It’s About to Get Worse

If you live in a rural area, healthcare is going to get more scarce

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I have been thinking about rural healthcare for at least a decade, since I left my job of 20 years in a medium sized hospital. That was when I started doing locums (travel) medicine in small hospitals. Since 2013 I have worked in about 27 facilities (actually a low number compared to some locums physicians I have met). And I have worked in SC, NC, GA, IL, IN, CO, KY and (now) WV. I feel as if I had a good ‘tour’ of American healthcare and that I can thus speak with some authority on the topic, especially since many of the placeds I worked were federally supported ‘Critical Access Hospitals,’ which are given some help in order to serve populations in areas with limited healthcare access.

My work took me to some of the most beautiful places in America, and to some of the hardest working, most wonderful people imaginable. Resourceful and tough, many of them came from families that have belonged to their communities for decades or centures. They engage in important jobs, often in agriculture, heavy industry, manufacturing or mining. (Or the jobs which support the others, like transportation, healthcare or food services.)

America depends on these people. America loves good, healthy food, manufactured goods and energy. Americans love beautiful woodwork and minerals brought from the earth. Americans adore vacations in remote areas where there are ski slopes, rivers for fishing, whitewater for kayaking, trails to bike. America loves it’s open, empty places for the peace and solace they bring.

America does not seem terribly concerned with the fact that people the people who live and work in those places are facing greater and greater difficulty accessing healthcare.

Many rural hospitals closed before COVID. During COVID those remaining rural hospitals struggled bravely to do their best with limited resources, and with few places where the sickest of the sick could be transferred.

I worked through most of that time and it was ugly. It was frustrating. It was gut-wrenching. But I’ve never seen physicians, nurses, medics, techs, secretaries and all the rest try so hard in such difficult times. It was beautiful to behold. Alas, before long those big hearted, compassionate folks may not have places to work in their communities.

The article linked below from Vox points out that there was some money available to help rural hospitals navigate the pandemic. But it’s drying up. And it’s likely that more small hospitals will close.

Of course, even if they stay open, staffing them will be an enormous challenge. People are leaving healthcare in droves as the Newsweek article below highlights.

Nor are they leaving irrationally. Burned out, abused, exhausted, physically and emotionally unwell, unappreciated by employers, they eventually recognize the ‘sunken cost fallacy.’

In short, they finally realize that their devotion, their hard work, their sacrifice, will never be appropriately rewarded by a system focused only on profit and metrics. Or maybe that life is too short to work under such duress. Probably all of the above.

So what I’m saying is that in the next year, or two or ten, a perfect storm will occur, unless people more influential than I am get their act together.

  1. There won’t be enough hospitals and thus not enough hospital beds. In part because rural hospitals will close, reducing total beds in the US. In part because those rural patients who can get to urban or suburban facilities will add their numbers to already stressed and overburdened remaining health systems. Hospitals don’t get built overnight. It takes years. Sonexpect years of what we’re seeing this flu season. Not enough nurses, physicians (primary care or specialist) and not enough room in hospitals for the sick. Waiting rooms exploding with sick, frightened and angry people. All spreading viruses to one another.
  2. People outside of urban or suburban areas will struggle. They have too little primary care already. They often count on rural hospital emergency departments to fill in the gap. More so if they are poor, if they are old, if they have limited transportation, if they have issues with addiction or mental illness.
  3. People outside of urban or suburban areas will simply die. Some conditions are just time sensitive. Complicated deliveries and premature babies come to mind. Heart attacks and strokes. Sepsis. Major trauma. Overdoses of particular drugs. People suffering from these things, especially in a time when we are short of ambulances and paramedics, just won’t get where they need to be in time.
  4. People inside of urban or suburban areas will simply die. Especially as urban addiction keeps pace with rural addiction and urban violence continues to spiral out of control. We have limited resources and those will be strained far beyond the breaking point.
  5. Because the poor, the mentally ill, the addicted will all use the remaining facilities and use them a lot, those facilities will be financially stressed and may themselves close. Or be closed by investors as ‘not financially viable.’ That is, not lucrative. The overwhelmed remaining staff will continue to try and leave healthcare as soon as they can.
  6. Rinse, repeat.


What else does this mean? It means that when a ‘dazzling urbanite’ (thanks Blazing Saddles) is traveling through the ‘middle of nowhere’ on vacation, or for business, and has that heart attack, rolls that nice car over a mountain, breaks that femur fishing in the pristine river, then bad things may result. People used to having instant access to care won’t. People who would have survived in the city will suffer delays in care and will sometimes suffer loss of life or limb in the beautiful but increasingly deadly countryside.

I’m being blunt. But I gave my credentials. I’ve seen this dissolution. I’m not that academic physician who says they ‘have done some rural medicine,’ but really means they worked a few shifts a few years ago at a small hospital, or who gives a day every couple of months to see how the other half lives then scurries back to a nice, large hospital. I’ve prayed for helicopters and for patients, and I have watched them die when I couldn’t give them what they needed.

I’m all for some capitalism but we need to have a national system, a robust national system, to preserve our small, rural hospitals. In the process we can take the stress off of those in more populated areas so that they aren’t the only facilities admitting patients. We need to increase our nursing and physician staffing, and the numbers of

What we mustn’t do is let big business continue to make big business decisions that will wreck the lives of millions and put untold numbers into graves dug too early in their lives.

Call your representatives. Talk to your chambers of commerce and universities. Say your prayers. Volunteer. Pop a flare. Do something. But be careful.

Because I’ve got a bad feeling about all of this.


Originally posted on my Substack feed.









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