and we hope after, the COVID-19 pandemic?
The health care problems in the rural US include inadequate
physicians and an assortment of socioeconomic factors such as
lower incomes, more families on supplemental nutrition assistance,
the lack of public transportation, the increased use of tobacco, the
higher rate of mortality from motor vehicle accidents, the ongoing
high rates of diabetes and heart disease and the severely decreased
accessibility to mental health care. 9-13
Multiple factors influence rural hospital closings. Sadly, this has
become a corporate business decision rather than an assessment of
local needs, which was the basis of the Hill-Burton Act in 1946. The
US has moved from considering health care as an essential public
service to considering health care a commodity to be exploited by
profit-driven entities.
The 60 million living in rural America are sicker, older and
poorer than the rest of the country. The economic decline is the
result of loss of employers in textiles, mining and farming. Patients
with private health insurance tend to travel to bigger hospitals in
urban areas. Decreasing Medicare and Medicaid reimbursement
and slow adaptation to the use of preventive care and outpatient
care are also factors.
The health impacts of rural hospitals closing are a decrease
in access to care, specifically emergency care and specialty care
including obstetrics and mental health. Low income patients have
transportation issues getting to a hospital or office that may be 30-
40 miles away, then returning home. Physicians and other health
care providers leave the community, and it becomes difficult to
recruit new providers.
The economic consequences of rural hospital closure can be
significant and devastating. Hospitals are important parts of rural
communities, often the largest employer. 14 Closure of a rural hospital
results in an average loss of 100 jobs. 15 There are secondary economic
losses to the community because of the loss of all the other jobs related
to running a hospital which can range from garbage collection
to food purchases to maintenance and repairs. The negative effect
on the tax base has consequences for schools and public service,
and it becomes difficult to recruit new industries/employers. Why
would a widget factory locate in rural Kentucky or West Virginia
if the nearest hospital is 50 miles away?
So, where do we go from here? The other 30+ countries considered
first-world/developed with market economies have all figured
out different ways to provide the basic health care needs for their
citizens, rural and urban. These health care systems have not wrecked
the economy of any country and have provided the foundation that
has allowed a coordinated response to the coronavirus pandemic,
at which the US has failed miserably.
Under the National Health Service in the U.K., rural hospitals
have adequate resources and staffing to meet the local community
needs. Support of rural health care exists in other countries that
resemble the US. Canada, Australia and New Zealand all have
recognized the challenges of providing health care in rural communities
and have established some type of regional authority to
address these issues as a governmental responsibility. 16-18
The opportunity for change is at hand. Hopefully, the citizens of
this country will make wise choices to allow serious assessment of
the dismal state of health care and provide new federal opportunities
to make long overdue corrections. These corrections would establish
the universal health care that all other developed countries provide
to their citizens. Failing that, we must champion the revision and
revival of the Hill-Burton Act in its original intent, with extremely
vigorous funding, including provisions to support graduate medical
education for future rural specialists in surgery, emergency medicine,
OB-GYN and primary care, at the very least.
References:
1
Kenny Rogers 1977 hit song written by Roger Bowling and Hal Bynum
2
“Defining the Rural Population,” [Online] Available https://www.hrsa.gov.
(2020, July).
3 “
What is Rural?” Archived 2007-20-17 at the internet archive Wayback Machine,
USDA, National Agricultural Library, Rural Information Center.
4
Bresnick, J., “Population Health Management May Worsen Physician Shortage,”
[Online]. Available https://www.healthitanalytics.com/news/population-health-management-may-worsen-physician-shortage.
(2020)
5
New York Times, Sunday Review, November 17, 2019
6
hrsa.gov/get-health-care/affordable/hill-burton/index.html
7
Navigant analysis of CMS data, Modern Healthcare, 8/13/2019
8
Scott, D., “1 in 4 rural hospitals is vulnerable to closure, a new report finds,”[Online]Available
https://www.vox.com/policy-and politics/2020/2/18/21142650/
rural-hospitals-closing-medicaid-expansion-states. (2020, July).
9
Hing, E., Hsiao, C., “State Variability in Supply of Office-based Primary Care
Providers: United States, 212. Department of Health & Human Services, NCHS
Data Brief No. 151 (2014, May). [Online] Available https://www.cdc.gov/nchs/
data/databriefs/db151.pdf (2020, July)
10
Bailey, J.M., (2014, July) “Supplemental Nutritional Assistance 10) Program
and Rural Households.” [Online] https://www.cfra.org/news/140730/snap-benefits-and-rural-households.
11
Rural Health Information Hub, “Substance Abuse in Rural Areas.” [Online]
Available https://www.ruralhealthinfo.org/topics/substance-abuse (2020, July).
12
Myers, S., Branas, C., French, B., Nance, M., Wiebe, D., Carr, B., “Safety in
Numbers: Are Major Cities the Safest Places in the United States?” American
College of Emergency Physicians 62, No 4 (2013);
13
Health Resources and Services Administration (HRSAhub) [Online] Available
https://www.hrsa.gov. and Rural Health Information Hub (RHIhub) [Online]
Available https://www.ruralhealthinfo.org. (2020, July)
14
healthline.com/health-news/rural-hospitals-closings#1
15
The Economic Impact of rural Hospital Closure on Rural Communities,
National Center for Rural Health Works, July 2015
16
https://www.healthdirect.gov.au/rural-health-services-in-australia
17
http://www.cjrm.ca/article.asp?issn=1203-7796;year=2020;volume=25;issue=1;spa
18
http://www.nzirh.org.nz/
Dr. Shively trained in general surgery in Louisville with Dr. Hiram C. Polk, in the same
group as Dr. Frank Miller and Dr. Neal Garrison. He practiced general surgery for 42
years in Campbellsville, Kentucky at Taylor Regional Hospital.
Dr. Flynn is a retired surgical oncologist.
FEATURE
SEPTEMBER 2020 23