Logan Reid
Rural hospitals are critical to the communities they serve, with an estimated 57 to 61 million Americans relying on them for essential healthcare services. However, rural hospitals face unique challenges, such as workforce shortages, economic constraints, and limited access to reliable infrastructure like broadband internet and electricity. These obstacles have led to rural hospital closures, with over 100 closing between 2013 and 2020, and a record 19 in 2020 alone. As a result, rural residents often face reduced access to healthcare, longer travel distances for services, and poorer health outcomes, especially in maternal and infant health, mental health services, and reproductive healthcare. Understanding and addressing the specific needs of rural populations are crucial to improving healthcare access and outcomes in these underserved communities.
| Characteristics | Values |
|---|---|
| Number of people relying on rural hospitals | 57-61 million Americans |
| Obstacles faced by rural hospitals | Economic factors, cultural and social differences, educational shortcomings, lack of recognition by legislators, and sheer isolation |
| Obstacles faced by patients in rural areas | Transportation, insurance, workforce issues, lack of broadband internet access, and long distances to receive services |
| Impact of rural hospital closures | Residents have to travel farther for common and less common services, fewer healthcare providers overall, increased health risks, and loss of hospital-based obstetric care leading to poor maternal and infant health outcomes |
| Initiatives to support rural hospitals | Rural Emergency Hospital (REH) conversions starting in 2023, Rural Hospital Leadership Team Award from the AHA, and efforts to protect Critical Access Hospitals and other rural hospital designations |
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What You'll Learn
Rural hospital closures
Over 57 million rural Americans are dependent on their local hospitals, which serve as a critical component of their community's social and economic fabric. However, rural hospital closures have been a growing concern, with nearly 200 rural hospitals closing their doors over the past two decades. From 2010 to 2021, there were 136 rural hospital closures, with a record 19 closures in 2020 alone. These closures have significant impacts on the communities they serve, forcing residents to travel farther for essential healthcare services.
Rural hospitals face unique challenges due to their location, size, workforce availability, payment systems, and access to capital. Inadequate payments from health insurance plans, including Medicaid reimbursement cuts, are significant contributors to rural hospital closures. When a rural hospital closes, residents not only lose access to critical healthcare services, but they may also face increased health risks due to a lack of insurance coverage and limited access to alternative care options.
Telehealth services have emerged as a potential solution to address limited provider availability in rural areas. However, as of 2019, at least 17% of people living in rural areas lacked broadband internet access, creating barriers to accessing telehealth services. Additionally, certain populations, such as pregnant individuals, American Indians, Alaska Natives, and veterans, may face unique challenges in accessing the specialized care they need in rural areas.
To prevent further rural hospital closures, there is a critical need for policies and legislation that address the unique needs of rural hospitals and ensure adequate reimbursement from insurance plans and government programs like Medicaid. The American Hospital Association's Rural Advocacy Agenda aims to address these issues and protect Critical Access Hospitals and other rural hospital designations. By advocating for policy changes and extending key Medicare provisions, the AHA strives to improve access to rural healthcare and ensure that rural communities can continue to rely on their local hospitals for essential care.
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Obstetric care
There are several factors contributing to the decline of obstetric care in rural hospitals. One significant challenge is the difficulty in recruiting and retaining maternal health providers in these areas. Rural hospitals often struggle to compete with urban centres for a limited pool of specialists, including physicians, nurses, and anesthesiologists. Additionally, the lower volume of births in rural hospitals can impact their staffing models. Hospitals with a lower birth volume tend to rely on family physicians and general surgeons for deliveries, while higher-volume hospitals have more obstetricians and midwives attending births.
Financial challenges also play a role in the decreasing availability of obstetric care in rural areas. Medicaid, which covers a higher proportion of births in rural communities, does not fully reimburse the cost of providing obstetric services. This creates financial strain for rural hospitals, especially in states that have not expanded Medicaid. Additionally, obstetric care is associated with higher round-the-clock staffing expenses, and rural hospitals may struggle to offset these costs due to the overall decline in birth rates.
The loss of obstetric services in rural hospitals has significant implications for maternal and infant health. It is associated with an increase in out-of-hospital births, preterm births, and poorer outcomes for both mothers and newborns. To address these challenges, various strategies have been proposed. These include increasing Medicaid reimbursement rates, establishing regional partnerships between larger and smaller hospitals, implementing telehealth and simulation training programs, and providing education and resources to pregnant individuals.
While the decline in obstetric care in rural hospitals is concerning, there are efforts to improve access and quality. The University of Utah Health, for example, has initiated biweekly videoconferences to educate rural maternity care providers about treating high-risk pregnancies. Additionally, the University of Minnesota's Rural Health Research Center is studying rural hospitals and communities that have maintained or innovated obstetric services and postpartum support. These initiatives aim to bridge the gap in maternity care access and enhance the safety and well-being of mothers and infants in rural areas.
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Telehealth services
More than 57 million rural Americans rely on their local hospital as a critical source of care. However, rural hospitals face numerous challenges, including financial constraints, limited infrastructure, and shortages of specialists and other healthcare providers. These issues have led to an increasing number of rural hospital closures, with over 100 closing between 2013 and 2020, and a record 19 closures in 2020 alone.
Before the COVID-19 pandemic, rural telehealth use was already on the rise, with a consistent positive trend in the number of hospitals adopting these services. During the pandemic, telehealth use expanded even further as geographic restrictions were removed and reimbursement requirements were relaxed to curb the spread of the disease. This led to a significant increase in the share of outpatient visits conducted via telehealth, with 44% of Medicare users in rural areas utilizing these services.
Despite the benefits of telehealth, there are also challenges to its implementation in rural areas. One major challenge is the lack of broadband internet access, with 17% of rural residents lacking broadband access compared to only 1% in urban areas. Additionally, digital health literacy is necessary to fully utilize telehealth services, and rural residents may face difficulties in effectively using smartphone applications for healthcare purposes. Financial barriers also pose a significant challenge, as the current reimbursement model directs payments to remote specialists rather than local hospitals, making it difficult for rural hospitals to recover their costs.
To address these challenges, several policy solutions have been proposed. Adjustments to reimbursement models have been suggested, allowing rural hospitals to be compensated for telemedicine consultations. Expanding reimbursement to include a wider range of telehealth services, such as teleneurology and telebehavioral health, could also improve financial sustainability. Additionally, providing rural hospitals with access to subsidies or grants to support the initial investment in telehealth infrastructure can help overcome financial barriers and encourage greater adoption of telehealth services.
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Transportation
The availability of transportation options can influence the accessibility and quality of healthcare for rural communities. Rural residents may face challenges in travelling to urban areas for medical care, as the distance can be a barrier, particularly for those without access to reliable transportation. This can lead to a greater reliance on local rural hospitals and healthcare providers.
In the United States, there have been initiatives to address transportation challenges for rural residents. For example, the VHA's Office of Rural Health allocated funds in FY 2022 for transportation initiatives for veterans travelling to VA facilities. Additionally, the Critical Access Hospital (CAH) designation is given to rural hospitals that are located more than 35 miles away from the nearest hospital, recognising the importance of distance and transportation in accessing healthcare.
The closure of rural hospitals can further exacerbate transportation difficulties for rural residents. When a rural hospital closes, residents may have to travel even farther to reach the nearest healthcare provider, increasing the demand for transportation options.
Overall, transportation plays a crucial role in understanding the reliance of people in rural areas on their local hospitals. The availability and accessibility of transportation can impact the healthcare options for rural communities, and initiatives to improve transportation can help address healthcare access issues in these areas.
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Insurance coverage
One in seven Americans live in rural areas and rely on rural hospitals and health systems for their healthcare. Rural residents face greater challenges in accessing healthcare due to a number of factors, including a lack of insurance coverage options, geographic isolation, and a shortage of healthcare providers.
Medicaid is a significant source of coverage for individuals and families in rural areas who would otherwise not be able to afford insurance. In nearly all states, Medicaid covers a larger share of both adults and children in rural communities than in urban communities. Nearly 50% of children and 18% of adults in rural communities are covered by Medicaid, and nearly 50% of babies born in rural areas are covered by Medicaid. Medicaid is the second-largest source of healthcare coverage in both rural and urban areas. However, it covers a somewhat higher share of people in rural areas (24%) compared to urban areas (21%).
In rural communities, more people receive and rely on Medicaid coverage than their urban counterparts due to lower incomes, a greater percentage of older adults, a higher cost of private insurance, and fewer private coverage options. Cuts to Medicaid funding would be devastating for rural families, as the cost of care for vulnerable rural residents would rise to unsustainable levels. If Medicaid funding is reduced, it will result in higher rates of uninsurance across the US, with a higher impact on vulnerable rural areas.
In addition, rural residents tend to be poorer, with the average per capita income in rural areas being $9,242 lower than the average per capita income in the United States. This contributes to the higher uninsured rates in rural communities. Rural residents also face greater transportation difficulties in reaching healthcare providers, often having to travel long distances to access care.
The Affordable Care Act (ACA) Medicaid expansion is associated with improved hospital financial performance and a lower likelihood of hospital closure, particularly for rural hospitals. Expansion states have a somewhat larger share of individuals enrolled in Medicaid in rural areas (25%) than states that did not expand Medicaid (22%). This contributes to a lower uninsured rate in rural areas – in expansion states, 7% of people are uninsured compared to 11% in states that did not expand Medicaid.
However, despite the importance of Medicaid in rural communities, Congress is considering policy options that could reduce federal spending for the Medicaid program by hundreds of billions of dollars over the next 10 years. These cuts would undermine the ability of hospitals, especially rural hospitals, to continue serving their patients. The proposed cuts include reductions in supplemental payments, which are critical for states to target support to rural hospitals and lessen the gap between Medicaid base payments and the cost of providing care.
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Frequently asked questions
It is estimated that 57 to 61 million rural Americans rely on their local hospitals.
Local hospitals are critical in emergency situations where minutes can make a big difference. Additionally, they serve as a pillar of the community, providing economic and social value.
People in rural areas often face challenges such as long travel distances to receive healthcare services, lack of insurance coverage, limited broadband internet access, and shortages of healthcare providers.
The loss of hospital-based obstetric care in rural counties has been associated with increases in pre-term births and adverse infant health outcomes. Rural areas also have higher rates of injury-related deaths, diabetes, and coronary heart disease.
Strategies to improve access to healthcare in rural communities include enhancing transportation options, addressing insurance coverage issues, increasing the rural healthcare workforce, and improving broadband internet access to facilitate telehealth services.
