O’Connor, M.D. is chair of Movement is Life, a multistakeholder organization dedicated to promoting health equity, and professor of orthopedics and rehabilitation at Yale School of Medicine. Finerfrock is the co-founder and executive director of the National Association of Rural Health Clinics.
We are finally receiving optimistic news that the COVID-19 virus is beginning to peak in the areas where it first established a foothold in our country. However, the virus is not finished spreading through our nation. The problem may be just beginning for rural America.
A report from the Kaiser Family Foundation shows the rate of increase in both numbers of cases and patient deaths is greater in rural areas compared to urban regions. This higher rate of death from COVID-19 reflects the troubling set of challenges facing rural America.
One challenge is a misperception that health disparities affect only urban communities of color. Rural America is made up of people of all races and ethnicities who often face similar barriers to accessing health care as urban patients. Pre-COVID-19 rural America had worse health outcomes than urban and suburban populations, reflecting the severity of these health disparities.
Another challenge is access to medical care. COVID-19 infections may be diagnosed at a later stage due to the shortage of primary care providers in rural America who perform many of the COVID-19 tests. While most COVID-19 patients do not develop severe disease and can recover at home without hospitalization, one’s recovery depends on access to a robust primary care system, which is often lacking in rural America.
Federally certified rural health clinics (RHC) — the backbone of the rural primary care system — are closing at an alarming rate. Between 2012 and 2018 nearly 400 federally certified RHC ceased operations.
The most severe cases of COVID-19 require hospitalization. Critical Access Hospitals (CAH) that serve many rural communities are similarly closing at distressing rates. A pre-pandemic study showed that rural hospital closures increase mortality rates by 5.9%. Thus, these closures exact a high cost to their communities both in terms of lost loved ones and negative financial impact.
Additionally, CAHs are not designed to facilitate long-term inpatient stays. Since many rural areas do not have the population density necessary to support a large inpatient hospital, CAHs are intended to stabilize patients before transferring them to a larger hospital if a prolonged stay is necessary. This means there are entire counties without a single intensive care unit (ICU) bed or hospital.
COVID-19 could exacerbate these closures. CAHs already operate on slim margins. During the pandemic, CAHs have seen a huge decline in elective outpatient procedures that make up most of their revenue. The administration recently began distributing $10 billion to rural hospitals and providers to help cover the cost of lost revenue from canceled procedures and the investments they made to prepare for and respond to COVID-19. This level of funding may be insufficient to save some rural hospitals.
There are ways to address these gaps that support the existing rural health infrastructure. Recent expansions of telehealth coverage will help bring primary care to underserved areas. This expansion should become permanent after the public health emergency is over. Some areas of the country lack access to high-speed Internet. A rural broadband infrastructure improvement program must be part of any comprehensive, long-term solution.
Rural hospital infrastructure gaps are uniquely challenging. It does not make sense to build more permanent rural hospitals if the ones that currently exist can barely survive. Existing rural hospitals must have more consistent and meaningful financial support to remain viable.
We must also create a plan to rapidly scale the rural health care system in times of emergency. We all saw the dramatic and inspiring entrance of a Navy hospital ship into New York Harbor. Unfortunately, a hospital ship cannot reach rural Nebraska.
The federal government must prepare plans to convert buildings into temporary hospitals. Rural America needs the domestic equivalent of our military’s Mobile Army Surgical Hospital (MASH) model to bring surge capacity where it is needed.
Improved containment strategies must be developed for both urban and rural America. We have learned that COVID-19 outbreaks in rural areas occur in pockets. Sometimes, they are mostly isolated to specific facilities.
Creating a response plan that emphasizes prompt testing to identify the scope of a rural outbreak and quickly increase the area’s health care capacity with telehealth and temporary facilities to address the surge in cases will save lives.
Urban America depends on the heartland for essentials, particularly food. Addressing the critical need for better health care for all, and for rural America in particular, needs to be a strategic priority for the nation.
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