After Years of Disinvestment, Rural Health Care Systems May Be Ill-Equipped to Cope with an Outbreak

April Simpson March 17, 2020

On March 14, a hospital employee stands in front of a sealed space for nursing staff to don necessary equipment for testing at Dayton General Hospital. Dayton, a small town in rural southeast Washington with an aging population, recorded its first positive test for Coronavirus and is waiting on results of more tests.

Edi­tor’s Note: This arti­cle was orig­nal­ly pub­lished by State­line, an ini­tia­tive of The Pew Char­i­ta­ble Trusts. Read the orig­i­nal arti­cle here.

If you’re exhibit­ing coro­n­avirus symp­toms and meet the cri­te­ria, you should get tested.

But if you live in rur­al Pre­sidio Coun­ty, on the west­ern end of the Texas-Mex­i­co bor­der, be pre­pared to trav­el. Coun­ty res­i­dents who are severe­ly ill are being told to go to Big Bend Region­al Cen­ter in Alpine, Texas, which is near­ly 90 miles away from the city of Pre­sidio. The hos­pi­tal will sta­bi­lize those patients before send­ing them near­ly 200 miles to El Paso, accord­ing to a hos­pi­tal spokeswoman.

Patients in the region seek­ing test results should be pre­pared to wait. The 25-bed hos­pi­tal in Alpine takes sam­ples and sends them to the near­est test­ing site, also in El Paso. Those tests are report­ed in a day or two. Three local clin­ics also have a hand­ful of coro­n­avirus tests, but those are tak­en by a couri­er to El Paso on week­days, and then flown across the state to a lab in Dal­las. The turn­around time is three to four days, said Dr. Adri­an Billings, with Pre­ven­ta­tive Care Health Ser­vices in Alpine.

Peo­ple who live out here in West Texas, we’re used to it,” said Gary Mitschke, emer­gency man­age­ment coor­di­na­tor of Pre­sidio Coun­ty. If you don’t have 100 miles — well, you real­ly haven’t got­ten anywhere.”

As in the rest of the coun­try, most of Texas’ coro­n­avirus cas­es have been in its largest cities, includ­ing Austin, Dal­las, Hous­ton and San Anto­nio. But the virus is mov­ing toward less pop­u­lat­ed areas. 

El Paso also is met­ro­pol­i­tan, but it’s far west of the coro­n­avirus clus­ters in the east­ern and cen­tral parts of the state. On Fri­day and Sun­day, the City of El Paso Depart­ment of Pub­lic Health report­ed its first two pre­sump­tive pos­i­tive test results for COVID-19, also the ear­li­est report­ed cas­es in West Texas. 

We’re just as exposed as any­body else in the coun­try as far as I’m con­cerned,” Mitschke said.

Rur­al peo­ple often trav­el to urban cen­ters for food, shop­ping and health care. For exam­ple, Har­ri­son Coun­ty, Ken­tucky, which saw the state’s ear­li­est cas­es of coro­n­avirus, has a pop­u­la­tion of rough­ly 19,000 peo­ple. But it’s less than an hour’s dri­ve from an urban cen­ter, Lexington.

Rur­al areas face numer­ous chal­lenges should they encounter a coro­n­avirus out­break. There are few­er hos­pi­tals, res­i­dents trav­el longer dis­tances to get med­ical care and a high­er pro­por­tion of peo­ple are old­er, poor­er and sicker.

By some mea­sures, such as adult obe­si­ty, Pre­sidio Coun­ty fairs bet­ter than Texas over­all. But 32% of the pop­u­la­tion is in poor or fair health com­pared with 18% of Tex­ans, accord­ing to the 2019 Coun­ty Health Rank­ings State Report from the Uni­ver­si­ty of Wis­con­sin Pop­u­la­tion Health Insti­tute. There is one pri­ma­ry care physi­cian for every 2,320 peo­ple, com­pared with one per 1,660 peo­ple statewide.

On aver­age, 69% of the U.S. rur­al pop­u­la­tion is over the age of 65, com­pared with 35% of the non-rur­al pop­u­la­tion, accord­ing to Jan­u­ary 2020 research from the Char­tis Group, a health care con­sult­ing firm, pro­vid­ed to the Nation­al Rur­al Health Association.

If you have no place to go or if you have to dri­ve an addi­tion­al hour or two to get some­where, peo­ple just don’t go,” said Doug Far­quhar, pro­gram direc­tor for envi­ron­men­tal health at the Nation­al Con­fer­ence of State Leg­is­la­tures. This virus doesn’t seem to be avoid­ing rur­al areas.”

For exam­ple, in Col­orado, sev­er­al rur­al areas have doc­u­ment­ed cas­es, includ­ing moun­tain areas such as Eagle, Pitkin and Sum­mit coun­ties that are pop­u­lar with tourists.

After years of pub­lic health dis­in­vest­ment, rur­al health care sys­tems are ill-equipped to fight an out­break of the coro­n­avirus or ward off its spillover effects to local economies, accord­ing to experts.

Since the Afford­able Care Act went into effect in 2010, 126 rur­al hos­pi­tals have closed their doors. Last year, 19 rur­al hos­pi­tals shut­tered, the most of any year since 2005, when the North Car­oli­na Rur­al Health Research Pro­gram at the Uni­ver­si­ty of North Car­oli­na-Chapel Hill began track­ing clo­sures.

This year we’re on track to break the record,” said Mag­gie Ele­hwany, gov­ern­ment affairs and pol­i­cy vice pres­i­dent at the Nation­al Rur­al Health Association.

But in Ken­tucky, some experts push back on the idea that rur­al hos­pi­tals aren’t up to the task.

The occu­pan­cy rates may actu­al­ly be low­er in quite a few rur­al hos­pi­tals,” said Ty Bor­ders, direc­tor of the Rur­al and Under­served Health Research Cen­ter at the Uni­ver­si­ty of Ken­tucky in Lex­ing­ton. They could actu­al­ly have more capac­i­ty to take in more severe patients.” 

Rur­al providers are pre­pared for a rea­son­able surge, accord­ing to Ele­hwany, but they would need equi­table access to the U.S. Depart­ment of Health and Human Ser­vices stock­pile of med­ical and phar­ma­ceu­ti­cal sup­plies should there be a wide­spread pandemic.

We need to make sure there’s an equi­table dis­tri­b­u­tion and find out pro­por­tion­al­ly where the pock­ets of the pan­dem­ic are,” Ele­hwany said. If they’re in rur­al com­mu­ni­ties, we need to be ready to get some sup­plies to them right away.” 

Texas leads the coun­try in rur­al hos­pi­tal clo­sures, with 24 clos­ing since 2005. Of 152 rur­al hos­pi­tals in the Lone Star State, 77 are con­sid­ered vul­ner­a­ble, as deter­mined by oper­at­ing mar­gins and rev­enue, accord­ing to the Char­tis Group. Forty-eight per­cent of rur­al hos­pi­tals have neg­a­tive oper­at­ing margins. 

What busi­ness­es can stay open when they’re oper­at­ing at a loss?” Ele­hwany asked.

Addi­tion­al vul­ner­a­ble” states, where more than 40% of rur­al hos­pi­tals risk clo­sure, include Flori­da, Mis­sis­sip­pi, Mis­souri and Ten­nessee. Along­side Texas, none expand­ed Med­ic­aid under the Afford­able Care Act, which would have insured more low-income peo­ple. Rur­al hos­pi­tals in non-Med­ic­aid expan­sion states are treat­ing more peo­ple who have no insur­ance. There­fore, they are pro­vid­ing more care for which they aren’t reimbursed.

We Have No Cushion’

The Uni­ver­si­ty of Kentucky’s Bor­ders expects sim­i­lar coro­n­avirus expo­sure rates in urban and most rur­al areas, with the pos­si­ble excep­tion of extreme­ly remote areas, such as moun­tain­ous Appalachia in east­ern Kentucky.

My hunch is those areas are more pro­tect­ed from coro­n­avirus because there’s less expo­sure,” Bor­ders said. 

But Ele­hwany isn’t sure that any rur­al areas are safe.

I’m wor­ried there’s a sense, false assur­ance, that we’re not at risk,” Ele­hwany said. I think we need to be pre­pared for it because cer­tain­ly the com­mu­ni­ties in rur­al Amer­i­ca are very close-knit, espe­cial­ly when you talk about areas where faith-based care and faith-based con­tact is very strong and very significant.”

A. Scott Lockard, pub­lic health direc­tor of a dis­trict that cov­ers sev­en east­ern Ken­tucky coun­ties, has worked non­stop since the Blue­grass State got its first case of COVID-19 ear­li­er this month. 

So far, there are no report­ed cas­es in Lockard’s area, but the virus is creep­ing clos­er. The first cas­es were clus­tered in Har­ri­son Coun­ty, where at least six peo­ple have con­tract­ed the virus. By Mon­day, the virus had moved fur­ther east to Mont­gomery, just one coun­ty away from Lockard’s cov­er­age area.

We have no cush­ion,” Lockard said. We’re oper­at­ing at peak effi­cien­cy just to do our jobs right now and when­ev­er you have a cri­sis like this, you have to let some­thing else go.” 

It’s hard to imag­ine where else to cut, Lockard said. He has only one epi­demi­ol­o­gist. He’s redi­rect­ing oth­er staff, includ­ing a home health nurse. It’s an all-hands-on-deck approach right now,” Lockard said. 

State bud­get cuts, ris­ing require­ments for pen­sion con­tri­bu­tions and the decline of the coal indus­try are among the forces that have ham­pered Kentucky’s pub­lic health infra­struc­ture and erod­ed its work­force. As the local pop­u­la­tion declined, pub­lic health lost about 25% in fund­ing from prop­er­ty tax rev­enue, Lockard said.

Last year, the local health depart­ment work­force was 2,269, down 34% from 2012, accord­ing to the Ken­tucky Cen­ter for Eco­nom­ic Pol­i­cy. With­out the abil­i­ty to invest in peo­ple or pro­grams, it’s hard for Lockard to fill positions. 

It’s all tak­ing a toll on our abil­i­ty to respond,” Lockard said.

Offi­cials in Har­ri­son Coun­ty are mon­i­tor­ing 160 peo­ple dai­ly who were con­nect­ed to the county’s first six cases. 

So you can imag­ine the [demand for] man­pow­er that cre­ates for us in terms of call­ing and ask­ing how these peo­ple are feel­ing, mon­i­tor­ing their tem­per­a­tures,” said Crys­tal Miller, pub­lic health direc­tor of the WED­CO Dis­trict Health Depart­ment. It’s helped that the dis­trict serves four coun­ties who’ve been able to share resources, Miller said.

Mean­while, five rur­al hos­pi­tals across Ken­tucky have closed since 2009, accord­ing to the North Car­oli­na Rur­al Health Research Pro­gram. Eight of the 71 exist­ing rur­al hos­pi­tals are con­sid­ered at high risk of finan­cial dis­tress, accord­ing to an April 2019 study by the program.

Every­thing Is Canceled

States includ­ing Texas and Ken­tucky are lim­it­ing vis­i­tors to nurs­ing homes and pris­ons, encour­ag­ing tele­work­ing and instruct­ing school dis­tricts to devel­op appro­pri­ate plans. The Ken­tucky Office of Rur­al Health can­celed upcom­ing train­ings, con­fer­ences and workshops. 

Every­thing is being can­celed for fear of hav­ing too many med­ical providers in one loca­tion,” said Tina McCormick, exec­u­tive direc­tor of the Ken­tucky Rur­al Health Association.

As the coro­n­avirus spreads, local offi­cials in Pre­sidio Coun­ty, Texas, are try­ing to edu­cate the pub­lic. There’s lit­tle else they can do with lim­it­ed resources. 

We’re always on the verge of being overex­tend­ed,” said Mitschke, the coun­ty emer­gency man­age­ment coor­di­na­tor. He’s also the fire chief for a local vol­un­teer fire department. 

The county’s two major cities, Pre­sidio and Mar­fa, are about 60 miles apart. Mar­fa, the coun­ty seat, draws inter­na­tion­al tourists to its thriv­ing arts com­mu­ni­ty. Vis­i­tors some­times dou­ble the county’s pop­u­la­tion of rough­ly 7,000, accord­ing to Mitschke. 

Both cities have ambu­lance ser­vices to respond to local med­ical calls and back each oth­er up.

If we get two or three [calls] at one time,” Mitschke said, that pret­ty much takes care of our resources in the coun­ty for EMS calls.”

The near­est hos­pi­tal and mutu­al aid emer­gency med­ical ser­vice are at least 20 miles from Mar­fa. Tack on anoth­er 60 miles from the city of Presidio.

April Simp­son reports on rur­al issues at State­line. Before join­ing Pew, April was asso­ciate edi­tor of Cur­rent, where she cov­ered pub­lic broad­cast­ing and non­prof­it media. April was a Ful­bright fel­low in Botswana and East­ern Demo­c­ra­t­ic Repub­lic of Con­go fel­low with the Inter­na­tion­al Women’s Media Foun­da­tion. She has writ­ten for the Seat­tle Times and the Boston Globe, among oth­er pub­li­ca­tions. April is a grad­u­ate of Smith Col­lege and the Lon­don School of Eco­nom­ics and Polit­i­cal Science.
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