Are You Aware? A Pandemic in the Country

This is part I in our “Rural America” Awareness Wednesday series. Read the other posts in the series here.

When my family goes on road trips, we often measure our progress relative to population centers — sometimes pulling off the highway, briefly, to stop at a convenience store or a fast food joint along the way. Yet, sometimes, I find myself thinking about what life is like in the space between.

My mother was born and raised in the mountains on the border of Washington and Idaho. We laugh at stories of her and her three sisters waking each other to venture out to the outhouse in the middle of the night, and accounts of my grandfather driving all the kids down the mountain in their old all-wheel-drive military weapons carrier to get to the bus stop on their way to school. But for many Americans living in rural communities, some of the issues they face are no laughing matter.

Life in rural America can be peaceful and idyllic, and communities are often close knit. I can tell you that my grandparents raised hard-working, independent, and resilient children. But, increasingly, a number of compounding issues are making life in rural communities challenging. As one resident of Kansas said, “Rural America is dying. All the money and all the people leave.” And it’s dying in both figurative and literal ways. The pandemic has drawn the issues out in even sharper relief.

Around 46 million Americans live in rural communities — that’s one-fifth of the population of the United States. Some of the concerns individuals in these communities face are poverty, job loss, aging populations, poor health, addiction, inadequate and obsolete infrastructure and sanitation, and limited access to transportation, technology, and education. It’s not hard to see that when added together, these issues contribute to, and exacerbate, one another. The problems become self-perpetuating.

For as long as the government has kept track, poverty rates have been higher in non-metro areas than in metro areas, though the margin between the two has shrunk over time. Both poverty and job loss rates reached a peak (not seen since the Great Depression) during the Great Recession. Those rates had not fully recovered in rural areas when COVID hit. While unemployment has not been as high in rural areas as in metro areas, the jobs that have been lost during the pandemic have contributed to growth in poverty and added stress to an already stressed system.

Some of the problems in these communities are similar to what we see in inner cities: domestic violence and drug and alcohol abuse — which contribute to poor health outcomes — and a shortage of affordable housing. Homelessness is often associated with urban areas, but it is a problem in rural areas as well. People experiencing homelessness in rural areas often go uncounted, and there is greater difficulty connecting them to services. And, as we have learned over the last year, the unsheltered and those living in close quarters — whether it be in shelters or multi-generation homes — are at a higher risk for contracting COVID.

One-fifth of older Americans live in rural areas. A recent report showed that 17.5% of rural populations are 65 or older compared to 13.8% in urban areas. Also, according to the CDC, rural Americans are more likely to smoke, to have high blood pressure, and to be obese. They are also less likely to have health insurance. These factors all contribute to a less healthy population. Suicide rates, too, are higher in rural America than in urban settings. So wide are the disparities from region to region that there is as much as a 20-year difference in life expectancy in different parts of our country.

In the last 15 years, 174 hospitals have closed in rural areas, many of them in areas serving minority communities. One of the biggest factors contributing to this problem is that many hospitals in states that did not adopt Medicaid expansion have a negative operating margin. Medicaid covers nearly a quarter of the non-elderly in rural areas. As of January 2020, non-expansion states were home to 59% of the non-elderly uninsured in rural areas. Another issue is that many rural hospitals are categorized as “critical access hospitals” for Medicare purposes. Those hospitals are required to maintain a certain number of inpatient beds for reimbursements. There is a provision in the proposed COVID relief bill that would create a new classification for rural hospitals, which, if it passes, could help resolve some problems.

Access to quality health care has long been a problem in many rural communities. For years, my aunt would drive my cousins from southeastern Utah to Utah County to bring them to dental and orthodontist appointments. During the pandemic, one in four rural households has reported that someone in their home has been unable to get medical care for serious conditions. They are more likely to report long waits, cancelled procedures, poor access to mental health care, and a need to travel long distances. Among those households, half of them reported a family member having negative consequences because of an unresolved medical problem.

While the rural healthcare system was already stressed before the onset of the pandemic, things have only gotten worse. It was, at best, difficult to attract skilled medical personnel to rural communities, but with the anti-science sentiment that has grown out of the pandemic and the increased politicization of health care, those workers, who provide an important structural element to a community, are deciding to leave rural communities and are increasingly difficult to replace.

According to Alan Morgan, CEO of the National Rural Health Association, “It’s been a terrible, an absolute terrible, no-good year for rural health.” Moran went on to explain that rural hospitals were in trouble before the pandemic. The increase of extremely sick and highly contagious patients made it difficult for hospitals to continue the elective outpatient procedures that help keep them in business. The small staffs in these hospitals have been run ragged, and they are often the target of vitriol. Many public health administrators have quit, retired, or been fired this year. Some have gotten death threats and some have hired armed bodyguards.

Hospitals are frequently the largest employer in rural communities. The loss of a hospital and the associated health care workers can further undermine rural economies.

Now that we have vaccines, rural communities are struggling to get their populations vaccinated. Vaccination, in some rural communities, was delayed months after urban areas had started large-scale vaccination — partly due to the lack of proper refrigeration units to meet the requirements for the new Pfizer and Moderna vaccines. There are also 111 rural communities in the U.S. with no pharmacies to distribute vaccines. Even where there are pharmacies, demand is high.

My mother-in-law was willing to drive to a Walmart an hour and a half away from her home, because she was having a hard time getting an appointment at her local Walmart in rural Arkansas. Sometimes, getting an appointment when they are available is a struggle. One-third of rural households have difficulty connecting to the internet, and many of them have unreliable phone service. Combine all this with high rates of vaccine hesitancy, and it makes for some real hurdles in achieving herd immunity in these communities

In spite of the fact that all of us depend on rural America for critical sources of water, food, energy, and recreation, federal policy has often passed over rural communities, or treated them as monolithic, rather than as disparate systems with unique needs. Also, many individuals with intersecting risk factors help make up these communities. Though it is true there is often less diversity in rural communities, 22% of the people living outside urban areas are ethnic or racial minorities. Indigenous people, immigrants, LGBTQ+ folks, and disabled people also contribute to sustaining rural communities in meaningful ways. All of these people face increased challenges on top of those experienced by the rural population at large.

With the events of this year in full view, compounded with the state of things as they were pre-COVID, is it any wonder that many people living in rural communities feel left behind? In spite of desire and hard work, and all the things rural communities do well, circumstance and policy place the American Dream out of reach for millions. We can do better.