Expert Commentary

Rural health care and COVID-19: A research roundup

As COVID-19 hot spots continue to emerge throughout the U.S., rural health care systems face challenges unlike those in urban areas.

rural health
(Martha Dominguez de Gouveia for Unsplash)

During the first few months of the coronavirus pandemic in the U.S., most outbreaks were centered in cities and their surrounding areas. Preparations for critically ill patients focused on the capacity and readiness of hospitals in high-population and high-density communities. As hot spots continue to emerge throughout the country, rural health care systems face challenges unlike those in urban areas. This research roundup focuses on the state of rural health care and its capacity to respond to a pandemic.

Overall, rural health care systems are not as robust as metropolitan area systems. They have fewer hospitals, fewer physicians specializing in critical care and fewer intensive care unit beds per capita. Non-metropolitan areas have about half the number of ICU beds as metropolitan areas after adjusting for population age, per an April brief from the Peterson-KFF Health System Tracker, a partnership between the Peterson Center on Healthcare and the Kaiser Family Foundation, which monitors various aspects of the health care system in terms of quality and cost. According to an April report from the Chartis Center for Rural Health — part of The Chartis Group, a private consulting firm for the health care industry — 63% of U.S. rural hospitals have no ICU beds.

Even before the pandemic, many rural hospitals were under financial strain. Since 2005, 171 rural hospitals have closed, according to data from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. Another 450 rural hospitals are vulnerable to closure, according to a February 2020 Chartis Center report. Hospitals in cities and rural areas have halted profitable elective procedures since the pandemic began, while taking on unexpected costs to prepare for and treat COVID-19 patients and protect staff.

The strain on rural health care infrastructure may carry into metro areas. For example, during a May 22 press conference, Steven Reed, mayor of Montgomery, Alabama, said his city had run out of ICU beds and not all patients were local: “Many people in Montgomery hospitals are not from Montgomery. They’re suffering because they don’t have the rural health care system in place that they need.”

Spreading to rural communities

As early as March, researchers from University of Chicago showed hot spots cropping up in rural areas. Many rural counties have had fewer deaths compared with large cities, but higher relative infection or death rates. On May 28, The New York Times reported that rural Trousdale County in Tennessee had the nation’s highest per capita infection rate, linking the spike to a local prison. The Times maintains a U.S. coronavirus map with infection, death and per capita rates by county.

Several factors are likely to increase infection rates in rural America. As reported in the Washington Post, people travelled farther in the past month, sometimes from hot spots to rural areas, for recreational opportunities or to access services that have been closed in their communities due to pandemic restrictions. Potential “super-spreader” environments can also create hot spots. Meat processing plants with large COVID-19 outbreaks are mostly in rural areas, the U.S. Centers for Disease Control and Prevention has documented. A May article in Wired describes why conditions in those plants facilitate infection transmission.

Prisons are also a risk as super-spreader environments, as explained by Vox, with potential for large outbreaks among the incarcerated population, as well as staff, who can infect their families and communities. As explained in The Conversation, of the over 1,000 prisons constructed from 1970 to 2000, about 70% were built in rural communities. Finally, nursing homes and other elder care facilities have also been hot spots of infection outbreaks in cities. Such facilities in rural areas also face similar problems, but with fewer critical care resources.

Rural residents at high risk

Rural areas are older, poorer and sicker than their urban counterparts, according to research from the Rural Health Research Gateway, funded by the Federal Office of Rural Health Policy. Older people and those with underlying chronic health conditions — such as hypertension, diabetes, obesity and coronary artery disease — have a higher risk of becoming seriously ill from COVID-19.

Roughly 23% of older Americans live in rural areas, according to a report from the U.S. Census Bureau covering 2012 to 2016. About 18% of the rural population was age 65 and older, compared with 14% in urban areas. In Vermont, Maine, Mississippi, West Virginia and Arkansas, more than half of people over age 65 are in rural areas, according to the Census report.

From 2010 to 2017, rural areas had a higher percentage of preventable deaths than metropolitan areas for the five leading causes of death, according to a 2019 CDC report. The gap in preventable deaths from cancer, heart disease and chronic lower respiratory disease widened between the most rural and most urban counties during the study period. The gap decreased for unintentional injury and remained steady for stroke.

Racial and ethnic minorities, who make up 22% of the rural population, are at an even higher risk. Non-Hispanic black and Indigenous rural residents have higher rates of chronic health conditions and poorer access to health care, placing them at higher risk for COVID-19, as noted in a May commentary in the Journal of Rural Health. Navajo Nation has suffered among the highest per capita case rates in the country. High Country News reports, “Decades of negligence and billions of dollars in unmet need from the federal government have left tribal nations without basic infrastructure like running water and sewage systems, along with sparse internet access and an underfunded Indian Health Service.”


Policy and issue briefs

The policy and issue briefs highlighted in this section were written and developed by university-based researchers, typically for research centers. While usually not peer reviewed, such briefs often include useful statistics and contextual information for journalists and policy makers. For this research roundup we’ve sourced policy briefs on the rural impact of COVID-19 and other issues of risk from academics working at centers focused on health care or rural communities.

Many policy briefs, data visualizations, maps and other resources on rural health care are available through the Rural Health Information Hub and their ten rural health research centers at state universities across the country. These centers are a national clearinghouse of rural health issues. Each center focuses on areas of specialization by geography and topic. The Federal Office of Rural Health Policy under the U.S. Department of Health and Human Services funds the centers.

Why Coronavirus Could Hit Rural Areas Harder
Shannon Monnat. Lerner Center for Public Health Promotion at Syracuse University, March 2020

This brief summarizes many issues regarding rural health care during the pandemic, including that the overall health care infrastructure is less robust in rural than metropolitan areas. Rural areas tend to have fewer hospitals and limited availability of health care personnel, ventilators and personal protection equipment. As has happened in metro areas, cancelling elective surgeries and other procedures while increasing funds for COVID-19 planning has put enormous financial strain on urban hospitals, according to this brief. Many rural hospitals were already in financial peril pre-pandemic and on the verge of closing. In addition, rural populations are older than urban populations and the chronic health conditions that increase the risk of serious illness from the coronavirus are more prevalent in rural areas. Rural physicians are also older than those in metro areas, putting them at greater risk as well.

The report concludes by pointing out that “the impacts of the coronavirus epidemic on rural communities will also have major implications for urban populations. Rural America supplies disproportionate shares of the nation’s food, energy, military personnel, and natural amenity recreation.”


Metropolitan/Nonmetropolitan COVID-19 Confirmed Cases and General and ICU Beds
Fred Ullrich and Keith Mueller. Center for Rural Health Policy Analysis at the University of Iowa, Policy Brief, May 2020

One factor for measuring the availability of acute care and ICU beds is the historical occupancy rate: What percentage of ICU beds is typically available? Using historical occupancy rates of general and ICU hospital beds in rural hospitals, the authors find 56 rural counties at risk of having “more COVID-19 cases than ICU beds.”


Occupancy Rates in Rural and Urban Hospitals: Value and Limitations in Use as a Measure of Surge Capacity
North Carolina Rural Health Research Program at the University of North Carolina at Chapel Hill, March 2020

This policy brief also addresses rural hospital capacity based on historical occupancy rates, and includes additional variables that will affect capacity. Occupancy rates for acute care and intensive care units are lower in every state for rural hospitals compared with urban hospitals. The brief cautions that other factors will contribute to whether rural hospitals will exceed acute care and ICU surge capacity. Among these are:

  • More beds will be freed up by cancelling nonessential procedures.
  • Other sites, like dorms and military bases, may handle surge capacity; non-COVID-19 patients could be redirected to alternative sites.
  • Rural hospitals have fewer ICU beds per capita compared with urban hospitals, making them less capable of handling a surge.
  • Many rural hospitals historically have transferred severely ill patients to larger hospitals, which may not be able to accept more patients during a surge.
  • Patients routinely bypass their local hospitals for others they consider as higher quality, affecting the distribution of patients among hospitals in a region.


Quality of Care in Rural Hospitals
Rural Health Research Recap, Rural Health Research Gateway, January 2019

The Centers for Medicare & Medicaid Services rate hospitals nationwide using the Star Quality Ratings for Hospitals, which is based on self-reported data. Among the measured areas where rural hospitals received worse scores on the one- to five-star scale in 2017, “Emergency rooms in small rural or isolated small rural area hospitals saw a higher percentage (67%) of patients with non-emergent conditions compared to urban hospitals (62.2%),” this research recap reports.

If emergency departments in rural hospitals experience a COVID-19 surge, it could affect rural residents who typically seek their non-emergent care at emergency departments.

Rural hospitals also had lower overall star ratings compared with urban hospitals, and also lower ratings for preventable hospitalizations, post-hospital discharge follow-up care among Medicare beneficiaries, and certain screenings. However, rural hospitals did have fewer adverse drug events.

The recap notes there’s “no consensus on which measures are clear indication of quality health care.” It also cautions that due to their small size and sometimes limited services, 34% of rural hospitals did not receive a star rating compared with 12% of urban hospitals in 2017 and so “some stakeholders argue that [the CMS Star Quality Rating] is not an effective quality measure for hospitals and excludes many small rural hospitals.”


Most Rural Hospitals Have Little Cash Going Into COVID-19
North Carolina Rural Health Research Program at the University of North Carolina at Chapel Hill, March 2020

Metro-area hospitals have been losing money on cancelled non-essential procedures while incurring unexpected costs for supplies, equipment and staffing for pandemic response. This paper uses something called median cash days on hand — the number of days the hospital could operate without receiving additional cash — and Medicare data to determine which rural hospitals may face financial struggles.

“Based on recent cost report data, rural Prospective Payment System (PPS) 26-50 bed hospitals had a median of only 21.3 days cash on hand and rural Medicare Dependent Hospitals (MDH) hospitals had a median of only 28.4 days cash on hand prior to the onset of COVID-19 in the United States,” the brief states. “These hospitals are the most likely to be the first to have a cash crunch.”

The brief notes that once hospitals run through their cash on hand they may not be able to make payroll unless they can “borrow money, sell assets, or seek emergency funding.”


Trends in Risk of Financial Distress among Rural Hospitals from 2015 to 2019
Sharita R. Thomas, George H. Pink, Kristin Reiter. NC Rural Health Research Program, Findings Brief, April 2019

This brief tracks the predicted proportion of financially high-risk hospitals from 2015 to 2019 by geographic census region and by Centers for Medicaid & Medicare Services reimbursement type. The authors report that the proportion of rural hospitals at high risk increased from 7.1% in 2015 to 9.2% in 2019. Further, states in the South had large increases in the percentage of financially at-risk hospitals.


Relevant academic journal articles

Exposing Some Important Barriers to Health Care Access in the Rural USA
Douthit, S. Kiv, T. Dwolatzky, S. Biswas. Public Health, May 2015

The authors of this literature review look at research published before and after the passage of the Patient Protection and Affordable Care Act of 2010. They detail multiple barriers to health care access in rural America. The barriers they address that may be relevant to rural health during the COVID-19 pandemic include:

  • Obstacles to getting to a doctor.
  • Lack of access to hospitals or specific health care specialties and services.
  • Financial burden.
  • Lack of access to broadband for telemedicine, or even to the Internet for health information, especially for those over 65.

“Significant differences in health care access between rural and urban areas exist,” they write. “Reluctance to seek health care in rural areas was based on cultural and financial constraints, often compounded by a scarcity of services, a lack of trained physicians, insufficient public transport, and poor availability of broadband internet services. Rural residents were found to have poorer health, with rural areas having difficulty in attracting and retaining physicians, and maintaining health services on a par with their urban counterparts.”


Trends in Emergency Department Use by Rural and Urban Populations in the United States
Margaret Greenwood-Ericksen and Keith Kocher. JAMA Network Open, April 2019

If more rural than urban residents use emergency departments for non-emergent health care needs, what might this reveal about the rural health care system? Since emergency departments are designed to treat acute, not chronic, conditions, increased emergency department visits for non-emergent care means rural patients may be receiving fragmented, inconsistent care for chronic conditions.

The authors of this paper write that rural emergency departments (ED) are “increasingly serving a larger proportion of traditionally disadvantaged groups and with greater pressure as safety-net hospitals.”

Using a data set from the National Hospital Ambulatory Medical Care Survey, they determine that from January 2005 to December 2016, “Rural ED visit rates increased by more than 50%, from 36.5 to 64.5 per 100 persons, outpacing urban ED visit rates, which increased from 40.2 to 42.8 visits per 100 persons. Rural ED use increased for those aged 18 to 64 years, non-Hispanic white patients, Medicaid beneficiaries, and patients without insurance, with a larger proportion of rural EDs categorized as safety-net EDs.”


Rural risk: Geographic Disparities in Trauma Mortality
Molly Jarman, et al. Surgery, December 2016

The authors of this paper examined rural trauma mortalities based on data from the 2009–2010 Nationwide Emergency Department Sample. They find rural residents are 14% more likely than nonrural residents to die after traumatic injury. “This disparity varies by trauma center designation, injury severity, and U.S. Census region,” they note.

This study may be relevant to COVID-19 because, as the authors write, “Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization.”


Predictors of Primary Care Physician Practice Location in Underserved Urban and Rural Areas in the United States: A Systematic Literature Review
Amelia Goodfellow, et al. Academic Medicine, September, 2016

The authors of this literature review recommend strategies of financial incentives and training programs to increase the number of primary care physicians in underserved areas. In prefacing their findings, they describe the lower distribution of primary care physicians in rural areas:

“Although there are approximately 80 primary care physicians per 100,000 people in the United States, there are only 68 per 100,000 practicing in rural areas compared with 84 per 100,000 in urban areas,” they report.

Describing the importance of primary care physicians, they write: “Prior research has shown that higher concentrations of primary care physicians are independently associated with better health outcomes in multiple domains, including cancer, management of chronic disease, self-rated health, and overall mortality.”

Strategies for increasing the number of primary care physicians in underserved communities include:

  • Identifying and supporting medical students who enter training interested in underserved communities.
  • Increasing graduate medical education training in underserved areas, since physicians typically end up practicing near the geographical area of their training.
  • Increasing funding support, because physicians who received support or were without debt were more likely to practice in underserved areas.
  • Increasing placement in rural medicine programs and rural practice locations.


Will Community Health Centers Survive Covid-19?
Brad Wright, et al. The Journal of Rural Health, May 2020.

Community health centers are an integral part of health care services in underserved communities, including rural areas. The authors of this commentary report that CHCs are currently experiencing a 70% to 80% drop in net revenue as residents stay home fearing exposure to the new coronavirus. Staffing is also reduced as CHC providers step in to relieve hospital staff.

The authors write, “Federally qualified community health centers (CHCs) are the nation’s primary care safety net, serving a patient population of whom 68% have incomes below the poverty level, 63% identify as racial/ethnic minorities, and 82% are uninsured or publicly insured. Today nearly 1,400 CHCs operate some 13,000 health care delivery sites nationwide.”

CHCs have already received and continue to request emergency funding during the pandemic. The paper’s authors argue that maintaining the CHCs will be “critical to our nation’s ability to respond to COVID-19 in rural and underserved communities.”


Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings
Yiyang Yuan, et al. Journal of Post-Acute and Long-Term Care Medicine, October 2018

The authors of this paper reviewed 15,090 Medicaid/Medicare-certified nursing homes and found that “those located in nonmetropolitan counties received significantly fewer stars on the quality measure ratings.”

(Nursing homes and other elder care facilities have emerged as hot spots in the COVID-19 pandemic. According to a June 1 press release from Centers for Medicare & Medicaid Services, of the 80 percent of the 15,400 Medicare and Medicaid nursing homes reporting data, there were 60,000 confirmed COVID-19 cases and almost 26,000 deaths: “Early analysis shows that facilities with a one-star quality rating were more likely to have large numbers of COVID-19 cases than facilities with a five-star quality rating.”)


Unequal Distribution of Covid-19 Risk Among Rural Residents by Race and Ethnicity
Carrie Henning-Smith, Mariana Tuttle, Katy B Kozhimannil. The Journal of Rural Health, May 2020.

Rural America is not as monolithically white as often imagined, note the authors of this commentary.

“Approximately 1 in 5 rural residents is a person of color or Indigenous and 11% of rural US counties are majority non-white,” the authors write, explaining that race and ethnicity-based disparities that existed in rural health care before the pandemic are ones that could adversely affect COVID-19 patient outcomes in these communities. The authors describe “non-Hispanic black and Indigenous rural residents facing higher rates of mortality and Hispanic rural residents facing poorer access to care relative to their non-Hispanic white counterparts.”

They argue, “Differences in health and health care access by race and ethnicity among rural residents are direct results of historical and current structural racism.” To address these disparities, they recommend both media attention and health care resources should be directed to those communities.

Regarding media coverage: “Without deliberately centering on their voices, there is a risk of portraying rural areas as monolithically white, which they are not, or losing sight of the deepest tragedies because averages can mask disparities, especially for minority populations.”

Regarding resources: “Policy intervention to address COVID-related suffering in rural America should prioritize those places that already have the fewest resources and the poorest health outcomes, namely black and Indigenous rural residents and racially diverse rural communities.”


Regional Strategies for Academic Health Centers to Support Primary Care During the COVID-19 Pandemic: A Plea from the Front Lines
Jennifer E. DeVoe, Anthony Cheng and Alex Krist. JAMA Insights, April 2020

The authors describe an approach of health care practices partnering with academic health centers at universities to help rural regions, among other communities, address overwhelmed primary care systems during the COVID-19 pandemic. The reasons they offer for supporting primary care are threefold:

  1. Primary care teams are the often the first health care providers patients contact, and can divert patients from emergency departments who don’t require emergency care.
  2. They are also managing moderately ill patients who remain home and those who have been released from hospitals.
  3. Primary care physicians are among those providers covering shifts at overwhelmed hospitals and as ill staff are quarantined.

The authors point to the example of  Oregon Health & Science University, which has established the COVID-19 Connected Care Center, a service staffed by university clinicians.

In the first two phases of this three-phase model, hotlines staffed by medical students, residents and faculty shared real-time information — first to patients and then to primary care practices. “This hotline mirrors an existing OHSU specialty consult line, which serves the primary care community in rural and frontier counties,” the authors explain.

Phase III will expand the service “to the 25% of Oregonians without access to primary care and patients of small practices that lack the resources of larger health care systems, offering them nursing advice and video visits, if needed.”


Additional resources


What is rural?

What is the definition of “rural?” The Rural Health Information Hub lays out the official government definitions, and their uses and parameters, from the three federal agencies whose definitions are most widely used: The U.S. Census Bureau, The Office of Management and Budget and The Economic Research Service of the U.S. Department of Agriculture.

The Rural Health Information Hub has an “Am I Rural?” tool to determine if a location is rural.

What is a community health center?

Community health centers were first created in 1965 and are meant to serve vulnerable populations. As described by the CDC, “Community health centers are community-based and patient-directed organizations that serve populations with limited access to health care.”

Operating as private non-profits, and governed by a community board, CHCs provide primary health care, but also related services including translation, education, transportation, nutrition, care management and pharmacy services.

Updated rural COVID research and figures

The Cecil G. Sheps Center for Health Services Research at the University of North Carolina has created the resource Rural COVID Research and Figures. This resource includes continually updated maps and graphs of “Rural and Urban COVID-19 Hot Spots” and “COVID-19 Growth in Rural Counties” as well as the occupancy rates and vulnerability ratings of rural hospitals as relates to COVID-19. The Sheps Center also documents causes of rural hospital closures and updates a Rural Hospital Closure Page that tracks the number of closed hospitals.

Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020
Kathleen Hartnett, et al. Morbidity and Mortality Weekly Report, June 2020

On June 3, 2020, the CDC released a Morbidity and Mortality Weekly Report that reports emergency department visits from March 29 to April 25 declined 42% compared with the same time period in 2019. These declines were highest in areas with the largest pandemic outbreaks.

While some patients may have been treated by primary care physicians, and injuries may have been fewer due to changed behaviors during the pandemic, emergency department visits for nonspecific chest pain and acute myocardial infarction decreased during the studied period.

Racial/Ethnic Health Disparities Among Rural Adults – United States, 2012-2015
Cara James, et al. Morbidity and Mortality Weekly Report – Surveillance Summaries, November 2017

Nationwide self-reported data from the CDC’s Behavioral Risk Factor Surveillance System was analyzed for this report that describes racial/ethnic disparities including “health-related quality of life, health care access and use, health-related behaviors, and chronic health conditions.”

The authors of this summary report write that one of the limitations of the report is that the BRFSS data is self-reported. While this is most recent multi-year summary, the CDC’s more recent BRFSS data is published at the BRFSS site.

Solution-based information
The Rural Health Information Hub has a section on Rural Health Models and Innovations. Projects are organized by topic, state, and by levels of evidence. They’ve also created a page documenting COVID-19 innovations. It includes crowdsourced examples of how rural communities have been addressing the pandemic.

Rural news coverage
Who knows how to cover rural stories? We asked for recommendations from Dr. Carrie Henning-Smith, an assistant professor in the Division of Health Policy and Management, University of Minnesota School of Public Health and deputy director of the University of Minnesota Rural Health Research Center. She recommends The Daily Yonder.

For more information, check out these 4 tips for covering rural health care amid COVID-19 and these other 3 tips for reporting on rural health.

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