Illustration: Sarah Grillo/Axios

Rural America is stuck in a cycle of increasingly vulnerable patients with declining access to health care.

Why it matters: Rural patients often can't afford care, are being hounded by hospitals and collection agencies over their unpaid bills, and are facing the reality of life in communities where the last hospital has closed.

Rural Americans tend to be older, sicker and lower-income than urban Americans. They suffer from higher rates of obesity, mental health issues, diabetes, cancer and opioid addiction, as my colleagues Stef Kight and Juliet Bartz reported.

  • They're also more likely to be uninsured or covered by Medicare or Medicaid, which pay doctors and hospitals less than private insurance does.
  • A small and shrinking population, mostly covered by insurance plans that don't pay very much, many of whom need a lot of care, puts more financial pressure on providers, especially hospitals. Physician shortages are common.

What they're saying: “Rural hospitals have long been right there on the edge on average, and we’re seeing more and more of them flip over to red," said Mark Holmes, a professor at UNC-Chapel Hill and director of the Cecil G. Sheps Center for Health Services Research.

And hospital closures often exacerbate the problems communities were already facing.

  • Hospitals are often the largest or second-largest employer in a rural community.
  • 113 rural hospitals have closed since 2010, according to the Sheps Center.
  • These are disproportionately located in the South — the region with the nation's worst health outcomes, and where most states haven't expanded Medicaid — leaving hospitals with more uninsured patients.
  • A 2018 study in Health Affairs found that Medicaid expansion is "associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets."

The bottom line: "What we have here is not one root cause; there’s multiple things going on here," Holmes said. "All these sort of modest kind of trends are adding up to something that’s quite considerable.”

Go deeper:

  • Bloomberg Businessweek reported on eastern Montana's sole psychiatrist, despite being the state with the nation's highest suicide rate.
  • The Washington Post detailed a hospital in Missouri's practice of suing its patients for payment — money that the hospital needed but patients generally don't have.
  • Kaiser Health News and NPR have profiled the fallout in a rural community in Kansas after its sole remaining hospital closed, which included a 2-week lapse in nearby emergency care.

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