Haywood Park Community Hospital was the closest hospital to many people living in Brownsville, a rural town in east Tennessee.
Some residents credit the facility with saving their loved ones’ lives, but others in this majority-black city drive miles to hospitals or forgo care altogether. The facility closed in 2014 after a drop in patient numbers.
“Despite my bad experiences and bad feelings in that environment, there are poor people in Haywood County who need to go to the closest facility,” said Alma Jean Thomas Carney, who said the hospital’s white staff were not welcoming.
According to the Centers for Disease Control and Prevention, diseases like heart disease, cancer and stroke kill rural residents sooner than their urban counterparts, but over the past decade, hospitals in rural America have closed, leaving some of the 46 million people who live in these areas with fewer options to get the care they need when they need it.
Advocates, hospital and clinic administrators and rural residents say changing disparities in health outcomes and health care services in rural America must start at the local level, especially in communities of color who may lack trust in the medical field.
This effort is already happening in Brownsville, where hospitals are fully reopening in 2022; in North Carolina, where mobile clinics are providing after-hours care to undocumented farmworkers; and in California, where community health workers in the Fresno area are going door-to-door to help Punjabi Sikh immigrants, who often work on farms and in meatpacking plants.
“We’ve learned that we have to go to people, where they are. They’re not going to come to us,” said Mandip Kaur, health director at the nonprofit Jakara Movement.
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More than a third of the nation’s rural hospitals, about 700, are at risk of closing due to “serious financial issues,” according to a July analysis by the Center for Healthcare Quality and Payment Reform. Harold Miller, president and CEO of the center, said the closure of one hospital can send ripples through rural communities.
“Without the hospitals, you wouldn’t have any doctors,” Miller said. “You wouldn’t have anywhere else to go to get tested outside of those hospitals. You might not have anywhere else to get nursing homes or rehab or long-term care outside of those hospitals.”
If hospitals stay open in vast, sparsely populated rural areas, they may not be able to see the number of patients they need to turn a profit, said Arianna Planey, who studies health policy and management at the University of North Carolina.
Brownsville leaders searched for a buyer for the hospital, which was eventually purchased by the county. Privately held Braden Health then took it over with two conditions from county supervisors: that it be a full-service hospital with a 24-hour emergency room, and that it hire staff as quickly as possible. Local officials say the hospital is breaking even.
Tennessee is one of 10 states, many of them in the South, that hasn’t expanded Medicaid. Michael Mate, director of the Center for Rural Health Research at East Tennessee State University, said expansion would clearly solve the widening health care disparities in rural areas. More people would be covered, Mate said, and hospitals would make more money.
“They’re providing a lot of unpaid care,” he said of those states’ rural health care systems.
Miller acknowledged that Medicaid expansion could help, but argued that pinning his hopes on it “saved private insurance plans from the brink.”
“In some cases, small hospitals are losing more on private insurance than they are on Medicaid, which is really surprising,” he said, “and yet they’re getting paid so little by private insurance plans.”
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Low Medicaid reimbursements, along with staffing shortages and declining birth rates, are contributing to the closure of rural obstetrics units. According to a separate recent analysis by the Center for Healthcare Quality and Payment Reform, more than half of rural hospitals have stopped offering maternity services. This can lead to longer travel times and higher risks of complications and death. Black mothers have the highest maternal mortality rates in the United States.
When Alexis Ratliff, 29, was pregnant with her second child, she had few options for obstetric care: The hospital in Rocky Mount, Virginia, didn’t have a delivery room, and one about a 40-minute drive away was closing in 2022. Instead, Ratliff, who is Black, commuted to Salem, more than an hour away, for all her prenatal care. She had used up all her paid vacation time and had no paid maternity leave.
But she did have a doula, who is Black and whose services were covered by Medicaid, a benefit that Virginia began offering in 2022.
“I really wanted someone else to help advocate, especially because women of color have a higher mortality rate, so I was like, ‘Anything can happen,'” she said. “My family has never had a good experience at any doctor’s office here, even for routine appointments.”
In southern states, immigration status can complicate health care: North Carolina is home to about 150,000 farmworkers and their families, many of whom speak Spanish, don’t have permanent residency and don’t qualify for Medicaid, meaning they have to pay out of pocket or can’t get care at clinics.
Several organizations in the state offer mobile clinics. Campbell University’s Community Care Clinic partnered with Sembrando Salud of NC FIELD for its first outreach mission in 2017, diagnosing 68 people with diabetes. Four of them had very high blood sugar levels, said Dr. Joseph Cacioppo, a clinic volunteer and chair of Campbell’s Community and Global Health Programs.
“Three of them were lucky – they had little to no organ damage when they were found,” he said, adding that the fourth suffered kidney failure and liver damage “after years of not realising he had diabetes”.
There’s something else communities should strive for, says Alana Knudson, director of the NORC Walsh Center for Rural Health Analysis: a positive attitude and outlook. “It’s not all dystopia,” she says.
“I think we’re really trying to change that narrative, because here’s the challenge: Who wants to come from an older, poorer, sicker neighborhood? It doesn’t matter if they’re from the slums of America or they’re from rural America,” Knudson said.
“Being labeled like that doesn’t maximize how people feel about themselves.”
