Five Rural Priorities: Healthcare
Author’s note: on March 2, 2022, I published my Five Rural Priorities for State Government, as a set of nonpartisan issues for discussion in the 2022 Texas election process and beyond. This list is not intended to be comprehensive. Rather, these are simply five areas that I believe to be vitally important to the future of rural communities and their ability to prosper and thrive in the future. This is the third part of a weekly series elaborating on the five areas. If you’d like to discuss more (as an interested voter, a candidate, a party leader, a member of the media, or otherwise), please email me from this page.
III. Healthcare
A. The Problem
Rural healthcare is less a problem and more a catastrophe. This is not a new phenomenon. According to American Public Media Research Lab, 135 rural hospitals have closed across the United States in the last decade. Texas has the ignominious distinction of leading the way with 24 hospital closures since 2005. The National Rural Health Association estimates that approximately 800 more rural hospitals remain perilously at risk of closure. To put that in an even more stark perspective, that constitutes about 1/3 of all rural hospitals in the country.
The rural healthcare crisis is a long and winding road. It coincides with the post-World War II rural decline and is exacerbated by ever-increasing difficulties in healthcare policy. In 1946, Congress passed the Hill-Burton Act. This transformative mechanism for funding public and nonprofit hospitals set off a boom of rural hospital construction, particularly in the South and other underserved communities. As discussed in last week’s essay, this era signified the peak in rural population. The ensuing decline in rural populations led to a decline in rural hospital revenues.
This decline was coupled with a series of changing federal policies on the reimbursement rates that were paid for healthcare services by Medicare and Medicaid. In some cases, rural hospitals reacted poorly to federal policy. In other cases, they made intelligent decisions that turned sour when federal policy changed. As rural hospital finances deteriorated, rural hospitals struggled to retain doctors and bled more patient revenue, turning their finances into a death spiral. In a last-ditch rescue effort, some rural healthcare leaders made risky financial decisions or sought new revenue sources, which backfired in many cases. To be clear, many wounds were self-inflicted. But much like the economic development discussion, desperate communities with few options often take whatever opportunities are available and reap the consequences therefrom.
If Texas is the epicenter of America’s rural healthcare problem, then Stamford exemplifies the Texas problem. In the summer of 2018, shortly after I was sworn in as Mayor, Stamford’s hospital district announced the closure of its inpatient and hospital and emergency room. This left our community 15 miles from the nearest emergency room and in a state of shock and uncertainty. Like other rural communities that have lost their hospitals, this was the culmination of years of financial difficulties. Stamford was not alone in this plight, but that was no comfort to its citizens who were left vulnerable.
B. Why It Matters
It is a minimum expectation for quality of life that a community have a baseline level of accessible healthcare for its citizens. This is especially important in rural communities for two reasons.
First, as rural communities struggle with brain drain (the loss of younger residences to educational and economy opportunities elsewhere), the rural population continues to age upwards. Naturally, an older population has more health issues and is more likely to need medical attention of both the emergency and non-emergency variety. Aging populations tend to value accessibility to medical facilities in their residential decisions. Current residents are more likely to move away if medical facilities are not accessible and older citizens are less likely to move to a community without those facilities.
Second, rural jobs are, on average, more dangerous than the average job in America. This is not because of some particular peril in rural areas. Rather, certain types of jobs with higher accident rates (including agriculture, oil and gas, mining, and others) are more heavily concentrated in rural communities. Employees and employers alike are at greater risk when accidents occur and healthcare is less accessible. Delayed response times and longer trips to the ER often result in more serious side effects, longer recovery times, more downtime and lost wages, and more expense on an already burdened healthcare system.
C. How to Solve It
This series of Five Rural Priorities is not a Pollyannaish look at rural needs, nor is it a nostalgic call for days gone by. It is a sober assessment of issues that face our rural communities and the obstacles we must overcome to prosper in the years to come.
Ever since Stamford lost its hospital in 2018, I have had countless conversations with local citizens about how to improve Stamford’s healthcare. Never do I hear a longing for the re-opening of our in-patient hospital facility. Before it closed, that facility averaged less than one hospitalized patient per day. In-patient hospitalization in rural communities is largely obsolete and used for observation and little more. Significant hospitalizations take place in larger hospitals in larger cities. Our communities are cognizant of that. In Stamford, 100% of these conversations revolve around emergency care. Our path forward for rural healthcare must focus on improving that frontline care:
As healthcare finances have deteriorated, rural communities have struggled to attract and retain practitioners. American healthcare has generally struggled to produce family practitioners, so it is no surprise that shortages are highest where healthcare finances are worst. Institutions like Texas Tech University have established financial incentives for students interested in family medicine and in rural practice. This should be supported and expanded. Rural communities should learn from organizations elsewhere in America that offer scholarships, tuition reimbursement, and student loan forgiveness in exchange for a practitioner’s multiyear commitment to a community. Once a community invests in a provider, and once a provider puts down roots, they are much more likely to stay. Mid-level providers (nurse practitioners and physician’s assistants) are vitally important to primary care for patients, so rural communities should seek to attract the best and brightest providers, be they doctors, mid-level providers, or all the above.
Next, rural communities and policymakers should train their energy on improving emergency medicine, starting with their ambulances and EMS providers. As distances to emergency rooms increase, ambulances become more vital. They should be treated less as a ferry to an emergency room and more as a mobile emergency room itself. A well-equipped ambulance with a highly-skilled staff can be the difference between life or death, which is the gravest concern in a community without a physical emergency room. Emergency care should focus on the following:
1. Much like relationships with practitioners, communities should invest in scholarships, tuition reimbursement, and other options for EMS staff, so that ambulances can be staffed with paramedics as much as possible.
2. Technology should play a significant role in in the future of rural healthcare in general, but especially emergency care. The COVID—19 pandemic offers helpful lessons on the potential of telemedicine as a treatment option. Furthermore, some rural emergency rooms are now staffed with telemedicine to virtually bring elite-level emergency doctors to patients. This model should be considered to increase the level of care in rural emergency rooms.
3. Telemedicine should also be considered as an on-board care solution for EMS vehicles. This model has been studied and there are obstacles as to reliable Internet connectivity and the ability for practitioners to confidently make informed treatment decisions. Policymakers should examine these obstacles and determine whether Texas can offer solutions to make this a viable EMS model.
The Texas State Office of Rural Health and TORCH (Texas Organization of Rural and Community Hospitals) are to be commended for their efforts on these topics and I encourage you to support their work.
Finally, the elephant in the rural healthcare room is the duo of Medicare and Medicaid. In many rural communities, Medicare and Medicaid provide 2/3 or more of all payments for healthcare services. Private insurers and private-pay clients are only a fraction of rural healthcare revenues relative to other communities. Solutions that are centered around private insurers and private payment are not viable in the current rural healthcare environment. Simply put, barring a massive change in the American healthcare ecosystem, solutions that do not work financially with Medicare and Medicaid are simply not solutions for rural communities.
Much has been made of Texas’ refusal to expand Medicaid coverage in the aftermath of the 2010 passage of the Affordable Care Act. At the time, Texas leaders opined that accepting this federal expansion of healthcare coverage to millions of uninsured patients would bankrupt the states. To date, only 12 other states have not expanded Medicaid. None of the other 38 states have gone bankrupt as a result. On the other hand, rural hospital closures have disproportionately affected Texas and the other states that declined expansion, in no small part due to the lack of additional federal funds that would have come to rural hospitals. Texas’ path has been wholly disastrous for rural healthcare. Our communities deserve better. Our communities deserve a solution and not a state government actively attempting to harm us, which has been the effective result of the decision to decline Medicaid expansion in Texas.
In summary, rural Texas needs a minimum level of healthcare to make our communities viable for current residents and to attract new residents. Rural leaders should focus on investing in practitioners and shoring up emergency care. State leaders should establish avenues to assist rural leaders. Ultimately, state leaders must also reckon with the failures of the last decade and the consequences of those decisions, lest they prove fatal to rural healthcare.
James Decker is the Mayor of Stamford, Texas and the creator of the West of 98 website and podcast. Contact James and subscribe to these essays at westof98.substack.com and subscribe to West of 98 wherever podcasts are found.