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The Crisis in Rural America

Annals of Emergency Medicine

Rural hospitals are closing at an unprecedented rate—and residents are dying for lack of access. Will policymakers step in?

There’s never a good time to have a heart attack. But when 48-year-old Portia Gibbs had one in 2014 in rural North Carolina, the timing was particularly bad. Just a week before, the only hospital in her area closed. Under the new emergency medical services protocol, she was to be airlifted to the closest emergency department (ED). She waited for more than an hour for the helicopter to arrive. The long wait had dire consequences: Gibbs died before emergency physicians could help her. Her husband is convinced she would have lived if she had gotten to the hospital sooner. “If you live in this area, you might as well have the mind-set that if anything happens to your [health], you’re likely going to die,” he told STAT News.

Across the United States, rural communities are experiencing a spate of hospital closures and the subsequent absence of emergency medical care. In recent years, rural hospitals have shuttered at an alarming rate: 161 rural hospitals have closed in the United States since 2005, and between 2013 and 2017, the closure rate was double that of the previous 5 years, according to an August 2018 report by the US Government Accountability Office.

The problem shows no sign of abating: A February 2019 report by Navigant Consulting looked at rural hospitals’ financial viability and found that 21%, or 430 hospitals across 43 states, are at high risk of closing. When a hospital closes, its ED closes along with it. So when crises occur, people in rural areas spend substantially more time getting to a medical care facility with adequate resources—time that often means the difference between life and death.

“Patients have to travel farther to access care when rural hospitals close,” said Caitlin Carroll, PhD, an assistant professor in the Division of Health Policy and Management at the University of Minnesota, who has studied the effect of hospital closure on the cost and quality of health care. Indeed, after a rural hospital closes, patients spend, on average, 77% more time in an ambulance—25.1 minutes compared with 14.2 minutes—as researchers at the University of Kentucky found. Similarly, a September 2019 report by the Center for American Progress, “Rural Hospital Closures Reduce Access to Emergency Care,” calculated that the distance between financially at-risk hospitals and the next-closest ED averaged 22 miles. The delay in care leads to a problem that any emergency physician could predict: “Mortality rates increase among patients with time-sensitive health conditions” such as stroke or heart attack, said Dr. Carroll.

What is causing this crisis? Demographics play a role.

“Rural hospitals can face additional financial pressure because they are smaller, serve an older population, and provide higher rates of uncompensated care,” said Emily Gee, PhD, health economist for the Center for American Progress and coauthor of the center’s September report. What’s more, as Dr. Gee pointed out, whereas Medicaid expansion under the Patient Protection and Affordable Care Act can help alleviate some of the economic challenges that rural hospitals face, many of the states that chose not to accept the Medicaid expansion were those that may have needed it most, including places where rural hospital closures were more likely to have occurred. Indeed, a North Carolina op-ed about Portia Gibbs described her as “the first victim of the first rural hospital to close its doors after federal funding was cut off by state governments’ refusal to expand Medicaid under the Affordable Care Act.”

Read more.

KHN’s ‘No Mercy’ Explores the Fallout After a Small Town Loses Its Hospital

Kaiser Health News Launches Podcast Series

‘No Mercy’ is Season One of ‘Where It Hurts,’ a podcast about overlooked parts of the country where cracks in the health system leave people without the care they need. Our first destination is Fort Scott, Kansas.

Midwesterners aren’t known for complaining. But after Mercy Hospital Fort Scott closed, hardship trickled down to people whose lives were already hard. In Chapter 1, we meet Pat Wheeler, who has emphysema. Her husband, Ralph, has end-stage kidney failure, and the couple are barely making ends meet as they raise their teenage grandson. Pat is angry with hospital executives who she said yanked a lifeline from residents. “I don’t understand how they can just so blatantly close the hospital. I mean, I understand dollars and cents,” Wheeler said. “But at the same token, where’s the humanity? You know, what are people like us supposed to do?” she said.

Click here to listen.



Pennsylvania Human Services Secretary Urges Senators Casey, Toomey to Continue SNAP Waivers and Flexibilities During the COVID-19 Health Crisis

Pennsylvania Department of Human Services (DHS) Secretary Teresa Miller sent a letter to Pennsylvania Senator Bob Casey and Senator Pat Toomey to urge them to grant DHS continued flexibility to manage changing needs during the COVID-19 health crisis, especially pertaining to Supplemental Nutritional Assistance Program (SNAP) waivers.

“The economic impact of this crisis has not yet been fully mitigated and for that reason, we expect SNAP enrollment to continue to grow. We urge you to support the adoption and extension of these waiver flexibilities, which will be necessary to support the provision of critical benefits to Pennsylvania households in need,” wrote Secretary Miller. “Granting Pennsylvania the flexibility of these waivers will ensure that DHS can continue to effectively manage the COVID-19 public health emergency and its ensuing economic impact.”

DHS specifically requested that senators Casey and Toomey pass resolutions that would extend existing waivers DHS has found valuable in managing people’s changing needs during the health crisis, including:

  • The ability to extend SNAP benefit certification periods and adjust periodic reporting requirements;
  • The ability to allow household reporting through periodic reporting; and
  • The ability to adjust interview requirements for SNAP.

Without the continuation of these waivers, DHS may need to authorize overtime or hire additional staff to keep pace with existing work due to an expected increase in need for assistance programs over the fall and winter months. Charitable food networks may also be further stressed, as they play an important intermediary role in keeping people fed as households await SNAP eligibility determinations.

SNAP helps more than 1.9 million Pennsylvanians expand purchasing power by providing money each month to spend on groceries, helping households have resources to purchase enough food to avoid going hungry. Inadequate food and chronic nutrient deficiencies have profound effects on a person’s life and health, including increased risks for chronic diseases, higher chances of hospitalization, poorer overall health, and increased health care costs. As the nation faces the COVID-19 pandemic, access to essential needs like food is more important than ever to help keep vulnerable populations healthy and mitigate co-occurring health risks.

Applications for SNAP and other public assistance programs can be submitted online at Those who prefer to submit paper documentation can print from the website or request an application by phone at 1-800-692-7462 and mail it to their local County Assistance Office (CAO) or place it in a CAO’s secure drop box, if available. While CAOs remain closed, work processing applications, determining eligibility, and issuing benefits continues. Clients should use COMPASS or the MyCOMPASS PA mobile app to submit necessary updates to their case files while CAOs are closed.

Pennsylvanians who need more immediate help feeding themselves or their family should find and contact their local food bank or pantry through Feeding Pennsylvania and Hunger-Free Pennsylvania.

Read a copy of Secretary Miller’s letter here.

Pennsylvania Governor: Pennsylvania is COVID-19 Prepared with PPE 

Pennsylvania Governor Tom Wolf announced that Pennsylvania is prepared with a stockpile of ​personal protective equipment (PPE​) now and should it be needed to fight the COVID-19 pandemic in the coming months.

PPE includes protective clothing, helmets, gloves, face shields, goggles, facemasks and respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness. It is not the same as cloth or paper masks that people are required to wear when they leave their homes to protect them and those they interact with.

“I want all Pennsylvanians to know that the commonwealth is prepared now for battling the ongoing pandemic that is COVID-19 and that preparedness extends to a possible resurgence this fall,” Gov. Wolf said. “There are still many unknowns with this virus, and we can’t control those, but we can control what we know and we know that by being ready with enough PPE, we can protect our health care workers, first responders and other essential workers and not overwhelm our health care system.”

To date, the state has distributed close to 5.4 million N95 masks, more than 736,000 gowns, more than 2.75 million procedure masks, close to 7.7 million gloves, close to 1.3 million face shields and a little less than 1 million bottles of hand sanitizer.

Last week the governor visited Americhem International, a Middletown-based wholesale distributor of janitorial and sanitizing products that serves a variety of industries, to thank businesses that worked to supply PPE during the pandemic and outlined the myriad efforts undertaken to ensure the commonwealth is and will be prepared for all PPE needs.

PPE is necessary to protect health care workers, first responders, those working in long-term living and correctional facilities, and those they care for. It is vital for facilities to have preparedness plans and for the state to assist when needed.

“The state, through procurement, sourcing and buying of PPE, is prepared for fall,” Gov. Wolf said. “We have significantly more PPE on hand to assist those who need it than we had prior to COVID-19. We continue to push PPE to those who need and request it and will work to ensure we keep our stockpile filled.

“In the early days of the pandemic, this administration took numerous steps to secure sources of PPE to ensure that Pennsylvanians were protected and that our health system was not overwhelmed. Our proactive and ongoing efforts to secure PPE, coupled with the flexibility and ingenuity displayed by Pennsylvania’s business community, helped us secure and allocate PPE. Because of the steps we took, our hospitals were not overburdened, and our medical system was not strained. Now, six months after the virus first appeared in the commonwealth, we can say with confidence that we are prepared to stay safe as we continue to fight this pandemic.”

NIH Community Engagement Alliance (CEAL) Against COVID-19 Disparities

The CEAL Alliance is equipping community leaders with resources that can help them talk with their communities about COVID-19, the vaccines being developed, and the importance of participating in research studies. Examples of resources include fact sheets and videos.

  • Fact Sheets
  • Videos

CHW Toolkit & Others on RHIhub

The Rural Health Information Hub (RHIhub) has recently updated one of their toolkits that includes information on the role of community health workers (CHW) in rural communities, examples of CHW programs and resources to implement a program for your community. To view the toolkit and other step-by-step guides to help build effective community health, click here.

HAP Launches New Resources to Foster a Resilient Workforce

The COVID-19 pandemic has brought a sharper focus on the need to support healthcare worker wellbeing. To support Pennsylvania’s healthcare workforce, The Hospital and Healthsystem Association of Pennsylvania (HAP) has developed a resource tool entitled, Resources for a Resilient WorkforceThis resource tool provides an overview of the impact of burnout on healthcare workers, finances and patient safety. It also includes guidance to build resiliency and a compendium of resources and strategies to implement resiliency initiatives, as well as best practices from Pennsylvania hospitals.

Supreme Court ACA Overturn Could Impact 340B, Gut HRSA Enforcement

On Nov. 10, the Supreme Court is scheduled to hear arguments over whether Congress, in scuttling the Affordable Care Act’s (ACA) individual mandate to buy health insurance, rendered the entire health care reform law unconstitutional. The ACA extended 340B eligibility to rural and free-standing cancer hospitals. It also told the U.S. Health and Human Services (HHS) secretary to recertify providers’ 340B eligibility annually, develop guidance on avoiding duplicate 340B discounts and Medicaid rebates, create a 340B ceiling price database, impose fines on drug manufacturers and providers for 340B program violations, develop a formal 340B dispute resolution process and conduct selective audits of drug manufacturers for 340B program compliance. The ACA also required a Government Accountability Office study of 340B that led to 340B covered entity audits. It also said the newly eligible 340B hospitals could not get 340B pricing on orphan drugs. All the health care reform law’s 340B provisions would be wiped out if the Supreme Court strikes down the entire law. Ruth Bader Ginsburg’s replacement with a conservative justice by Nov. 10 could increase the odds that the court will declare all of the ACA unconstitutional.

Willingness to Take 1st Generation COVID-19 Vaccine Plummeting

The share of Americans who say they’ll try a first-generation coronavirus vaccine is dropping based on the new Axios-Ipsos Coronavirus Index and the trend is true among both Democrats and Republicans. The steep drop in those willing to take the vaccine illustrates the high risk of politicizing the virus and its treatments and the uphill battle health authorities will face in convincing enough Americans that a vaccine is safe and effective. Based on the national survey:

  • Many respondents feel a vaccine will be risky.
  • Only half are prepared to pay out of pocket for it.
  • Just 13% say they would be willing to try it immediately.
  • Men remain more likely than women to take the first-generation vaccine.
  • Black Americans are about half as likely as Hispanics or whites to take it.

Read more.