The challenges facing rural healthcare and potential policy solutions.
By Jenna Hughes
Nearly 46 million people in the U.S. live in rural areas, and roughly 77% of rural counties in the U.S. are considered healthcare deserts, or geographic regions where residents face significant barriers to healthcare access, according to the National Rural Health Association (NRHA).
There are numerous ways to define rural health. The federal government designates more than 70 different ways of defining rural health across various agencies.
NRHA, a national membership organization that represents more than 90% of the nation’s rural hospitals, rural health clinics, and rural community health centers, strongly recommends that definitions of rural be specific to the purposes of the programs in which they are used, and that they are referred to as programmatic designations and not as definitions.
“At NRHA, we define rural America as a place where those most in need of healthcare services often have the fewest options available to access that care,” said Alan Morgan, Chief Executive Officer of NRHA. As CEO, Morgan oversees the organization’s educational, program and policy activities.
NRHA aims to address rural health challenges by identifying best practices, sharing those best practices for replication and working through legislation and regulation to remove barriers to expanding them.
“NRHA has stayed true to the same mission for more than 40 years – promoting leadership and developing healthy rural communities both for the health system and for healthcare delivery,” said Morgan.
Barriers to healthcare access
There are underlying similarities in healthcare access challenges among those living in rural America, regardless of location. These include workforce shortages, greater distances for patients to be able to seek care between access points, and significant health disparities.
“It is not unusual to have a life expectancy among rural populations that are 20 years less than their urban counterparts,” said Morgan. “It is unacceptable that an individual’s length and quality of life is determined simply on where they live.”
Another issue is distance. Rural residents tend to travel farther to access care than urban residents.
“Where we find the greatest disparities among urban and rural populations is within behavioral health, maternity care, pharmacy access, long-term care, and more,” said Morgan. “This is due to fewer providers available, a culture that doesn’t always embrace behavioral health, distance from care, and higher rates of economic and community pressures than in urban areas.”
“Maternity deserts found in rural America are also substantial, and if a community lacks access to proper maternity care, young families will not be able to move there,” said Morgan.
Women in rural areas experience markedly higher rates of maternal morbidity and mortality due to lack of access to consistent maternity care, reproductive services, and postpartum support, according to the Rural Health Information Hub.
Rural community pharmacies also face many challenges to staying open, including low volume purchasing, slim profit margins, unfavorable insurance practices, and a limited pharmacy workforce.
“Over the last 15 years, more than 1,000 rural pharmacies have closed across the U.S., and more than 500 rural nursing homes have closed over the past decade,” said Morgan.
The loss of vital health services in these locations results in reduced access to care, increased healthcare costs, and significant economic strain withing rural communities.
The impact of hospital closures
Another challenge facing rural America is the widespread closure of hospitals and emergency rooms, a trend that threatens not only access to essential medical services but also the overall stability of rural communities – impacting emergency care response times to local economies and population health outcomes.
Since 2010, nearly 190 rural hospitals have shut their doors or discontinued inpatient services, according to NRHA. Nationally, nearly 50% of rural hospitals are operating with negative margins and are therefore vulnerable to closure.
“Rural hospitals are closing not because of low patient volumes or because people are moving out of rural America,” said Morgan. “Small rural hospitals are closing today because they have a disproportionate share of patients with high health needs and the inability to pay for that care, and bad debt is the reason these hospitals are closing across the U.S.”
When a rural hospital closes, not only does the community lose access to accessible health care, but a major employer and community cornerstone ends, affecting the community at large.
“The problem when you lose a rural hospital is that you lose an anchor institution, a point of care, and in many cases the largest employer in the county,” said Morgan. “When a rural hospital closes, often the community follows. You lose the direct jobs in the hospital; you lose the indirect jobs that support healthcare. It is tough to quantify the loss of individuals that leave or do not move to the community because they don’t have access to 24/7 emergency room service care.”
Facing the rural staffing crisis
Addressing the rural healthcare crisis requires a variety of tactics, including telehealth, incentivizing healthcare providers to work in rural areas, the use of artificial intelligence, and strengthening state and federal funding for rural healthcare facilities.
One of the major reasons for rural hospital staffing issues is a lack of incentives for recent graduates to move to rural areas for work.
“Fewer than 4% of the nation’s incoming medical students come from rural America. Upper income urban students are going to school in urban areas, being trained in urban areas, and do their residency in urban areas,” said Morgan.
Training physicians in rural areas through rural residency programs not only provides greater access to care for rural communities, but also increases the likelihood of physicians practicing in rural parts of the country, according to the Health Resources & Services Administration.
“Rural residency training programs serve to attract rural kids with academic instructors that are passionate about healthcare in rural America, and these students are more likely to end up staying and practicing in rural areas,” said Morgan.
Addressing workforce shortages also requires the introduction of technological solutions to ease patient load and administrative burdens on existing staff.
“Telehealth and telemedicine are also a great solution that’s successfully working within rural areas to address workforce shortages,” said Morgan. “Additionally, Artificial Intelligence (AI) technology is increasingly being used for documentation, coding, and other administrative functions, freeing up staff time from nurses to clinicians to admin staff, and has had a real beneficial impact very quickly in rural communities”
Yet another obstacle facing rural Americans is patients needing to travel to receive healthcare. Often, residents in remote areas may have to travel significantly farther distances than those in urban communities to show up to in-person care.
Providers have increasingly relied on solutions like telehealth and AI to allow for more patient-facing time for rurally located, eliminating the burden of frequent travel for many residents with travel barriers.
“Telehealth is a great tool to expand primary care, but never a replacement for primary care,” said Morgan. “We must find the happy medium as to how we utilize technology to address workforce shortages without utilizing technology to eliminate any points of access to care that are currently there.”
Policy for change
Collaboration among healthcare providers, community organizations, government agencies and educational institutions is crucial to developing and implementing policy changes that benefit communities facing location-based health disparities.
“Federal, state, and local policy leaders must be good partners with local healthcare because in many cases, they are the payors for this healthcare,” said Morgan.
“At NRHA, our partnerships with Group Purchasing Organizations (GPOs), technology companies, and medical device companies are incredibly valuable because they bring the real-world data from their customers and we’re able to make a strong policy case on the implications of adverse policies,” said Morgan.
NRHA’s advocacy policies include investing in a strong rural healthcare infrastructure, reducing rural healthcare workforce shortages, and building rural health opportunities.
“Promoting a policy approach that keeps Americans healthy and out of hospitals in the first place, and promoting a public health wellness approach across communities helps both patients and providers, and is the first step to a healthier nation overall,” said Morgan.
The challenges associated with rural healthcare delivery often require physicians and health systems to find creative approaches to continue delivering patient care. Hundreds of towns across the U.S. are currently serving as ‘innovation hubs,’ or healthcare settings stretched thin that are consequently fostering collaboration and innovation; and these places are having a significant impact on the redesign of the nation’s healthcare system as a whole.
“All of the innovative, creative things that are happening within healthcare delivery and policy today are beginning in small towns across America,” said Morgan. “If you want to see what the healthcare system is going to look like 20 years from now, visit any small town today and you will see coordinated care, an emphasis on primary care, the use of community healthcare workers as a bridge between the community and providers, telehealth use, and AI technology solutions. The rural health system is stretched to the max with high health needs and low reimbursement, but through creative approaches these physicians are making it work.”
Access issues
About 77% of rural U.S. counties are healthcare deserts, facing severe challenges like workforce shortages, long travel distances for care, and lack of access to services such as maternity care, behavioral health, and pharmacy support. These disparities often result in significantly lower life expectancy for rural residents compared to urban populations.
Closures threaten rural communities
Since 2010, nearly 190 rural hospitals have closed, primarily due to financial instability, not lack of demand. These closures remove vital access points for healthcare, eliminate key employers, and contribute to the economic decline and depopulation of rural communities.
Solutions
The National Rural Health Association (NRHA) promotes solutions such as rural medical training programs, telehealth, AI tools, and public policy reforms. Innovation is emerging from rural “healthcare hubs” that are finding creative ways to deliver care despite limited resources, helping shape the future of U.S. healthcare.