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Getting Health Care Was Already Tough In Rural Areas. The Pandemic Has Made It Worse

A road sign for a nearby hospital along a rural road outside Sandwich, Ill., in April.
A road sign for a nearby hospital along a rural road outside Sandwich, Ill., in April.

Even when there isn't a pandemic, finding the right doctor can be tough in rural eastern Ohio. Reid Davis, 21, and his mother Crystal live in Jefferson County, which hugs the Ohio River near West Virginia. Their home is surrounded by farms, hayfields and just a few neighbors.

"To the nearest hospital, you're talking about 50 minutes to an hour," Reid Davis says.

Davis' mother has rheumatoid arthritis, a severe autoimmune condition, for which she sees a specialist. That doctor prescribes an injectable medication and also works on her joints to ease inflammation and pain, he says.

But when the pandemic began, that doctor stopped seeing patients. Nearly six months went by, and only recently was Crystal Davis able to resume in-person visits.

In the meantime, her condition got worse.

"There have been days where she's just been unwilling to get out of bed because of pain," Davis says.

There were only a few other rheumatologists within a two-hour drive and none of them were accepting new patients at the time.

Even before the pandemic, the health care systems that serve rural Americans were in decline: rural hospitals were closing their doors, and the medical workforce was shrinking. This year, as the coronavirus outbreak has made its way from major cities to rural America, threats to the rural health care infrastructure have only increased.

A new nationwide poll shows that one in every four rural U.S households have been unable to get medical care for serious problems. Among those households that had trouble getting care, more than half reported that a family member experienced negative health consequences as a result.

The poll was conducted by NPR, the Harvard T.H. Chan School of Public School and the Robert Wood Johnson Foundation.

"The crisis is really widening the fractures that have already existed in rural communities," says Brock Slabach, senior vice president of the National Rural Health Association, based in Kansas.

New coronavirus infections in rural America are now at record levels, with 54% of rural counties in the "red zone," defined as places with an infection rate of 100 or more new cases per 100,000 residents.

Only 14% of the U.S. population lives in rural counties, but last week 20% of new cases and 23% of COVID-19-related deaths were in rural counties, according to an analysis by The Daily Yonder, an online newspaper that covers rural America.

Rural Americans contacted for the NPR poll — from Montana to Georgia to upstate New York — discussed problems getting treatment for many types of health problems, including the virus.

In the U.S., one of the biggest obstacles to getting health care is the simple fact of not having health coverage, and people living in rural areas are more likely to be uninsured compared to other Americans. Not having insurance can also mean higher out-of-pocket payments for treatments or medications, on top of other pandemic-related financial stresses.

But the poll also revealed many non-financial obstacles. In interviews with NPR, rural respondents talked about being forced to cancel surgeries and procedures, waiting months for appointments, putting mental health care on hold, or spending hours on the road in search of specialists. Some talked specifically about their struggles to get a coronavirus test. Because of these problems, many were experiencing increased pain, anxiety or financial hardship.

Over the past 15 years, 174 rural hospitals have closed in the U.S. and the pandemic may be accelerating the trend. So far, 15 rural hospitals have closed in 2020, casualties of the pandemic-related shutdowns that forced hospitals to cancel elective surgeries, an important source of their revenue. Because of the pandemic, some people also avoided going to the hospital, even for life-threatening emergencies. Among the rural hospitals that remain, more than half don't have an intensive care unit, according to Slabach.

"As the hotspots grow, where do these people go? A lot of them have serious illnesses," says Harvard professor Robert J. Blendon, a co-director for the NPR poll.

Unlike major metro areas where hospitals have lots of beds, many smaller hospitals in geographically isolated places are not equipped to handle COVID-19 patients and other emergencies at the same time, Blendon says.

"People are hundreds of miles away and many rural hospitals have been deciding, 'Can I take anybody else but COVID?' " he says.

Long waits mean pain, delayed surgeries, and dental problems

The poll looked closely at two especially vulnerable groups: rural households that include someone living with a chronic illness, and rural households that include someone at high risk for a serious case of COVID-19 (due to age or underlying health conditions). In both groups, about a third of the households reported problems getting medical care.

"It's really scary that there's a very large number of rural households at risk at this point, and we haven't figured out a better way to provide care for them," says Mary Gorski Findling, a researcher with Harvard's polling team.

"The rural health care workforce was already disproportionately small," says professor Carrie Henning-Smith, who studies rural health at the University of Minnesota.

The pandemic disrupted a root canal for Stephen McDonald, and he ended up losing the entire tooth, and incurring additional costs.

McDonald lives about 70 miles outside of Missoula, Mont., and was left stranded after many doctors and dentists temporarily shut down their offices in the spring. His dentist had begun the root canal, but had to call off the follow-up appointment.

With limited options in his area, McDonald had to make do with the temporary filling.

"During that period of waiting, my tooth cracked and the tooth was no longer salvageable," McDonald says.

Even to remove the cracked tooth proved difficult. A local dentist couldn't see him, so McDonald went to a different dentist an hour away.

But that dentist could only extract a portion of the cracked tooth.

"Because of the procedures they had to follow for COVID, they weren't able to extract the rest of the tooth, so I had to go to an oral surgeon," he says.

While many health care providers tried to cope by using telehealth, it doesn't cover urgent problems that require hands-on treatment. In addition, the NPR poll found that a third of rural households have serious problems connecting to the Internet.

Slabach says ensuring people have adequate broadband connections would help, but even that wouldn't be enough.

"Many of our rural citizens are older, poorer and sicker, and so they don't have iPads. They don't have the necessary means, perhaps, to communicate," Slabach says.

Cynthia Davis, who lives in central Missouri, says she had lots of trouble using telehealth.

"I've got a small phone so I had a three-inch screen to do these online video appointments," Davis says of her efforts to use telehealth. "That did not work well, and even the phone would not work half the time."

Along with obstacles to health care, many rural households are under immense financial pressure during the pandemic, according to the NPR poll. More than 40% reported they are facing serious financial problems.

For Black and Latino households, the economic toll is especially stark in rural America. More than 80% of those households are facing serious financial problems, compared to only 36% of white rural households.

More than 40% of rural families also said at least one person in their household had lost a job, been furloughed, or had wages or hours reduced. In addition, more than half of families also shared that they are having serious problems caring for their children.

Even as more clinics and doctors have resumed in-person appointments, some patients are encountering long wait times because there are not enough providers in rural areas to handle the backlog of patients.

In Arkansas, Elizabeth Booher says she scrambled to get her husband to the right doctors, when he started having severe abdominal pain in early August.

Until last week, she kept hearing that the earliest he could get surgery was late October.

"He's lost a ton of weight because he can't eat," Booher says. "I feel like this is being elongated because doctors have been closed, and now they're just trying to play catch up."

Brett Corbett of Glens Falls, N.Y., says that last spring all of his doctor's appointments were called off. Corbett is in recovery for substance use disorder.

"All my mental health appointments got cancelled across the board," Corbett says. "It's December before anyone can get a doctor's appointment around here."

Even with so much attention on the coronavirus, some living in rural America are barely able to find tests.

Sunshine Peebles, who lives an hour outside Syracuse, N.Y., worried she might have COVID-19 when she spiked a fever.

"There's a lot of people who have access to free testing, where I am in upstate New York, that's not an option," Peebles says.

Peebles can't afford health insurance and says money was tight because her family's small construction business was out of work because of the pandemic.

"I should have gone sooner. I just couldn't wait any longer. I had to go to an urgent care," she says.

She had to pay $150 out of pocket. Luckily, her test result came back negative, but she knows others in her community have encountered similar problems.

"I think it's a big dilemma for people who live in the more rural areas," she says.

Copyright 2020 NPR. To see more, visit https://www.npr.org.

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