Have you ever wondered what it’s like to have a heart attack? Or maybe you’ve had one. What about that same heart attack on a single-lane, pitted road flanked by cornfields on both sides, two hours from the nearest city? This is the reality for rural Americans, and it becomes more extreme by the day. Rural hospitals are sometimes the only tertiary care centers for hundreds of miles, and they’re in danger.
Fortunately, a new bill was introduced into the Senate in May by Dick Durbin and James Lankford: the Rural Hospital Closure Relief Act. This landmark bill builds on a former piece of legislation passed two years ago and provides rural hospitals with vital funds to continue operations. The big question is, why are rural hospitals continuously in peril?
Roughly 50 million people in the U.S. (about 20 percent of the population) live in rural communities. Some have lived in homesteads for centuries, while others may have moved away from cities to start new lives. It has long been accepted that rural communities experience disparities in health outcomes relative to their urban counterparts. Reports from as early as 2000 show that rural residents have higher premature mortality before the age of 75, as well as higher infant mortality, suicide rates, and overall death rates. It is vital to understand these striking disparities to fully comprehend the problem facing rural medicine.
Of the 6,093 U.S. hospitals, 1,796 of those are considered rural. According to the Center for Quality Healthcare and Payment Reform, 600 of those are at risk of closing in the near future due to persistent financial losses and low revenue. These community hospitals are usually the only sites for citizens to receive emergency or complex care for miles, and 47 percent have 25 or fewer beds. Rural hospitals face an immense challenge from private insurance companies, which typically do not compensate them at the same rate as their urban counterparts due to lower patient volume. They do not possess the bargaining power to demand higher compensation, so they resign themselves to making less revenue, which means less compensation for providers, fewer beds, and critical care services. Rural communities suffer because of corporate profit margins, and these hospitals end up closing. Moreover, a lack of tertiary care centers reduces opportunities for specialists or hospital-based providers to practice, driving them away from rural areas.
As providers continue to avoid rural areas and medical resources are diverted from these communities, health care disparities will continue to worsen. It is unacceptable that such a large percentage of our country is left without options for care. Federal and state governments have a responsibility to their citizens, and with increasingly prevalent hospital closures, that responsibility is being avoided. While this is not a call for a nationalized health care program, there must be some form of funding to keep rural medical centers open, regardless of their revenue. The most likely route would be to increase Medicaid and Medicare compensation to pay rural hospitals and providers equitably for their work in underserved areas, forgoing private insurance companies. The Rural Hospital Relief Act functions along those lines; it tweaks the requirements for rural hospitals to be classified as “critical access hospitals” to receive extra federal funding. It is vital that we continue to protect some of our most vulnerable communities; contact your representatives to express your support for this new bill and urge Congress to push this legislation through.
Yet hospital closures are a symptom of a complex pathology in rural medicine. In addition to infrastructure, only 10 percent of physicians in the U.S. work in rural communities, a hugely disproportionate number relative to the population. There are 13 physicians for every 10,000 people in these settings, compared to more than double—31 per 10,000—in urban centers. There is a glaring lack of care for these Americans, and yet the problem worsens year after year as medical students choose to practice in urban areas over rural ones.
Thus, equally crucial as the Relief Act, health care workers need to be incentivized to practice in these areas. Starting in medical school, grants and scholarships, from programs such as HRSA, have been offered for commitments to practice in rural and underserved areas. Despite these programs, the gap between urban and rural physician density grows yearly. Better equipment, health care centers, and resources for health care providers would help to recruit and retain local physicians. At the same time, rural physicians are reimbursed at a lower rate by Medicare and Medicaid than their urban counterparts, much like the hospital system. As we lobby for increased rural hospital compensation from federal programs, increased payments to independent practices and physicians would be impactful in reducing the overwhelming disparity in coverage.
Additionally, compensation may not be the only answer. Medical schools can also recruit more heavily from students with rural backgrounds, who have a pre-existing commitment to serve their communities. Research has shown that medical students with a rural background were more amenable to practicing in rural communities. Residency is also an area for improvement: Physicians who receive part of their training in a rural setting are more likely to practice rurally. As of July 26th, the Department for Health and Human Services has pledged $11,000,000 to establish rural residency programs. Our rural communities are already struggling; this support must continue and be increased to effectively aid these areas. To lend your voice, contact your Congressman to vote yes on the Rural Physician Workforce Production Act, which will allow hospitals to receive funding for residents who opt to pursue rural residencies.
It is clear that rural medicine will continue to face complex challenges, in both infrastructure and personnel. No matter the route forward, change must be imminent, or we risk losing health care coverage for a group of Americans who already make do with so much less.
Dylan Angle is a medical student.