Quality vs Quantity? Maximizing Care.

In the year 2019, 17 rural hospitals closed throughout the United States. (1) These hospitals, serving patients from states including Texas, Georgia, Pennsylvania, and Illinois, closed likely due to their inability to sustain high operating costs while providing for patients. While these closures may seem to be the result of COVID-19, another 130 rural hospitals had closed in the decade prior to 2020. While rural hospital closures destroy local economies that depend upon hospitals to provide employment and medical care, they also disproportionately affect inhabitants of rural communities which include low-income, vulnerable, and elderly populations. From a legislative perspective, how might we understand what causes rural hospital closures and how hospital closures and physician shortages affect the health of rural Americans?

Here is a graph produced by the UNC SHEPS Center for Health Services Research depicting rural hospital closures throughout the US since 2005. (2) In the graph, blue locations depict rural hospital closures in large communities, green locations depict rural hospital closures in small communities, and yellow locations depict rural hospital closures in isolated communities (no nearby hospitals).

The National Rural Health Association finds that over 50 million Americans (approximately 15.6%) live in rural communities but only 10% of physicians practice in those communities. Thus, the issue is not solely with rural infrastructure and funding but also with incentives. By incentives, I refer to the idea that many healthcare professionals hope to and do live in large urban areas and by providing financial or economic motivators to encourage these professionals to move to rural communities we can work to bridge the gap.

The American Hospital Association has found that hospital expenses have increased significantly (>10%) over the past several years and sheer costs alone threaten to push struggling hospitals into bankruptcy. (3) For example, Dr. Krishnamurthy (director of the American Hospital Association) finds that overall hospital expenses increased by 17.5% between 2009 and 2022, which is 7.5% greater than the increase in Medicare reimbursement during the same time period. Thus, policymakers must work with rural hospitals to ensure that they stay operational and can treat patients using up-to-date practices and equipment.

In 2021, North Carolina Governor Roy Cooper unveiled his plans facilitating the state’s economic recovery post-COVID-19. (4) His $55.9 billion investment idea planned from 2021-2023 includes funding to alleviate the rural physician shortage in the state as well as increased funding to rural hospitals struggling to afford costs. He has also budgeted over $5 billion to expand Medicaid throughout the state. While these measures appear to indicate a solid path forward, these measures must still be approved and then passed before taking effect. Furthermore, states with the most rural hospital closures are generally ones with smaller budgets; these states more often than not have less available funding to invest into hospitals. Thus, the appropriate interventions to solve this issue must involve collaborations between the national government, state governments, county leaderships, and third party organizations.

However, while we can pressure policymakers to keep rural hospitals afloat, we must also ensure these hospitals are properly staffed to keep up with increasing patient volumes.

The National Rural Health Association conducted a survey finding that 81% of rural hospitals are finding physician recruitment difficult. This is largely because most medical school matriculants do not intend to work in a rural setting to begin with. The AAMC (Association of American Medical Colleges) finds that the number of medical students intending to practice in rural clinics declined by 28% between 2002 and 2017. (5) There are many unexplored reasons as to why this might be the case, but to maintain the sustainability of the American healthcare system, it makes sense for medical schools to provide opportunities and pathways for medical students to explore rural healthcare. Rural hospitals must develop programs for primary care physicians as well as specialized physicians, and county leaders must work to improve the quality of life of individuals in rural communities, by attracting businesses, building homes, and providing sources for recreational activity for physicians and their families.

Based on the arguments I pose, it is understandable that more and more medical schools are offering rural training tracks to provide graduating medical students with opportunities to work with underserved communities in rural areas. These jobs profoundly impact local communities, enabling new doctors to develop programs that target, prevent, and treat illness in communities where resources are more scarce. By addressing the unique challenges faced by rural communities, fostering collaboration between stakeholders, and ensuring equitable access to quality care, we can preserve essential healthcare services for the communities that need them the most.