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.”

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