Healthcare Desert

What Are 'Care Deserts'—And Why Are They a Huge Problem?

Care deserts contribute to the health inequities facing residents in rural and inner city areas.

  • Care deserts are areas where people don't have nearby access to healthcare.
  • Any medical desert may be the result of issues such as hospital closures or a lack of healthcare providers available for treating individuals.
  • A person may be able to find high-quality healthcare options with methods like using telemedicine, looking for local assistance, or calling the helpline 211.

One evening, Karolyn Gehrig began to feel unusual chest pains—the kind that might signal a serious heart issue. "I would have 100% gone to a hospital or an urgent care facility," Gehrig told Health. "Frankly, I was aware that an ambulance was unlikely to be available."

So Gehrig texted two of her friends and talked through her symptoms, checking her vitals repeatedly until she felt calm again.

Gehrig had been living in Marfa, Texas. She relocated there in March 2020, just before the COVID-19 pandemic. Marfa is a rural desert town, and Marfa City-County Emergency Medical Services (EMS) covers roughly 2,500 square miles.

The nearest hospital is about 30 miles away—a trip to just reach the ER can last anywhere between 20 minutes to an hour.

If you recognize Marfa, that's because the town with a population of under 2,000 has long led a double life. For artists and tourists, Marfa has served as a rural, off-the-grid respite from fast-paced living, a site for captivating art, and the birthplace of Marfa Myths, a multimedia festival.

But to its residents, Marfa and the larger Presidio county—where Big Bend Regional Medical Center is the only hospital serving patients within a 12,000 square mile area—could use a health care upgrade.

What Is a Care Desert?

A "care desert," or "medical desert," is a U.S. county that does not have any hospitals or healthcare providers. Care deserts can also refer to "maternal care deserts" (counties with few or no maternity health care services) or "pharmacy deserts" (geographical areas with limited access to a pharmacy).

Many of the towns within Presidio County, including Marfa, can be described as "hospital deserts"—a name for areas where there is a high need for a hospital but the hospital supply is lower. The supply issue could be related to:

  • Location
  • Bed supply
  • Travel time
  • Population

The only services in Marfa, for example, are the Marfa Community Health Clinic and Marfa Country Clinic, which only have primary care services. Both operate Monday through Friday from 8 a.m. to 5 p.m.

However, they're closed on weekends and do not offer emergency care. Marfa Country Clinic does have urgent care hours, but they're intended for patients who have "acute needs" like colds or ankle sprains.

Like Marfa, many rural communities across the country also qualify as care deserts. A CNN analysis found that 16% of residents living in the mainland United States are 30 miles or more away from the nearest hospital. And one study said that nearly 30 million Americans don't live within an hour of trauma care, classifying those areas as medical deserts.

How Do Care Deserts Happen?

Care deserts can be the result of a few different matters, like:

  • Narrow Medicare reimbursements
  • Having patients without high-paying private insurance
  • Not having enough physicians or having out-of-network physicians for different insurance companies
  • Condensed healthcare systems
  • Changes in demographics

But other big reasons can include rural hospital closures and Medicaid issues.

Rural Hospital Closures

As of January 1, 2020, 120 rural hospital facilities had closed in the span of 10 years. States in the Southeast and Midwest were hit the hardest, including:

  • Texas
  • Tennessee
  • Oklahoma
  • Georgia
  • Alabama
  • Missouri

In Clay County, Georgia, the only hospital in the county closed in 1983, and none have opened since.

One healthcare provider served this county of about 3,000 people, at least 500 of whom are seniors, Tara Gardner, Clay County resident and senior program manager at Clay County Health Partnership, told Health.

When the Two Georgias Initiative—a five-year-long grant program to improve healthcare conditions in some of the most medically underserved counties in the state—began in 2017, Clay County was at the bottom of the list.

"[W]e were the poorest county in the state of Georgia," said Gardner. "We were the highest in chronic diseases. We had one doctor. Our drugstore had closed, so people were scrambling around trying to figure out where to get medications."

The closest hospital was and still is roughly 30 miles away in Eufaula, Alabama. Even so, residents who needed hospital care wouldn't always be able to go there.

The county has just one ambulance and at times has to borrow one from a neighboring county. The ambulance may not be contracted to go to Eufaula but instead to hospitals either 45 minutes away or one an hour away.

Issues Related to Medicaid Expansion and Eligibility

The main factor for an increased risk of rural hospital closures was whether states had adopted the 2013 Medicaid expansion under the Affordable Care Act.

Research findings indicated that states without Medicaid expansion experienced negative effects on rural hospitals' ability to operate efficiently, and none of the states with the highest closure numbers had Medicaid expansion.

Opting out of the expansion not only directly affected the hospitals but patients as well. "In Texas, you have to be really, really, really poor to qualify for Medicaid," Rose Gowen, MD, of the Brownsville, Texas branch of Su Clinica, told Health, adding that Texas did not take part in Medicaid expansion.

Certain income limits made it very difficult for low-income adults and parents to qualify.

"The Texas legislature set a dollar-value cap on income for parents to qualify for Medicaid in 1985. The legislature has never updated or increased it," Stacey Pogue, a senior policy analyst at Every Texan, a nonprofit research organization focused on public policy in Texas, told Health.

A parent of two was capped at an annual limit of $3,846, or about $320 a month. "Among states that haven't expanded Medicaid, Texas is at the very bottom for parents," said Pogue.

Should you not qualify, the care gaps would be drastic. If you had Medicaid or commercial insurance and you want to get a physical exam, Dr. Gowen said you could get scheduled in Brownsville in a week or two. "But if you have neither and you go to either one of the community health clinics for your physical, it's a year wait," added Dr. Gowen.

That's why Dr. Gowen called Brownsville a medical insurance desert: "We have hospitals, certainly we have operating rooms, we have skilled surgeons, we have great neonatologists and all of that, but if you're not covered, you're not covered."

How Have Care Deserts Affected Urban Areas?

Hospital closures and insurance gaps have not only affected rural communities but urban areas as well, such as the South Side of Chicago.

"Within the past five years, we went from having seven hospitals with thriving labor and delivery units to now three," Karie Stewart, MSN, certified nurse midwife at the University of Chicago and founder of Melanated Midwives, told Health. This included:

  • Advocate Trinity Hospital and St. Bernard, which suspended maternity services during the height of COVID-19
  • Jackson Park Hospital, which closed its obstetrics unit
  • Holy Cross Hospital, which suspended its obstetrics services altogether

These closures and suspensions have left a majority African American population in a maternity care desert, explained Stewart.

Attention was also on the Bronzeville community and the close-call closure of Mercy Hospital, one of three hospitals left on the South Side with maternity services.

In July 2020, the hospital announced that it would be closing, arguing that it had "faced financial turmoil for decades as the population in the area has declined, hospital reimbursements have decreased, and capital needs have increased exponentially."

As a safety net hospital—a medical center that's obligated to provide health care regardless of insurance status or ability to pay—just over 40% of Mercy's revenue came from Medicaid. Medicaid didn't fully reimburse hospitals treating those patients who couldn't afford it.

Mercy entered into a nonbinding agreement with a non-profit that promised to keep the hospital running as a full-service acute care hospital. The sale was finalized, but Medicaid reimbursement gaps continued to trickle down into other sectors of care, creating further inequities.

In December 2020, Aetna dropped Walgreens from its Illinois Medicaid plan. That meant low-income Chicago residents, many of whom lived on the south and west sides, would have a much harder time filling their prescriptions.

Pharmacies get the lowest reimbursements for filling Medicaid prescriptions, which leads to pharmacy closures. The closures can then result in pharmacy deserts.

"It's unfortunate that money has to play a big, huge part in getting access to something that can make you feel better," said Stewart. Compounding the problem is that pharmacies are more likely to exist in communities with medical centers or hospitals.

"You tend to see pharmacies come up near medical parks or plazas where they can work with physicians who maybe own those private practices to build their clientele," Cheryl Wisseh, PharmD, assistant clinical professor, department of clinical pharmacy practice at the University of California Irvine, told Health.

Wisseh conducted the first study on pharmacy deserts in Los Angeles County. The study found that areas lacking pharmacy access were characterized by:

  • Greater poverty
  • Higher crime rates
  • Denser populations
  • Larger numbers of Latinx and Black residents
  • Less vehicle and home ownership
  • Less access to health professionals
  • A lack of health insurance

Under these conditions, a resident might opt to forgo a prescription because they have to put that money toward the water bill, or they skip their COVID-19 vaccine because they'd have to take two buses to get to the nearest pharmacy offering one.

How To Get High-Quality Medical Help in a Care Desert

You may wonder what someone who lives in a care desert can do. How can you get access to high-quality medical care if it's needed? Luckily, a few community-based programs are available to help.

Dial Star 211

Never heard of it? The helpline connects individuals in need with community-based organizations or government agencies that can assist them with paying utility bills, finding shelter because of homelessness, and also getting access to medical care, said Gardner.

Gardner also had 211 established in Clay County as part of her work with the Two Georgias Initiative. Visit to see if the services are available in your area.

Use Federally Qualified Health Centers (FQHCs) and Freestanding Emergency Departments (FSEDs)

Federally Qualified Health Centers (FQHCs) are outpatient clinics set up as "a safety net for health care across the nation," said Dr. Gowen, whose Su Clinica is an FQHC. FQHCs:

  • Serve underserved populations
  • Qualify for enhanced reimbursement from Medicare and Medicaid
  • Offer an income-based sliding fee scale to patients

If you're not sure where to find an FQHC, the Health Resource and Service Administration (HRSA) search tool can help you navigate one in your area. But remember, they do not provide emergency care.

If you're in an emergency situation and live far from a hospital, look for the nearest free-standing emergency center or department (FSED). FSEDs are separated from a hospital, and, unlike urgent care centers, they provide full emergency care to the public 24 hours a day.

FSEDs have advanced equipment including laboratories, X-ray machines, and CT scanners; emergency-trained doctors and nurses; and typically offer pre-arranged transfer for patients requiring inpatient hospitalization. FSEDs also have little to no wait times.

Researchers found that 32 states collectively had 400 FSEDs. The downside is that the cost of an FSED visit can be equal to—or greater than—the cost of a regular emergency room visit.

Medicare and Medicaid are typically only accepted at hospital-owned freestanding emergency clinics. However, this rule was temporarily lifted to include independent freestanding emergency departments in April 2020 in Colorado, Rhode Island, Delaware, and Texas in light of the pandemic.

Be sure to double-check whether the freestanding emergency care center near you is in-network or if it accepts Medicare and Medicaid before visiting.

Try Telehealth or Telepharmacy

These virtual resources can make all the difference for people who live in rural and urban medical and pharmacy deserts.

One report found a 154% increase in telehealth visits during the last week of March 2020 compared to the same time in 2019. Other findings indicated that physicians and other healthcare providers were seeing 50 to 175 times the number of patients via telehealth than they did before the pandemic.

Remote visits can also be useful for those living in rural areas who need specialty care, like Maggie Boxey, a resident of Leesburg, Georgia.

Boxey, a Navy veteran and stay-at-home mom of three, was able to see a neurosurgeon through telehealth at Emory University Hospital—a three-hour ride from her home. Boxey had a brain tumor consultation without ever leaving her home and kids.

"He [the neurosurgeon] set me at ease. He told me all about my tumor and explained what the different treatment types are," Boxey told Health. Talking to a healthcare provider virtually made her feel just as comfortable and cared for as she did during a previous in-person visit with her local hospital's neurologist, said Boxey.

Access to technology and the internet itself can be a challenge. Stewart pointed out that many of her patients were forced to choose between their kids' online schooling and having a virtual healthcare provider's appointment during the pandemic, due to limited internet access and poor connectivity.

Also, not all states have adopted telepharmacy—but the model has been successful in states that have adopted it.

A great example is the North Dakota Telepharmacy Project, where a licensed pharmacist at a central pharmacy site virtually oversees and approves via videoconference a registered pharmacy technician at a remote telepharmacy site as they prepare and dispense prescriptions. The patient also consults with the pharmacist virtually.

"Approximately 80,000 rural citizens have had their pharmacy services restored, retained, or established through the North Dakota Telepharmacy Project since its inception," according to North Dakota State University.

If this telepharmacy sounds like it could benefit you, you can look up your state's telepharmacy policies at the Center for Connected Health and see what's available to you.

And if traveling to a remote telepharmacy site is a concern, you can also check out organizations like Good Pill in your area, said Gardner.

Good Pill is a Georgia-based non-profit home delivery pharmacy that fills prescriptions for people who have copays that are too high or for those who are uninsured. The company will deliver 90-day supplies from your home within three to five days from when the prescription is received, and you can choose to pay now or later.

Look Locally for Help

This can be especially helpful in maternity care deserts, said Stewart. "Reach out to some of the local clinics that are in the area—they may have resources and know the ins and outs of where to go and get [the] proper care."

Getting to and from a hospital is one major hurdle Stewart's patients face. But what many of them don't know, said Stewart, is that hospitals may get bus cards and fare cards for Uber or Lyft through grant funds that they can give out to the patients when asked.

Also, sometimes insurance will provide transportation. For example, many of Stewart's patients are signed up for Illinois' County Care, a no-cost Illinois Medicaid-managed health plan.

"County Care will provide transportation for your prenatal visits. You just have to arrange and call to make those appointments and have them set up," said Stewart. "But the patients have to know that."

That's why Stewart also suggested getting connected with community caregivers, like certified nurse midwives and doulas.

About Certified Nurse Midwives and Doulas

Certified nurse midwives are healthcare providers who can deliver your baby in the hospital or at home in most states and also assist with pre-conception, pregnancy, and postpartum care. Doulas are birth assistants who provide physical, emotional, and educational support during delivery or postpartum.

Organizations like Melanated Midwives and the Black Parent Initiative are dedicated to educating and assisting women throughout their birthing journey—especially women of color who have negative birthing experiences at significantly higher rates than White women.

Rainbow Doula offers birth, postoperative, and postpartum doulas for the LGBTQ+ community in Washington, DC. Also, the Center for Indigenous Midwifery, based in Olympia, Washington, offers culturally centered care for Indigenous communities.

Check Your Newspaper and Community Facebook Groups

Both your local newspaper and community-based social media groups are great ways to find out about new resources and healthcare initiatives in your area, said Gardner, who helped produce the newspaper for Clay County.

"The newspaper has been going for the last four years to every household in Clay County," added Gardner. "It is filled with resources—like 211, that'll be on the head page for the end of May." Addison Mickens, project manager for the Appling County Coalition for the Two Georgias Initiative, suggested using Facebook as a resource, too.

Typing in search terms like "health," followed by the name of your county, can direct you to an event page for a community food bank or family planning initiative.

Visit the Rural Health Information Hub

The hub is funded by the Federal Office of Rural Health Policy. The website is dedicated to supporting health care and population health in rural communities. There you'll find healthcare-specific events, a state-by-state guide of rural health resources, and funding opportunities.

"They have a really robust database where they'll post upcoming grant announcements," Mickens told Health. That's really where change begins: when money and resources are invested back into these communities, Stewart pointed out.

In 2021, the governor of Illinois signed several game-changing plans and laws into effect, including a $150 million fund dedicated to community initiatives to improve health and medical care, as well as the Illinois Health Care and Human Services Reform Act, which:

  • Caps costs for blood sugar testing equipment
  • Amends the Employee Paid Sick Leave act to include care of children, parents, stepparents, in-laws, and grandparents
  • Expands the coverage of2 doula services, among other benefits.

Stewart was also well on her way to having a bill passed for a new birthing center on the South Side.

Change happened in rural communities, too. In just four years, both Mickens and Gardner implemented influential programming within their counties thanks to the $100,000 allotted each year through the Two Georgias Initiative.

Mickens brought the OrganWise Guys curriculum to elementary schools in Appling County to educate kids on nutrition. He also launched a pilot program for 50 individuals with diabetes and a low-income status in the community to have their health levels monitored daily and enrolled in nutrition classes.

Gardner and the Clay County Coalition launched a clinic with Mercer University, along with several other improvements to care. "We were able to bring in behavioral health services with New Horizon. We have brought in a new drug store. And now I'm doing vision clinics," said Gardner.

There's hope in these communities and in the people working to improve them. "I'm proud of the progress that we've made in medical because it gave the citizens of Clay County some choices," said Gardner. But this is just the beginning.

Gardner hoped to continue sharing what she did in her rural Georgia community with others so that they will be able to replicate it and do the same in medical deserts of their own. "It takes an army to move the barrier," said Gardner.

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