Heartache in the Heartland
Rural health care is in a state of collapse, and this reality portends potential future challenges for those living in suburban and urban areas
I grew up outside of Pittsburgh, Pennsylvania, in the 1980s and '90s and witnessed first-hand how suburban sprawl gobbled up family farms and spit out malls, megastores, and tract housing at an alarming rate. Pastures and fertile fields were plowed over in favor of highways and parking lots, all in the name of progress and the American Dream. Since then, Rural America has pushed further and further away from the urban core, exacerbating geographical divisions that have manifested as stark social, political, and economic disparities, especially in health care.
Rural Americans and their lived experiences became a point of fascination and study for me, which continues today. These feature prominently in my book, “The Super Age: Decoding Our Demographic Destiny” (Harper Collins), which examines how declining birth rates and population aging are literally and figuratively remaking the map in rural counties. People living in these areas were the first to experience population aging, which was complicated by outward migration and has led to depopulation. As a result, Rural America is older than the rest of the country, and they serve as proverbial canaries in the coal mine, signaling what may be on the horizon for suburban and urban areas in the coming years without change, and it’s rarely positive.
In short, a reckoning is coming for American health care thanks to demographic change. Without immediate innovation and intervention where Rural America serves as a testbed for new care delivery models, large swaths of the population, including those living in urban and suburban areas, could be left without access to adequate care in the future.
The Harsh Reality of Healthcare in Rural America
Today, in three-quarters of American counties and half of the states, most rural, deaths now outpace births. Left behind in many of the narratives about crumbling infrastructure and lack of opportunities in rural areas is the reality of a rapidly aging and declining population and the shuttering of healthcare centers, long-term care communities, and pharmacies across the region and how all of these intertwine to cause increasing hardship for families and rising death rates.
A shocking 195 rural hospitals have closed across rural America since 2005, 150 of those since 2010, according to research from the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. One hundred hospitals have closed entirely, and 95 facilities no longer provide inpatient services. These closures come at a time when the population of older adults needing services swells across rural America, leaving many people without adequate access to healthcare when needed most, a truly dire situation, causing a 5.9 percent increase in mortality in areas affected, according to a 2019 University of Washington study.
According to research from the Rural Health Research Gateway, “more than 500 nursing homes in rural areas had either closed or merged between 2008 and 2018,” limiting access to long-term care services and supports, further exacerbating the situation. These closures and mergers have pushed rural residents and communities to rely more on family caregivers than ever.
To further complicate rural healthcare realities, a 2022 study from the RUPRI Center for Rural Health Policy Analysis at the University of Iowa found that 600 rural retail pharmacies have closed in the region since 2003. During the same period, 70 franchise pharmacies closed, while chain pharmacies like CVS and Walgreens only added 90 stores. The study found that overall, the number of rural retail pharmacies declined by 9.8%, while the number in metropolitan areas, including suburban and urban communities, increased by 15.1%, widening the access gap.
The closure of rural pharmacies has created "pharmacy deserts" in underserved communities, leaving these Americans struggling to fill prescriptions. Unsurprisingly, these closures impact the communities that need them most, forcing many to shift to mail-order pharmacies or travel long distances to obtain life-saving medications.
New Rules for Change
The realities facing the sustainability and delivery of health care in rural areas present a significant challenge, and they could mean life or death for hundreds of thousands of people. Yet, the current funding models, including from public and private sources, often favor suburban and urban areas where it is easier to deliver services and support, thanks to population density.
Rural America has the potential to serve as a test bed for inclusive innovation since the areas facing the greatest challenges often yield the best solutions. A handful of organizations, like the U.S. Department of Veterans Affairs (VA) Office of Connected Care, are tapping into its potential. Their mission is to bring digital technology to extend access to care beyond the traditional physical office by focusing on improving health care through technology. Still, they can only do that with adequate investment and infrastructure, like the 2021 Infrastructure Investment and Jobs Act, which provides $42.5 billion for broadband expansion, $37.2 billion of that going to state entities based on a formula that considers the percentage of the nation’s unserved rural communities.
Communities across rural America must also invest in the realities of their demographic future, leveraging inclusive design and person-centered and community-driven solutions with and without technology, considering the local needs first and rejecting a one-size-fits-all approach.
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