Coronavirus in rural America (Part CXVIII): The difficulties of vaccine rollout

It’s a common sentiment amongst many news articles I’ve read this week that getting rural Americans vaccinated is much harder than getting those individuals in suburban or urban areas vaccinated. Bennett Doughty and Pamela Stewart Fahs explored this difficult issue in their piece, Why Getting Covid-19 Vaccines to Rural Americans Is Harder Than It Looks, and How to Lift the Barriers. Among the key obstacles in vaccinating rural Americans are storage, distribution, and misinformation.

The first issue has to do with storage. The first two authorized vaccines – one made by Pfizer and BioNTech and the other by Moderna – are mRNA vaccines that require storage in very cold temperatures. The Pfizer vaccine must be stored at minus 94 degrees Fahrenheit and Moderna’s at minus 4 Fahrenheit. Once thawed and prepared, the Pfizer vaccine must be used within five days and Moderna’s within 30 days. 

Unfortunately, small hospitals, which are more prevalent in rural areas, are less likely to have expensive freezers that can accommodate storing these vaccines. An article by Thomas C Ricketts, III and Paige E Heaphy puts forth a number of figures demonstrating the numbers and distributions of hospitals in rural America. I found the most telling statistic to be the following: 

Nonmetropolitan hospitals are smaller: 72% have fewer than 100 beds, and 42% have fewer than 50 beds. Twenty percent of all hospital beds are in rural hospitals. The median number of staffed beds for nonmetropolitan hospitals is 59 compared with 156 for urban hospitals, while the average number of beds per hospital is 82 and 245, respectively. Rural hospital inpatient days account for 20% of all hospital inpatient days in the United States. Medicare and Medicaid are important sources of payment for hospital patients.

Having always lived in a city or suburbia, I found it to be astounding that hospitals with fewer than 50 beds even existed. Moreover, with the influx of coronavirus patients, I can easily see how rural hospitals with these small numbers of beds would be overwhelmed with the number of patients they need to treat. 

On another note, this got me thinking: the time limit to use the vaccines, within 5 and 30 days respectively, proves to be a larger issue because rural populations are much smaller compared to their urban or suburban counterparts. I decided to do some research and came across the following Census data, where Census Bureau Director John H. Thompson noted, “Rural areas cover 97 percent of the nation’s land area but contain 19.3 percent of the population (about 60 million people).” As a result, rural areas may not have enough individuals to vaccinate within the time limit set by the FDA, thus leading to wastage of unused vaccine doses. 

This is a great 3-minute listen provided by NPR that discusses the significant challenges faced by rural hospitals to rollout mass vaccinations. 

The second issue has to do with big batches. The vaccine doses are currently being shipped in special containers with dry ice, and for now, vaccines are being delivered only in large batches. While urban areas will be able to quickly distribute these large batch doses, finding enough patients to vaccinate quickly in rural areas may be more difficult. As a result, the vaccine distribution efforts will favor hubs that cater to more populated areas to avoid wasting any vaccine or leaving patients unable to get their second dose. 

The article notes: 

The current vaccines’ cold storage requirements and shipping rules mean many rural hospitals can't serve as vaccination distribution hubs. That can leave rural residents – about 20% of the U.S. population in all – traveling long distances, if they’re able to travel at all.

The third issue has to do with difficult barriers to healthcare access. This is not a new problem in rural America. As Haider Warraich, Robert Califf and Sarah Cross discuss in their article, Beyond covid-19, rural areas face growing threat from chronic heart and lung diseases:

Rural hospital closures grab all the headlines and perhaps rightfully so. From 2010 until today, some 134 rural hospitals have closed, and a report released last spring, before the pandemic had hit many rural areas, showed a quarter of surviving rural hospitals in dire financial straits. Cancellation of routine medical care necessitated by the novel coronavirus, which causes covid-19, has pushed more hospitals off the cliff.

 The Rural Health Information Hub has also noted that:

Recent years, however, have presented challenges for rural hospitals. Factors such as low reimbursement rates, increased regulation, reduced patient volumes, and uncompensated care have caused many rural hospitals to struggle financially.” 

Rural areas have fewer health care providers that serve a more geographically diverse population than in urban or suburban communities. Moreover, in many of these areas, the closure of rural hospitals has forced individuals to travel farther for care. This got me thinking about more vulnerable populations such as the elderly and poor, which, I would imagine, have an even more difficult time traveling for care. Not only do these vulnerable populations lack access to public transportation to help them reach hospitals, at least in comparison to their urban or suburban counterparts, but at the same time, the “distance and geography, such as mountain roads, can mean driving to those sites takes time."

At a more local level, Hailey Branson-Potts notes in her article for the LA Times:

In the battle against COVID-19, health officials in Northern California face the daunting task of vaccinating more than 683,300 people spread across a mountainous, heavily forested region where calamity — either from illness or physical trauma — can mean hours-long drives to the nearest medical facility.

This further demonstrates the difficulty that rural areas across our nation face in regards to vaccinating a population that is much more spread out amongst various geographic areas. 

The fourth and last issue involves widespread suspicion and defiance. Aside from growing skepticism that the virus is a serious threat only in major towns, there is also a common fear amongst the rural community that the new vaccine is unsafe. Moreover, there has been a constant and continuous open rebellion against health orders.

As Hailey Branson-Potts discusses, “the pushback in rural parts of California is emblematic of the challenge in many parts of the United States, particularly outside more liberal urban centers.” 

"We’re getting very frustrated here in Northern California,” said Dr. Richard Wickenheiser, the Tehama County health officer. “We have a lot of anti-vaxxers and a lot of independent people who just feel that COVID was a hoax, that it was going to go away when the election was over. And that didn’t happen. ... The excuses just go on and on.” 

In Shasta County, some speakers at supervisors’ meetings have compared mask mandates to Nazis forcing Jewish people to wear a yellow Star of David and spouted conspiracy theories about vaccines containing tracking devices. The county health officer has been threatened repeatedly.

In Tehama County, where indoor dining is banned by the state, restaurants were still seating maskless customers in recent days. In downtown Red Bluff, signs in store windows read: “Please respect everyone’s personal space. ... Masks are welcome, but not required” and “Due to pre-existing health conditions, some of the staff are not wearing a face mask” and “MASKS OK."

The widespread suspicion and defiance exhibited by rural communities across Northern California are a telltale sign of the difficulties of vaccine rollout, not simply due to logistical issues, but rather of a more deeper belief system. 

This is a great podcast on the vaccine rollout in rural areas. 

Other posts on this topic are here, here, and here.

 

Big NYT feature on the federal effort to save rural hospitals, by ending inpatient care

Emily Baumgaertner reported yesterday for the New York Times under the headline, "A Rural Hospital's Excruciating Choice:  $3.2 Million a Year or Inpatient Care?"   Here are some excerpts from an important feature: 

For 46 million Americans, rural hospitals are a lifeline, yet an increasing number of them are closing. The federal government is trying to resuscitate them with a new program that offers a huge infusion of cash to ease their financial strain. But it comes with a bewildering condition: They must end all inpatient care.

The program, which invites more than 1,700 small institutions to become federally designated “rural emergency hospitals,” would inject monthly payments amounting to more than $3 million a year into each of their budgets, a game-changing total for many that would not only keep them open but allow them to expand services and staff. In return, they must commit to discharging or transferring their patients to bigger hospitals within 24 hours.

The government’s reasoning is simple: Many rural hospitals can no longer afford to offer inpatient care. A rural closure is often preceded by a decline in volume, according to a congressional report, and empty beds can drain the hospital’s ability to provide outpatient services that the community needs.

But the new opportunity is presenting many institutions with an excruciating choice.

“On one hand, you have a massive incentive, a ‘Wow!’ kind of deal that feels impossible to turn down,” said Harold Miller, the president of the nonprofit Center for Healthcare Quality and Payment Reform. “But it’s based on this longstanding myth that they’ve been forced to deliver inpatient services — not that their communities need those services to survive.”

Some rural health care providers and health policy analysts say the officials behind the rule are out of touch with the difficulties of transferring rural patients. Bigger hospitals — bogged down with Covid surges, pediatric R.S.V. patients and their own financial woes — are increasingly unwilling to accept transferred patients, particularly from small field hospitals unaffiliated with their own systems.

There are also blizzards, downed cattle fences and mountain pass roads that close for months at a time.

“I really want to give this policy a chance to work well,” said Katy Kozhimannil, director of the University of Minnesota Rural Health Research Center. But gambling with transfers could mean that “some of the most extremely remote and marginalized communities could end up with no care at all — and that’s what we were trying to avoid in the first place.”

More than 180 rural hospitals have closed since 2005.   

There's lots more recent reporting on rural healthcare worthy of note.  Here are just a few: 

This one, from the Texas Tribune, is about rural hospital closures in the Lone Star State, with Jayme Lozano reporting: 

Texas hasn’t had a hospital close since 2020, a much-needed relief following the previous decade of closures that were predominantly seen in rural communities.

That could change soon: A new report from Kaufman Hall, a health care consulting agency, that was made public Wednesday shows that nearly 1 out of every 10 Texas hospitals are now at risk of closure, twice as many as before the coronavirus pandemic began in 2020.

“Ultimately, our concern is this will impact patient care,” said John Hawkins, president of the Texas Hospital Association.

The report highlights the pandemic’s striking toll on hospitals in the state as they face growing strain from surges in respiratory illness, workforce shortages and rising costs of medication, medical supplies and labor. This has caused hospital expenses to increase greatly — the total expenses for Texas hospitals this year have cost $33.2 billion more than before the pandemic.

While the risk is greater for all Texas hospitals, it’s higher for rural hospitals than for urban facilities — a 26% risk of closing compared with a 5% risk. Hawkins said there is concern about the challenges rural hospitals could face in the near future.

Health experts have long credited support from the federal spending spurred by the COVID-19 pandemic for lessening the closure risk in 2020 and 2021. Those funds are expiring soon, leaving hospitals without that financial safety net. Nearly half of all Texas hospitals are in negative operating margins because revenue is not covering the cost of patient care.

“We know, as that federal funding runs out, we’ve created a fiscal cliff,” Hawkins said. “These operating challenges are going to continue to be real for rural hospitals.”

And two recent stories about rural health care in Colorado are here and here, both from the Colorado Sun.  

“Code Blue”: Medicare reimbursement reform needed to save the life of rural hospitals.

The healthcare industry has undergone drastic reforms over the last few years. It has been strained by inflating costs and pressed with questions about the Affordable Care Act’s implementation and future. Few hospitals and patients are immune from these stressors. Rural hospitals have been impacted especially hard. The hardships that rural hospitals face are largely a byproduct of the special Medicare rules for rural hospitals. These rules substantially differ from that of urban and suburban hospitals. 


Rural areas typically have hospitals that are categorized as “critical access” hospitals. Critical access hospitals are much smaller than their urban counterparts. These hospitals can have no more than 25 inpatient beds, they must maintain an annual average length of stay of no more than 96 hours, and they have to be a minimum 35 miles from the next nearest hospital.


Certification as a critical access hospital allows that hospital to receive cost-based reimbursement from Medicare, as opposed to the flat rate reimbursement that non-critical access hospitals typically receive. Medicare requires that a patient pay 20 percent of the amount that the critical access hospital charges. Patients also pay 20 percent coinsurance at non-critical access hospitals, however that 20 percent is based on the amount Medicare reimburses, which is typically significantly lower than what the hospital charges.


This reimbursement structure stresses both the critical access hospital and the rural Medicare patient. For example, in 2012, when a Medicare patient received an electrocardiogram at a rural critical access hospital, they owed an average of $33 for that procedure. Patients at other, more urban hospitals would only have had to pay about $5. According to a recent report by the inspector general at the Department of Health and Human Services, many Medicare beneficiaries who received treatment at these rural critical access hospitals have ended up paying between two to six times more for services than patients non-critical access hospitals.


When interviewed on this topic, Eric Draime, chief financial officer for Avita Health Systems, stated that this difference is not the rural hospitals' fault. "Critical access hospitals don't charge more. They charge less, but the way Medicare developed the system, the enrollee ends up footing more of the bill," CFO Draime said.


To make matters worse, the rural population is not only paying more, but their hospitals are closing due to this payment structure. USA Today recently reported on these closures, stating: “[l]ow Medicare and Medicaid reimbursements hurt these hospitals more than others because it's how most of their patients are insured, if they are at all.”

Thus, the costs that the rural population is currently facing is not only financial, but the cost in the length of time that it takes to get to the next nearest hospital post critical access hospital closure. In another USA Today report, this issue was shockingly addressed in the case of a man who had a stroke and, because of the closure of his local critical access hospital, had to be ambulanced for nearly 40 minutes to the county’s urban hospital. 

The inspector general’s office has advised that Congress change the law so that a Medicare beneficiary’s financial responsibility better reflects the cost of the service. Brock Slabach, a senior vice president at the National Rural Health Association, said that “[t]he reason this hasn’t been solved is it would require the Medicare program to subsidize more. . . .” 

In addition to reconfiguring the reimbursement aspect of Medicare, Congress should mandate that the 23 states that refuse to participate in the Medicaid expansion do so. Without reform, more hospitals will close, cost will continue to rise, and rural Americans will bear the burden of the very program intended to help them.

How the Dobbs decision worsens dire conditions in rural hospitals

Rural hospitals have been struggling, citing financial and staffing issues. More than 140 have closed nationwide since 2010, with many more facing challenges that could see them shutting doors in the future as well. An additional 114 rural hospitals ended all inpatient services from 2010 to 2019. 

One of the care units hit hardest by these problems has been the delivery room, which often pose unique challenges to many hospitals across the country due to their unprofitable nature under the current US healthcare system. In 2004, 55 percent of rural counties offered obstetric services. That number shrank to 45 percent by 2018, and continues to shrink to this day.

The Supreme Court's decision in Dobbs v Jackson has only exacerbated these issues. Dobbs held that the US Constitution does not provide a right to an abortion, representing a huge blow to women's rights and healthcare nationwide. Often overlooked, however, is the disproportionate effect the decision has on rural hospitals across the country. More reading on the Dobbs decision and the state of rural hospitals can be found on this blog here and here.

Following the outcome of Dobbs, trigger bills in many states across the country immediately went into effect. One of these states was Idaho, whose near-total abortion ban includes a provision which exposes physicians to both criminal and civil litigation for performing an abortion. Idaho is one of only six states in which health care providers are open to this type of prosecution. As a result, the already precarious situation rural hospitals find themselves in appears to be getting worse.

Bonner General Health, a hospital in Sandpoint, Idaho, recently announced that it would be discontinuing all obstetrical services starting mid-May of this year. As a result, labor and delivery care will be halted entirely. In a press release, the president of the hospital cited Idaho's political climate and staffing shortages as the main reason for these changes, saying: 

Highly respected, talented physicians are leaving . . . the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care . . . We hoped to be the exception, but our challenges are impossible to overcome now.

Sandpoint is a town with a population of roughly 9,000 residents, who recorded 265 births at Bonner General last year. New parents in labor will now have to travel to Kootenai Health in Coeur d'Alene, which is about an hour away from Sandpoint. 

To make matters worse, Kootenai Health is experiencing its own troubles. Similar to rural hospitals all across the country, staffing shortages and financial hardships forced the hospital to shutter its addiction recovery and outpatient psychiatry programs. Due to a recent staffing shortage and Covid-19 surge, a US Army medical team was dispatched to Kootenai Health to help the overwhelmed hospital. Given the looming closure of Bonner general Health's obstetrical services, Kootenai will likely face similar challenges once this change is put into effect on May 19th. 

Additionally, the Idaho legislature recently passed an "abortion trafficking" bill, which would bring criminal charges to those who help pregnant minors across state lines for the purposes of obtaining an abortion without parental consent. An amendment to the bill accepted by the House would add the ability for rapists to sue their victims for undergoing an abortion procedure. The bill could mean increased burdens on Idaho's neighboring states, who all currently allow abortions.

In Mississippi, a similar trigger bill went into effect post-Dobbs, banning all abortions except for cases of rape, incest, or danger to the pregnant person. Mississippi's only abortion clinic shut its doors shortly after. As a result, some in the state legislature predict an additional 5,000 babies will be delivered within the state. This reality will once again disproportionately affect rural hospitals already struggling to survive.

Hospitals in Mississippi's rural areas have already been suffering, as the state is one of only 10 to refuse federal Medicaid expansion funding. Medicaid currently finances roughly 42 percent of births in the US, and covers a majority of births from people with low incomes. While the funding is largely a temporary band-aid on a much larger problem, states that opted out of the program accounted for almost three-fourths of rural hospital closures from 2010 to 2021. 

While the state's rural hospital situation has improved slightly in more recent times, danger still remains. 38 percent of Mississippi's rural hospitals are in danger of closing, which would put 28 of the state's 65 rural counties without a hospital. Staffing shortages will similarly put a strain on obstetrical services within the state, where already limited delivery room capacities in rural areas may quickly become overwhelmed. 

It remains to be seen how these challenges facing rural hospitals can be solved, but it is clear that the Dobbs decision further worsens an already significant issue. Larger expansions to Medicaid may alleviate some stresses for the immediate future, but long-term solutions have yet to be offered by state legislators. Unfortunately, many hospitals in rural areas appear to be heading towards a bleak future, or complete closure. 

Coronavirus in rural America (Part LXIV): Rural hospitals overwhelmed(?)

Two stories today discuss the issue of rural hospitals getting overwhelmed with COVID-19 patients as the pandemic spreads to rural America.  The first is out of Georgia, by the Atlanta Journal Constitution, headlined "Georgia shifts 80 overflow beds southward amid rural virus outbreaks." Johnny Edwards reports that the beds are going to Milledgeville, population 17,715, but when you look at a map, you see that Milledgeville is only about and hour and half drive from Atlanta, even less from the greater metro area.  Here's an except from Edwards' story:

The Georgia Emergency Management and Homeland Security Agency said Wednesday that it will move beds out of the little-used temporary facility at the Georgia World Congress Center and set them up 100 miles southeast inside a shuttered youth military academy. As the downtown Atlanta site was designed to do, Milledgeville’s makeshift hospital will treat patients with mild to moderate symptoms who don’t need ventilators or critical care, relieving hospitals that could be overrun in another surge.

The story quotes Governor Brian Kemp's news release, which says Milledgeville

is more centrally located for many medical facilities throughout Georgia.  We continue monitoring the virus data to enable us to ‘right size’ the resources and response so we can ensure every COVID-19 patient gets the care they need.

Edwards also quotes Amber Schmidtke, an assistant professor of microbiology at Mercer University School of Medicine in Macon.  She said:

I think it’s mainly motivated to help with some of the rural hospital burden, because there are many counties that don’t have a hospital ... And especially in Region H, the hospitals can be two counties away, and some of these counties take 45 minutes to an hour to drive through.

The other piece is an op-ed in the New York Times by two employees of a rural Texas hospital.  Donna Boatright and Jennifer Liedtke authored "In Texas, 6 Critically Ill Covid-19 Patients Would Overwhelm This Hospital."  They write from Sweetwater, Texas, population 10,906, in west Texas, the southern part of the panhandle.  Sweetwater is, the authors explain, best known as the "World's Largest Rattlesnake Roundup."  Here is an excerpt from their op-ed:

With just two ventilators, Rolling Plains Memorial Hospital in Sweetwater, Texas, has been terrified of Covid-19 ever since March. ... Even the slightest outbreak would overwhelm Rolling Plains, which sits on a major highway that carries tens of thousands of travelers a day. 

Rural hospitals in America have been fighting for survival for years, mostly because of their relatively high numbers of uninsured patients.

The piece provides a great deal of additional context on the rural healthcare crisis, and it is well worth a read in its entirety. Lots of local color and empathy-inducing detail.  Plus, there is a video to accompany the op-ed.

Postscript from WyoFile, featuring a hospital out of Campbell County, Wyoming, population 48,133. This is deeply reported story by Dustin Bleizeffer and Mason Adams, providing lots of context on rural hospital closures, particularly in coal country like this area which, like Appalachia, has been struggling with an economic downturn for some time. 

And here is a June 26, 2020 story from the Houston Chronicle, featuring Big Bend National Park in west Texas.  Jeremy Wallace reports, but it's behind a paywall.

Noam Levy reports for the Los Angeles Times in this related story also dateline June 26, 2020. This story, which references what is happening in Texas, Arizona,  Florida, and California, is not especially rural focused, but it does note the major outbreak in Imperial County, population 174,528, the state's most southeasterly county, bordering Mexico and Arizona.  Hospitals as far north as Sacramento are taking patients out of Imperial County, whose hospitals are overwhelmed.   Interestingly, Levy reports an urban-to-rural patient reversal out of Texas, a phenomenon I'd not previously seen:

“We can see the storm coming,” said John Henderson, who heads the Texas Organization of Rural and Community Hospitals. 

Henderson noted that several member hospitals in suburban and rural areas around Houston are already being called on to take very ill patients from overburdened medical centers in the city, which is experiencing among the worst coronavirus outbreaks.

Another postscript: Two stories about rural hospitals and clinics were filed on June 29, 2020.  One is on Capital Press, by Sierra Dawn McClain, dateline Bend, Oregon, about the travails of that state's rural hospitals in the COVID-19 era.  I was not familiar with Capital Press but its subhead is "Empowering Producers of Food and Fiber."  Here's an excerpt:

In rural Oregon, a healthcare crisis is festering. Gov. Kate Brown labeled healthcare providers "essential" during COVID-19, but the pangs of the lockdown have thrashed providers. 

In March and April, many rural hospitals and clinics sat nearly empty with outpatient procedures and elective surgeries postponed. Delayed care may have health impacts for patients, and the revenue drop battered already-fragile rural health systems.

The second story was posted on North Carolina Health News and is by Liora Engel-Smith.  The lede follows: 

Federal support to rural hospitals helped some of the state’s most cash-strapped facilities through the first phases of the coronavirus pandemic, but advocates say providers will likely need more support down the line. 

Through the federal coronavirus aid package known as the CARES Act, hospitals got money for care and testing of uninsured people for coronavirus, but urban hospitals, which generally have a larger share of coronavirus patients, got the bulk of that aid.

Catching up on rural healthcare stories

I wrote several posts about rural healthcare this summer, mostly prompted by the consideration and passage of Trump's One Big Beautiful Bill, which was widely discussed as undermining rural health care and rural hospitals.  Since then, I've neglected the issues except to address some of them in this forthcoming law review article, which focuses on the challenge of maternal mortality for rural women.  

In this post, my plan is just to provide links to the stories I've seen about rural health care since the summer, making this something of a repository of resources to study how rural health care is faring in the Trump administration's first year and likely further degradation of services as a consequence of recent Republican policies.

First off, the Trump administration is withholding support to tsunami proof this hospital.  Katia Riddle reports from Astoria, Oregon.   One interesting aspect of this story is how local Republicans who supported Trump are flummoxed--or worse--about his administration's failure to support a rural hospital that has saved many local lives.  Here's some context:   

The Trump administration has canceled billions of dollars in federal grants across multiple agencies, and one of those grants is for a program that was designed to help local governments fortify places that are vulnerable to natural disasters.

* * *  

[The hospital in Astoria], called Columbia Memorial, was built decades ago. Now that we know more about earthquakes, it's hard to imagine a worse spot to build a hospital. Not only is the whole town in a major subduction zone, the building is just a few blocks from the water, on top of dangerously unstable ground.

And here's a key quote from a former mayor of Astoria, Willis Van Dusen, a Republican who voted for Trump but now is frustrated by the recent turn of events regarding the needed hospital work: 

Van Dusen: What is more important than a hospital in a rural community like Astoria? Now, it saved my life.

Riddle: Van Dusen points to a framed photocopy of a piece of paper - the EKG reading when he had a heart attack some years ago. At one point, he flatlined.

Van Dusen: All these are (imitating electric current), and they're hitting the paddles. And I had actually died.

Riddle: It was doctors at Columbia Memorial that brought him back. Van Dusen says he and many other people in Astoria wouldn't be here without this hospital. Making sure that it can keep providing care during an earthquake and a tsunami, he says, is the opposite of waste, fraud and abuse.

Van Dusen: And just to jerk that money away from us, I can't just say it makes - it's frustrating. It makes me livid. It makes me angry.

Riddle: Van Dusen says he's not the only one in this town who's mad.

Van Dusen: I know every single Republican that I have talked to is livid over what's happening.

This is a rare instance when I've seen a Trump voter whose mind has been changed by Trump's spending priorities--and how those priorities have played out in the voter's own community.  It shows that Trump voters can be swayed when Trump's spending priorities impact them, something rarely illustrated.  

Regarding the $50 billion "rural health fund," sometimes referred to as the rural slush fund, Sarah Jane Tribble of Kaiser Health News reported about ten days ago on how states are competing for these funds.  It hardly seems like a fair fight.   Tribble provides details on how and why substantial chunks of the funds might not even wind up in rural places:  

Nationwide, states are racing to win their share of a new $50 billion rural health fund. But helping rural hospitals, as originally envisioned, is quickly becoming a quaint idea.

Rather, states should submit applications that "rebuild and reshape" how health care is delivered in rural communities, Centers for Medicare & Medicaid Services official Abe Sutton said late last month during a daylong meeting at D.C.'s Watergate Hotel. Simply changing the way government pays hospitals has been tried and has failed, Sutton told the audience of more than 40 governors' office staffers and state health agency leaders — some from as far away as Hawaii.

"This isn't a backfill of operating budgets," said Sutton, CMS' innovation director. "We've been really clear on that."

Rural hospitals and clinics nationwide face a looming financial catastrophe, with President Trump's massive tax-and-spending law expected to slash federal Medicaid spending on health care in rural areas by $137 billion over 10 years. Congressional Republicans added the one-time, five-year Rural Health Transformation Program as a last-minute sweetener to win the support of conservative holdouts who worried about the bill's financial fallout for rural hospitals.

Yet, the words used by CMS Administrator Mehmet Oz and his agency's leaders to describe the new pot of cash are generating tension between legacy hospital and clinic providers and new technology-focused companies stepping in to offer new ways to deliver health care.

It's "what I would call incumbents versus insurgents in the rural space," said Kody Kinsley, a senior policy adviser at the Institute for Policy Solutions at the Johns Hopkins School of Nursing.

I further detail possible non-rural uses of the fund in my forthcoming law review article, which relies on Tribble's reporting. 

Finally, Abigail Ruhman reported for the Texas Tribune a few weeks ago on how Texas' rural hospitals are competing for a piece of that "rural slush fund."  

As Texas develops its application for a new rural health funding program, rural hospital leaders say the priority should be financial stabilization for their facilities.

The recent sweeping tax and spending plan includes a $50 billion appropriation for the Rural Health Transformation program. States will receive funding based on applications they submit in early November.

During an hours-long public hearing Monday to discuss the program, several hospital leaders raised concerns that without direct funding, the state may experience more rural hospital closures.

Erin Clevenger, CEO of Memorial Medical Center in Port Lavaca, southeast of Victoria, said her hospital is high on the list of Texas hospitals at risk of closure.

“Every day is a battle to make sure we don’t become one of those statistics,” Clevenger said.

In the last decade, Texas has lost 14 rural hospitals. Of the 156 rural hospitals currently in the state, about 70% have lost services, and more than half are at risk of closing, according to a report from the Center for Healthcare Quality and Payment Reform.

Memorial Medical Center is in the southern part of the state, but it provides critical services that benefit people across Texas – even patients in Dallas.

“When even large urban hospitals could not take on more patients, we opened a COVID care unit and accepted their transfers, even flying patients in from Houston and Dallas,” Clevenger said.

Keep an eye out for more news about whether rural hospitals are getting the benefit of the "Big Beautiful Bill" and its rural slush fund--and whether any funds they receive are sufficient to keep them open.  It'll also be interesting to see if the anticipated closure of rural hospitals will turn rural Trump supporters against him--if those closures happen during his presidency.  

Meanwhile, the reduction and reinterpretation of other federal funding streams, along with other strains,  have been threatening--and in one instance, closing--hospitals in rural California.  Read more here (Inyo County in the eastern Sierra) and here (Imperial/Riverside County).  

Health care reform and rural hospitals

A story on the McClatchy news service a few days ago ran under the headline, "Rural hospitals fear healthcare overhaul won't help them." It features Peach County Regional Medical Center in Fort Valley, population 8,005, in central Georgia. An excerpt from Halimah Abdullah's story follows:

Overhauling the system could offer a lifeline to hospitals, doctors and nurses that serve the nation's small towns and agricultural communities, they say. But they also fear that Congress might not provide either enough money or the right incentives to allow rural hospitals to cover their costs and recruit talented medical professionals. That, they fear, will make it nearly impossible for smaller hospitals to remains in business.

Blue Dog Democrat, Jim Marshall, from nearby Macon, Georgia, offered these observations:

Cash flow for rural hospitals is a challenge. An awful lot of our decisions concerning reimbursement flow from decisions in the 80s and we use a big city hospital model for determining costs for what reimbursement rates should be provided. It's unrealistic to expect the same cost efficiencies in low volume rural hospitals that you can obtain in high volume urban hospitals.

Another reason that rural hospitals are struggling is that they treat so many uninsured patients. The number of uninsured visits to rural emergency rooms is 33% higher than in areas with adequate doctors' offices and clinics, and hospitals are often uncompensated or under-compensated for these services. The challenges facing rural hospitals are thus linked to the broader health care and economic crises--and the consequences of these crises for rural residents.

On a somewhat related note, I recently came across this Rural Doctoring blog. The physician/author writes about her experiences working in two rural hospitals in northern California. Also, the Blog for Rural America is doing a lot of excellent coverage of rural medical debt and about health care reform generally. Read a recent post here.

When rural and urban compete for resources

That's the scenario at stake in the proposal of the Centers for Medicare and Medicaid Services  to shift some reimbursement funds to rural hospitals.  Because the pot of money is (apparently) fixed, this is a zero sum game, meaning that urban hospitals will lose what/if rural ones gain.  Bloomberg Law reports this morning under the headline, "Rural Hospitals See $200 Million Medicare Win at Cities' Expense."  Here's the lede from Tony Pugh's story:

Low-wage rural hospitals would see more than $200 million a year in additional Medicare payments under a Trump administration plan to shift money from urban hospitals in areas with higher wages, a leading health-care law firm found. 

The proposal by the Centers for Medicare & Medicaid Services is designed to cut payment disparities between urban hospitals and rural facilities. Rural clinics and hospitals are struggling in many states that haven’t expanded eligibility for Medicaid under the Affordable Care Act. 

Since the proposed rule was published earlier this month, "hospital associations in states with higher concentrations of urban facilities" have been protesting.  Pugh cites the analysis of the Hall Render law firm, which shows, for example, that California's Medicare payments would be reduced by $108 million annually.  Other big losers would be New York ($41 million); Massachusetts ($19 million) and New Jersey ($18 million).  Southern states stand to gain most, presumably because the South is the most rural region in the nation.  The reductions would be phased in, taking full effect in 2021.

Sarah Jane Tribble, covering the same issue for NPR, provides an illustration of the "wage index," which has been around since the 1980s. 

[It] means under the current index a rural community hospital could receive a Medicare payment of about $4,000 to treat someone with pneumonia while an urban hospital received nearly $6,000 for the same case, according to CMS.

They "why" for the shift is hinted at in the article's opening line:  the wages paid by rural hospitals are lower than those at their urban counterparts, and Medicare reimbursements have typically been pegged to an "area wage index."  This has meant rural hospitals with low local labor costs have typically received lower Medicare payments than urban ones, albeit for rendering the same services.  A related story on NPR, by Sarah Jane Tribble, is here.

I'm very sympathetic to the needs of rural hospitals, and I'll be fascinated to see if this proposal goes into effect because I've never seen a proposal that takes from the urban (rich?) and gives to the rural (poor?) implemented--at least I cannot recall such a circumstance.  For example, since it was published in 2010, I have been pondering the careful word choice of the California Commission on Access to Justice Report, "Improving Access to Civil Justice in Rural California," framed to avoid a rural-urban contest for funding streams.  Here's a quote of one of the key recommendations from that report:

2.  Expand Funding for Rural Legal Services The significant lack of funding for California’s rural legal aid programs must be addressed. All legal aid programs face the challenge of inadequate resources, including programs in urban as well as in rural areas; therefore any initiative to address the severe lack of resources in rural areas should not be developed in a way that unnecessarily undermines urban programs. The goal is to increase the total resources available for all legal services programs across the state, not merely to reallocate existing resources. 

In fact, what has happened in the years since that report was published is that per "poor person" funding for legal aid organizations serving rural populations has fallen relative to that for organizations serving urban populations.  This just emphasizes again how hard it is for rural institutions to get their "fair share" of funding in all sorts of contexts.

Maybe this Robin Hood-like move at CMR will go forward, however, at least if the Trump administration sees it as currying favor with the president's rural "base." 

Rural hospitals in the news, again

Axios' Northwest Arkansas newsletter led yesterday with the travails of rural hospitals.  Here's the scoop:  

71% of rural hospitals in Arkansas are running in the financial red, according to a recent report from health care consultancy Chartis. The same is true for half of America's rural hospitals.

Why it matters: Millions of Americans, especially those in rural states like Arkansas, rely on local hospitals for emergency and other forms of care.The report also points out: "Within many rural communities, the hospital is often among the largest employers and thus a major contributor to the local economy."

Driving the news: While COVID-era government aid helped alleviate financial pressure on rural hospitals, such support has largely ended.The growth of Medicare Advantage enrollment is also taking a toll. 

"The Medicare alternative's popularity with seniors is cutting into a typically better funding source for rural hospitals — traditional Medicare — as hundreds of rural hospitals face financial calamity," Axios' Arielle Dreher reported last August.

Stunning stat: The jump from 43% of rural hospitals operating in the red last year to 50% this year is the single largest change in percentage in a one-year period that Chartis reports seeing.

What they're saying: "When you see all of this negative pressure, what you're really talking about is loss of access in the places where we need it — one could arguably say, most," says Michael Topchik, partner and executive director of the Chartis Center for Rural Health.He points to problems like suicide, opioid overdoses, alcohol-related deaths and more that plague rural America in particular. 

"I'm focusing on data on the providers, on the hospitals. But in the end, what we're really talking about is the communities served — and these are the most vulnerable communities in America."

Of course, you'll find a great deal more content on rural hospitals here on Legal Ruralism.  

Coronavirus in rural America (Part XCIX): Democratic candidates raise the issue of rural hospitals

I noticed an ad about saving rural hospitals by Nicole Galloway, the Democratic candidate for governor of Missouri, a few days ago.  The ad takes to task Mike Parsons (R), the incumbent, for declining to take federal funding to expand Medicaid, which has resulted in the closure of rural hospitals in the Show-Me State.  I can't find that ad on her webpage, but it's still on her Twitter feed from just a few days ago.  

 Here's what Galloway's webpage does say about rural Missouri--yes, she has a tab for that!  Galloway was focused on rural hospitals' financial health even as state auditor, as reported in the St. Louis Post-Dispatch.  And here's a St. Louis Public Radio story from May 2018 about the implications of those rural hospital closures in southeast Missouri.  Lastly, here's a story from a few days ago in the Columbia Missourian about Galloway's tender years, career and campaign.  I'll just note that she grew up in suburban St. Louis but attended Missouri S & T in micropolitan Rolla, in the rural south central part of the state.  Interestingly, Rolla is Parson's city of birth.  

I also note that Steve Bullock (D), Governor of Montana who is running to be the state's junior U.S. Senator, has also been talking rural hospitals.  I'm pasting in a recent Tweet.   

Here is one of Bullock's ads, from this past summer, about saving rural hospitals.  

P.S.  NPR ran this 4-minute piece on rural hospital closures on Oct. 17, 2020.  It's from Sarah Jane Tribble of Kaiser Health News.  She features the hospital closure in Fort Scott, Kansas, near where she grew up.  It's one of the more in-depth stories I've consumed about rural hospital closures, discussing both alternatives to rural hospitals and the consequences of these closures on a community's sense of itself.  Here are the last two paragraphs of what Tribble had to say: 

I talked with a lot of people in Fort Scott who have really significant health care needs, and they were scared when the hospital closed. But even if the hospital had not closed, not all of their health problems could've been taken care of at the hospital. Hospitals are not always the best place for people who need help managing their chronic illnesses, like emphysema and diabetes, not to mention addiction and mental health issues.

I saw people in Fort Scott gradually come to terms with this idea that a traditional hospital may not be what they really need. Often, just a good community health clinic can fill some of the gaps. And some rural places have tried a kind of hybrid hospital - just an emergency room with maybe a few overnight beds.

RFK Jr. promotes AI nurses as a solution to the rural health care crisis

Robert F. Kennedy Jr., an environmental lawyer, has spent his career spreading health misinformation and conspiracy theories. Some of his most popular (often baseless and debunked) claims include that vaccines cause autism; Wi-Fi causes cancer and "leaky brain"; school shootings are attributable to antidepressants; chemicals in water can lead to children becoming transgender; and drinking raw milk is advisable.

His views on these issues and others have fostered great concern among the healthcare community, especially in the time since his nomination to lead the Department of Health and Human Services. In this role, Kennedy would oversee programs such as Medicare, Medicaid and the Affordable Care Act, public health response to epidemics, and approval of pharmaceutical drugs, vaccines, and medical supplies.

Kennedy promises to bring an overdue focus to American health problems through his “Make America Healthy Again” agenda, which targets frustrations with the health-care system, reliance on processed food, increase in chronic disease, and decline in life expectancy.

Kennedy has recently weighed in on the rural health care crisis. When asked during his January 29, 2025 confirmation hearing how he would address health care workforce shortages in rural communities and frontier areas, Kennedy replied that rural hospitals was one of the most unifying topics among lawmakers, and that President Trump had asked him to address the crisis with AI and telemedicine.

Kennedy told the Senate Committee on Finance that the Cleveland Clinic:

[H]as developed an AI nurse that you cannot distinguish from a human being that has diagnosed as good as any doctor. And we can provide concierge care [to] every American in this country, even through the remote parts of Wyoming, Montana, Alaska, etc.

It is true that rural hospitals and clinics are in dire need of government support. (Read more about the rural health care crisis here and here.)

As of 2023, one third of all rural hospitals in the country were at risk of closing because of financial constraints. Further, public health is expected to lose about 57% of its workforce by 2025, with most of the decline attributed to local services such as rural county offices, clinics, agencies, and services. This situation is worsened by a “rural mortality penalty” among rural residents, as consistently revealed by research.

During his first confirmation hearing, Kennedy attempted to address these concerns and emphasized that rural hospitals not only provide important health care for residents, but they also represent important economic opportunities.

However, Kennedy failed to address the most important action the federal government could take to stabilize rural hospitals: expand Medicaid. (Read more about the need for the expansion of Medicaid here.) 

In an MSNBC article, author Paul Waldman explained:

Most of the health care problems rural people face — from closing hospitals to a lack of clinics to a shortage of doctors and nurses — happen precisely because of the limitations of the free market. It’s just not as profitable to sell health care in places with small, often poorer populations spread out over large areas. These problems can only be solved by government intervention and assistance, whether it’s by paying for people’s coverage so hospitals can stay afloat or incentivizing doctors to move to rural areas.

Unfortunately, rural Americans continue to support and elect Republicans, despite their repeated attempts to cut vital programing and confirm unqualified candidates such as Kennedy to run important agencies. If confirmed, it will certainly be interesting to see whether Kennedy implements AI and telemedicine within rural health care systems, and whether the technological advance improves rural health outcomes.

The importance of pharmacies in rural areas

Pictured is Newfane Pharmacy, a rural pharmacy in Newfane, New York my family owns

Newfane has a population of roughly 3,400

When discussing access to healthcare in rural communities, the focus often centers on hospitals and physicians’ offices but rarely on pharmacies. Yet pharmacies are critical healthcare access points: they provide not only prescription and over-the-counter medications, but also direct access to highly trained healthcare professionals. Pharmacists counsel patients on medications, diagnoses, and general health concerns while serving as trusted, familiar faces in their communities. They answer questions about immunizations, referrals to medical services, common colds, heart attack symptoms, and even pet medications. Pharmacists have a uniquely valuable position in their community-- they possess specialized medical and pharmacological knowledge while maintaining close personal relationships with their patients. 

At the same time, rural hospitals are increasingly at risk of closure due to systemic challenges such as funding reductions, high operational costs, and insurance provider reimbursement inadequacies. An article written in November, 2025 from Boston University School of Public Health stated that over 100 rural hospitals have closed in the United States over the past decade. The article also reported that 700 rural hospitals are currently at risk of closing, with 300 of them being at immediate risk of closing. Rural healthcare systems are already strained, and hospital closures further restrict access to care and shift additional pressure onto remaining providers, including pharmacies, critical access hospitals and small clinics, all of which are already few and far between. 

As hospitals close and medical services shrink, rural pharmacies absorb much of the strain. They face growing patient volumes, inadequate reimbursement from insurers—sometimes resulting in financial losses on certain prescriptions—and increasing pressure to expand services such as compounding and immunizations. An analysis by the Rural Policy Research Institute found that 80% of rural independent pharmacies recieved reimbursement less than the cost of acquiring and dispensing medications. Some states, like New York, provide additional reimbursement rates for state medical programs in rural areas to bolster healthcare assess. Additionally, unlike chain pharmacies, independent pharmacies often have the flexibility to adapt. Many provide delivery services for patients without reliable transportation and they expand clinical offerings to fill gaps left by other providers.

Despite funding challenges and cuts, there are signs of support for rural healthcare infrastructure. On December 30, 2025, the New York State Department of Health announced that the state will receive $212 million in 2026 under the federal Rural Health Transformation Program to improve health care access and delivery in New York communities. While the announcement states that "to ensure the funding directly benefits rural residents across the state... [p]rogram implementation will be supported by ongoing stakeholder engagement, including feedback from providers, tribal and faith-based organizations, local leaders and community members to target resources where they will have the greatest impact," it remains unclear if the funds will truly reach rural areas in need. Nevertheless, programs like this are essential to sustaining healthcare infrastructure and providers in rural areas.

(An model antique pharmacy in upstate New York)

Some may argue that funding rural pharmacies is secondary to hospitals due to mail-order prescriptions or outsourcing of prescription services. Access to prescriptions has increasingly shifted to mail-order pharmacy services. While mail delivery can be convenient, particularly for maintenance medications, it presents its own set of challenges. Delays, incorrect dosages, stolen packages, or temperature-sensitive drugs compromised during transit can place patients at serious risk. Additionally, mail-order services do not offer the same in-person consultation and real-time problem-solving that community pharmacists provide. Although mail services play a role in rural healthcare delivery, policy efforts should prioritize sustaining brick-and mortar pharmacies that provide direct support. 

Recent retail pharmacy closures have further intensified the strain. The closure of all Rite Aid stores and numerous CVS locations has increased patient volume at independent pharmacies. With a large proportion of rural patients relying on government-funded insurance programs, reimbursement pressures can make profitability difficult. Independent pharmacists must balance delivering high-quality healthcare with managing the financial realities of running a small business. The dual responsibility of being a pharmacist and a business owner adds stress but many remain committed because of the meaningful and tangible impact they make in their communities.

With healthcare in rural areas experiencing increased strain, policymakers should consider how to strengthen pharmacies’ roles. Perhaps independent pharmacies should have the ability to prescribe some drugs in rural areas. Perhaps federal and state governments should allocate greater support to rural healthcare infrastructure compared to urban ones? Rural pharmacies are pillars of community healthcare—the question is whether policy will evolve to recognize, and adequately support, that reality.

Maternal mortality and rural access to services

This blog has recently touched on many topics concerning rural children, including newborns and opiate addictions, children and guns, education issues, child abuse, children with disabilities, and rural brain drain. But even before rural children begin facing these issues, pregnant women in rural areas must overcome multiple obstacles to give birth to these children.

Access to maternal health care in rural America is on the decline. Only 6.4% of OB/GYNs practiced in rural communities in 2008, and by 2010, 49% of the counties in the US did not have a single OB/GYN. These counties were predominately rural. As a result, "fewer than half of rural women live within a 30-minute drive of the nearest hospital offering obstetric services," and around 88% of women live an hour or more from such services.  

With the lack of access to maternal health care, both maternal and infant mortality are significantly higher in rural areas. In 2015, maternal mortality was 29.4 per 100,000 live births in rural areas, compared to just 18.2 in more metropolitan areas. 

Credit: Amanda Montañez; Source: CDC

According to researchers, there are a number of reasons for this disparity: geographic access, poor prenatal care, and/or underlying health conditions like diabetes or hypertension. However, one theory may be found by looking closely at what has recently happened in Texas.

While the worldwide rate of pregnancy related deaths is declining, Save the Children's 2015 report "State of the World's Mothers" showed that the United States performs worse than any other developed nation in maternal death. For example, a woman in the US is 10 times more likely to die from a pregnancy related cause during her reproductive years than a woman living in Austria, Poland, or Belarus.

One of the most shocking statistics I've seen recently is that the rate of pregnancy related deaths in Texas has more than doubled over the last few years. Between 2006 and 2010, the number of maternal deaths in Texas changed very little, with the lowest number being 69 in 2009 and the highest being 82 in 2008. However, the numbers rapidly increased to 148 in 2012, 140 in 2013, and 135 in 2014.

For those who have been following the blog for a while, you are probably very familiar with Lisa Pruitt's coverage of HB2 and it's effect on closing women's health clinics throughout Texas (see here, here, here, here, here, here, here, and here). As Pruitt points out, these closures are especially harmful in rural areas, where women were forced to travel over 200 miles to reach the nearest clinic. It's not difficult to link these clinic closures to the rise in maternal deaths. Yet, the Texas Department of State Health Services believes drawing a correlation between HB2 and the rise of maternal morality "isn't fair," that there is "no evidence," and the clinic closures "wouldn't have taken effect till September 2011 and it would have taken months to be reflected" in data.

Despite these data, in 2017 the Texas Legislature has only "sparingly mentioned" the issue of maternal deaths in the most recent legislative session, and the maternal mortality rate has not been listed as a top priority. (Meanwhile, two of the "top priority" issues that the legislature does have time for are: SB 8- "Fetal Tissue/Partial Birth Abortion" and SB 20- Prohibiting Abortion Insurance Coverage.")

While none of the data on the rate of maternal deaths in Texas has specifically investigated the rurality of the decedents, if we draw a connection between the closure of clinics and the increase in deaths, it would seem logical to infer that the closures may be disproportionately affecting rural women.

With this information in mind, we can zoom back out to the general issues of rural maternal healthcare throughout the US. Various groups have proposed solutions to his problem: allow telemedicine for prenatal care (though many rural areas struggle with access to internet), change laws so certified nurse midwives can take on more clinical responsibilities, launch OB/GYN residency programs in rural areas, and adopt the Improving Access to Maternity Care Act. The Act would provide student loan forgiveness for OB/GYN work in rural areas. (Interestingly, the Act was sponsored by a Texas representative who has strongly promoted the defunding of Planned Parenthood clinics.)

However, the problem still remains that OB/GYN care is difficult for rural hospitals and we are in a time where rural hospitals are floundering. Eighty percent of rural hospitals have closed since 2010, and the ones that remain open are underfunded and vulnerable to closure. In rural areas the typical hospital patient tends to be older, poorer, and less healthy than people who live in more metropolitan areas.

When rural hospitals need to cut their budget, OB/GYN units can be a tempting target. OB/GYN units are one of the pricier programs for a hospital and can account for more than 5% of the total hospital costs. Because of the older population in rural areas, fewer residents give birth at rural hospitals and it "makes it difficult for hospitals to financially justify having maternity wards at all."

Coronavirus in rural America (Part III: More on health)

A few days ago, the Washington Post published an important story by Dan Keating and Laris Karklis comparing flu deaths in rural America to what we might expect from COVID-19 as it spreads to rural places.  The points are mostly that rural America has a higher proportion of elderly and vulnerable populations and less well resourced health care.  Still, not all rural places/regions are "created equal," just as the same is true among urban areas.  Here's an excerpt from the story:

Covid-19 may pose the greatest risk to Americans in rural areas if deaths from the coronavirus pandemic are similar to those from the standard flu. Other concentrations of sick and old people may also be at risk. 

With more than 100 Americans already dead, scientists project the future by measuring the people at greatest risk and deaths from similar threats. 

Biostatistician and infectious disease specialist Nicholas Reich from the University of Massachusetts is participating in the White House Coronavirus Task Force modeling efforts. He said the death rates from flu for people over 50 could be a good indicator of vulnerability for covid-19. He said flu death rates are “probably not a perfect measure but a good place to start.”

The story also offers some interesting comparisons among urban places, and then among rural ones, including this information about the flu:

Rural and small city areas in Iowa and Missouri, around the Missouri River and Mississippi River, have had high death rates. Kansas, Nebraska, the Dakotas, Indiana and New England show rates higher than any of the big cities. 

The push for social distancing and isolation make dense crowds and public transportation in big cities seem like the deadliest environment. 

The pattern of flu deaths over the past five years, however, shows that big metro areas are not hot spots for high flu death rates. Most of the deaths are among the large population in big cities, but the risk for any individual person goes up dramatically where homes are sparse. 

Very rural areas have a 60 percent higher death rate from flu than the big metro areas, according to analysis of CDC death records.

See the story in WaPo to look at the infographics.

And here is today's National Public Radio story on the threat of rural hospital closures, reported by Lauren Weber.  The lede follows:

Rural hospitals may not be able to keep their doors open as the coronavirus pandemic saps their cash, their CEOs warn, just as communities most need them. 

As the coronavirus sweeps across the United States, all hospitals are facing cancellations of doctor visits and procedures by a terrified populace — profitable services that usually help fund hospitals. Meanwhile, the institutions also find themselves needing to pay higher prices for personal protective equipment such as face masks and other gear that's in short supply. 

* * * 

The American Hospital Association ... on Thursday [asked] Congress for $100 billion for all hospitals to offset coronavirus costs, citing rural hospitals' inability to withstand huge losses for long.

Alan Morgan, head of the National Rural Health Association, which represents 21,000 health care providers and hospitals, is quoted:

If we're not able to address the short-term cash needs of rural hospitals, we're going to see hundreds of rural hospitals close before this crisis ends. This is not hyperbole.

A March 17 story from In These Times/Pew Charitable Trust's Stateline is here, and an excerpt (focusing on West Texas) follows:

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.  

Another recent Legal Ruralism post (collecting sources) about rural health care challenges in the era of coronavirus is here.  A New York Times story about the significance of population density to spread, specifically in the NYC context, is here.