and act on them so people can live full and healthy lives.