By Rose Hoban

In the past six years, dozens of rural hospitals around the United States have discharged their final patients and turned out the lights, including three in North Carolina. The nation’s crisis of opiate addiction and overdose has been playing out most strongly in rural towns, where family and community ties are strong and overdose deaths hit hard.

And research shows there’s a persistent gap in life expectancy between rural and urban communities,  with data showing that rural areas experience poorer health on almost every measure and have less healthcare infrastructure to support residents.

Rural residents made their displeasure known during November’s presidential election, where they  gave the election to Pres. Donald Trump, sweeping Republicans into office on his coattails.

“These are not people who are necessarily racist,” political scientist Michelle Diggles told more than 500 rural health care providers who gathered last week in Washington, DC for the annual Rural Health Policy Institute, held by the National Rural Health Association. “These are not people who are prejudiced or anti-immigrant or whatever the issue of the day is.”

Diggles was speaking to the largest crowd to attend NRHA’s annual gathering in 28 years.

“My recommendation is to seize this political opportunity and turn it into a boon for rural America,” she told the crowd.

Traveling uptown

“I think rural America feels like it has a call to action,” said Maggie Elehwany, NRHA’s vice president for governmental affairs. “I think they really feel that Washington, both Republicans and Democrats have kind of forgotten about them. We tried to portray that, because of this closure crisis, because of the increasing mortality rates, and we have those studies saying that these are deaths of despair… on top of the jobs issue… all of that has a cumulative impact.”

bar graphs shows health disparities between urban/ rural populations, including child poverty, diabetes, premature death
Data, graph courtesy Michael Topchik, Chartis Center for Rural Health

Elehwany said she usually struggles to get legislators to speak to the annual gathering.

But this year, lawmakers rang her phone off the hook, asking for an opportunity to speak to the attendees.

More than a dozen senators, including North Carolina’s junior Sen. Thom Tillis (R), left Capitol Hill and traveled miles uptown to the hotel where the three-day conference took place.

“It’s been a refreshing difference,” she said. “Lawmakers are saying we want to understand what’s happening, we want to make a difference, want to figure out out how to make folks feel like they haven’t been left behind.”


Elehwany said that during this year’s conference, the “elephant in the room” was the Affordable Care Act. In many instances, the law has helped rural hospitals and rural health care practices stay solvent.

“Rural providers are disproportionately paid by government payers,” said Michael Topchik, a health care analyst from the Chartis Center for Rural Health. “They already have razor thin margins.”

In states that did not expand Medicaid, it’s been a different story. Eighty hospitals have closed since 2010, with the pace of closures picking up in 2013. In 2015 and 2016, a total of 34 hospitals closed, 26 of which were in states that did not expand Medicaid.

But the ACA has been a mixed bag in rural America.

map shows the effect of bad debt on hospitals that have closed, noting negative and positive profit margins as well as which states expanded Medicaid.
Hospitals in states with darker colors have more bad debt than those in lighter colored states. Outlines indicate which states expanded Medicaid. Each dot shows a hospital that closed. Map courtesy: Michael Topchik, Chartis Center for Rural Health

“In rural America, we’re more likely to have a tough insurance market,” said Cynthia Cox, from the Kaiser Family Foundation.

She explained that the exchange markets were meant to attract more insurance companies and improve competition by having more companies participate.

“We’ve seen that has not been the case,” she said. “One out of every three counties in the U.S. has only one insurance company, and a similar number has only two insurance companies on the exchange, and these are mostly rural areas.”

And in rural places where there are more older, sicker and uninsured people, that translated into higher premiums and faster premium growth for people who did buy coverage.

“On average in urban parts of the country, premiums rose 20 percent, but in rural areas, premiums rose 30 percent on average,” in 2016, Cox said. “Some rural areas saw huge premium increases of 180 percent.”

During the election campaign, “the only health care stories I had were farmers complaining about premium price, premium increases and complaining about regulations on employees,” said Chris Clayton, a reporter from The Progressive Farmer,  during a session on rural health and the election.

Repeal? Then what?

Jeff Spade, from the North Carolina Hospital Association, said with Congress undecided over what it’s going to do, there’s a lot of anxiety among providers.

“We’re waiting for the federal issues to get lined up,” he said. “I’m here just seeing what’s changing, what’s not changing, what it’s going to look like over the next several months.”

He said he was a little bit reassured over how the Republicans who spoke to the conference had softened their stances.

One of those softening his rhetoric was West Virginia Sen. Evan Jenkins (R). He said among Democrats, there was a “lockdown attitude to provide unflinching support” of the law. But Jenkins, a physician who headed the West Virginia Medical Association for 15 years said that’s no longer the case.

“Even Hillary Clinton campaigned on the ACA needs fixed (sic),” he told the group.

He encouraged people at the conference to make their voices heard.

“You folks have the white hats on,” Jenkins said. “People love rural America, you’re in the sweet spot,” for influencing policy.

He told the people at the conference to take the next year or so to get to know legislators, to work with them to come up with the eventual replacement.

“It’s not going to work out very well for you to say, ‘I like the old way.’ The old way’s a non-starter,” he said.

“There’s going to be changes. Help write those changes.”


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Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...