The Pandemic Hits the Heartland

COVID-19 is ravaging rural communities, and putting additional strain on an already overburdened countryside health care system in the United States.
The Pandemic Hits the Heartland

This article is part of a series in which OECD experts and thought leaders — from around the world and all parts of society — address the COVID-19 crisis, discussing and developing solutions now and for the future. Aiming to foster the fruitful exchange of expertise and perspectives across fields to help us rise to this critical challenge, opinions expressed do not necessarily represent the views of the OECD.

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First published in The Super Age on November 13, 2020.

An unfortunate hallmark of many of rural towns across the United States is that they have grown older and poorer, while most urban areas have remained relatively young and more prosperous. According to the United States Department of Agriculture, 19 percent of the rural population is 65 years or older, compared with 15 percent in urban areas. A remarkable 1,104 U.S. counties already meet the Super Age designation – 20 percent of the population older than 65. However, 85 percent those counties are rural. Dozens of those rural counties have a 65 and older population greater than 25 percent of the total population and a growing number of rural areas have median ages greater than 50. This has led to a decline in health care services in most communities. 

Over the past decade, 120 rural hospitals across the United States have closed, according to a study by the Chicago-based Chartis Center for Rural Health. As of January 2020, there were 1,844 rural hospitals in this country, so the closures represent about 7 percent of the previous total. The study also found that the shuttering of these facilities has sped-up in recent years with 19 hospitals closing in 2019 alone - the worst year of the past decade. The closure of these hospitals presents yet another challenge for rural communities that are already grappling to access health care in these regions.

Regardless of politics, this is a public health crisis for the Heartland unlike any we have witnessed in living memory.

It should come as no surprise that these hospital closures are primarily located in states without proper levels of public funding (e.g. Medicare and Medicaid) for the most at-risk populations (i.e. old, poor, or both), and the trend doesn’t show any signs of changing course. This coincides with a decrease in private-pay patients and elective procedures that are the primary revenue drivers for these hospitals that were already on a downward slope. The Covid-19 pandemic, which hindered elective procedures in many hospitals, may supercharge closure rates at hospitals nationwide, prompting the American Hospital Association to go so far as to request $100 billion in Federal emergency funding in 2020, citing rural hospitals inability to survive big losses for a long period. If the hospitals do close, this will have an outsized impact on the older population, which is more likely require hospitalization. 

Before the pandemic, according to Chartis, 453 rural hospitals - Critical Access Hospitals and Rural & Community Hospitals - were vulnerable to closure based on their performance levels. Critical Access Hospitals, for reference, are a designation by the U.S. Department of Health and Human Services and are eligible for greater levels of Federal funding. Their closure would represent roughly 20 percent of all rural hospitals in the United States – a devastating prospect.

More on the Forum Network: The Great Revealer: Emergence of the “Covid-Ready” World by David Nabarro, Special Envoy of the Director-General on COVID-19, World Health Organization, and John Atkinson, Director, Leadership Advisor

The loss of vital health infrastructure is playing out dramatically during the Covid-19 pandemic. Urban centers bore the overwhelming majority of the first 100,000 Covid-19 deaths in the United States, with rural communities making up about five percent of the total. However, the second 100,000 deaths told a much different story, with rural communities making up nearly 15 percent of the aggregate total. Rural communities in the South and Midwest are being hit hardest with some communities losing, per capita, the same or greater amount of people than New York City, during the height of its first wave in 2020. And it is not just the healthcare infrastructure that is faltering, it is also the healthcare workforce. 

The rural healthcare workforce has also aged at an incredibly fast and dramatic pace, which, according to the New England Journal of Medicine in its 2019 report, Implications of an Aging Rural Physician Workforce, reflects a broader pattern of younger physicians rejecting rural practice. From 2000-2017, the number of country doctors grew by only three percent, while the number of physicians under 50 decreased by 25 percent. This means that, if everything had remained constant, by 2030, there would only be 9.4 physicians per 10,000 people in rural locales, with some areas being affected worse than others. If Covid-19 has taught us anything, it is to assume the worst. 

Covid-19 may be moving up the retirement timeline for many doctors and healthcare workers, who typically enjoy longer than average careers. In the summer of 2020, the Physicians Foundation, a U.S. non-profit group, surveyed more than 3,000 physicians and found that 4 percent said they wouldn’t return to work, fearing their personal health, while 28 percent shared that they had “serious concerns” about catching the disease. Given the age of the rural healthcare workforce, the implications of these fears could make the projected changes happen even faster. 

Regardless of politics, this is a public health crisis for the Heartland unlike any we have witnessed in living memory. It will require that rural hospitals operate at full capacity for the foreseeable future, and these health care facilities may even be forced to turn people away. No matter what happens, there will be more death – a lot more – with older populations most likely to bear the greatest burden of an out-of-control pandemic and over-burdened health system.   

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