Millions of Americans Live in 'Care Deserts'—Here's What That Means and Why It's a Huge Problem
On a mid-March evening around 7 p.m., Karolyn Gehrig began to feel unusual chest pains—the kind that might signal a serious heart issue. "I would have 100 percent gone to a hospital or an urgent care facility," Gehrig tells 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 lives in Marfa, Texas. She relocated there in March 2020, just before the pandemic. Marfa is a rural desert town, and Marfa City-County Emergency Medial 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.
Many of the towns within Presidio County, including Marfa, can be described as a "hospital deserts"—a name for a community at least 30 miles from a medical facility that offers emergency care. The only services in Marfa, for example, are the Marfa Community Health Clinic and Marfa Country Clinic, which only has primary care services. Both operate Monday through Friday from 8 a.m. to 5 p.m., but they're closed on weekends and do not offer emergency care.
A hospital desert falls under the umbrella term "care desert," which can include a "medical desert" (a community at least 30 miles away from the nearest trauma care center), a "maternal care desert" (counties with few or no maternity health care services), and "pharmacy desert," a geographical area with limited access to a pharmacy.
Like Marfa, many rural communities across the country also qualify as care deserts. Sixteen percent of residents living in the mainland United States are 30 miles or more away from the nearest hospital, per a CNN analysis. And according to an Injury Journal study, nearly 30 million Americans don't live within an hour of trauma care, classifying those areas as medical deserts.
How did care deserts come to be—and why do so many people live in one?
The development of a care desert often starts with hospital closures. Take Clay County, Georgia, for example. The only hospital in the county closed in 1983, and none have opened since. One doctor currently serves this county of about 3,000 people, at least 500 of whom are seniors, Tara Gardner, Clay County resident and program director for the Two Georgias Initiative, a five-year-long grant program to improve health care conditions in some of the most medically underserved counties in the state, tells Health.
When the Two Georgias Initiative began in 2017, "we were the poorest county in the state of Georgia," Gardner says. "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 need hospital care won't always be able to go there; the county has just one ambulance and at times has to borrow one from a neighboring county, which may not be contracted to go to Eufaula but instead to either a hospitals 45 minutes away or one an hour away.
As of January 1, 2020, 120 rural hospital facilities have closed over the past 10 years, according to a recent study by the Chartis Center for Rural Health, an independent health care advisory firm. States in the Southeast and Midwest were hit the hardest, including Texas, Tennessee, Oklahoma, Georgia, Alabama, and Missouri . And the closures are predicted to continue, with the Chartis Center classifying 453 rural hospitals as vulnerable to closure.
A main factor for today's increased risk of rural hospital closures is whether the state has adopted the 2013 Medicaid expansion under the Affordable Care Act. According to the study, "hospitals located in states that have not adopted Medicaid expansion have lower median operating margin and have a higher percentage of rural hospitals operating with a negative operating margin. Of the eight states with the highest levels of closures since 2010, none are Medicaid expansion states."
Opting out of the expansion not only directly affects 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, tells Health, adding that Texas did not take part in Medicaid expansion. Those who qualify for full Medicaid benefits in Texas include children, pregnant women, parent and caretaker relatives, SSI recipients, people age 65 and older, those with disabilities, and former foster care youth.
But certain income limits make 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, senior policy analyst at Every Texan, a nonprofit research organization focused on public policy in Texas, tells Health. A parent of two is capped at 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," Pogue says.
Should you not qualify, the care gaps are drastic. If you have Medicaid or commercial insurance and you want to get a physical exam, Dr. Gowen says you can 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," she adds. That's why Dr. Gowen calls 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," she says.
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, certified nurse midwife at the University of Chicago and founder of Melanated Midwives, tells Health. This includes two hospitals (Advocate Trinity Hospital and St. Bernard) that suspended maternity services during the height of COVID-19, as well as one hospital that closed its obstetrics unit and another that suspended obstetrics services altogether (Jackson Park Hospital and Holy Cross Hospital, respectively), per The Chicago Reporter. These closures and suspensions have left a majority African American population in a maternity care desert, Stewart explains.
Most recently, the attention has been 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 has "faced financial turmoil for decades as the population in the area has declined, hospital reimbursements have decreased, and capital needs have increased exponentially," per CBS Chicago.
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 comes from Medicaid, which doesn't fully reimburse hospitals treating those patients who can't afford it, according to WBEZ Chicago. Since July 2020, Mercy has entered into a nonbinding agreement with a non-profit that has promised to keep the hospital running as a full-service acute care hospital, per the Chicago Sun Times. The sale was recently finalized, but Medicaid reimbursement gaps continue to trickle down into other sectors of care, creating further inequities.
For example, as of December 2020, Aetna dropped Walgreens from its Illinois Medicaid plan. That means low-income Chicago residents, many of whom live 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, which then creates pharmacy deserts—a term coined by Dima Qato, PharmD, PhD, Hygeia Centennial Chair and associate professor of pharmacy at the University of Southern California (USC) and director, Program on Medicines and Public Health at USC. Pharmacy deserts are communities where pharmacies are more than a half-mile from a home (for low-vehicle access communities), and a mile for others. "It's unfortunate that money has to play a big, huge part in getting access to something that can make you feel better," Stewart says.
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.
Wisseh recently 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 Latino and Black residents, less vehicle and home ownership, less access to health professionals and 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 if you live in a care desert
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, says Gardner—who recently had 211 established in Clay County as part of her work with the Two Georgias Initiative. Visit 211.org to see if the services are available in your area.
Look for a federally qualified health center (FQHC) or freestanding emergency department (FSED)
FQHCs are outpatient clinics set up as "a safety net for health care across the nation," says Dr. Gowen, whose Su Clinica is a FQHC. They serve underserved populations, qualify for enhanced reimbursement from Medicare and Medicaid, and 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). Unlike urgent care centers, FSEDs, "are full-service emergency departments, which by statute in most states are open 24 hours, according to Health Affairs. They 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.
As of December 2015, thirty-two states collectively had 400 FSEDs, per a 2016 Health Affairs study. The downside is that the cost of a FSED visit can be equal to or greater than the cost of a regular emergency room visit, and 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, according to the Centers for Medicare and Medicaid Services. 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. A US Centers for Disease Control and Prevention report found a 154% increase in telehealth visits during the last week of March 2020 compared to the same time in 2019. And physicians and other health professionals are now seeing 50 to 175 time the number of patients via telehealth than they did before the pandemic, according to a McKinsey & Company Health Care Systems & Services report.
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 is a Navy veteran and stay-at-home mom of three who was able to see a neurosurgeon through telehealth in January at Emory University Hospital (a 3-hour ride from her home) and have 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 tells Health. Talking to a doctor virtually made her feel just as comfortable and cared for than she did during a previous in-person visit with her local hospital's neurologist, she says.
But access to the technology and the internet itself can be a challenge. Stewart points out that many of her patients were forced to choose between their kids' online schooling and having a virtual doctor's appointment during the pandemic, due to limited internet access and poor connectivity.
Some states have been slow to adopt telepharmacy. Only 23 states allow the use of telepharmacy, while 11 states have laws or regulations that permit waivers or pilot programs to implement telepharmacies, according to RUPRI Center for Rural Health Policy Analysis. 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. This model has worked in urban areas, too. Broadway Medical Clinic Pharmacy in the greater Chicago area is a telepharmacy that filled about 400 scripts a week, according to Drug Tropics in 2019. Most of the patients are walk-ins, without working cars, and with varying forms of insurance.
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, Gardner says. 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 3-5 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, Stewart says. "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 proper care." Getting to and from a hospital is one major hurdle Stewart's patients face. But what many of them don't know, she says, 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 your 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," Stewart says. "But the patients have to know that."
That's why she also suggests getting connected with community caregivers like certified nurse midwives (health care 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) and doulas (a birth assistant who provides 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. And the Center for Indigenous Midwifery, based in Olympia, Washington, offers culturally centered care for Indigenous communities.
Check your newspaper and community Facebook groups
Both are great ways to find out about new resources and health care initiatives in your area, says Gardner, who helps produce the newspaper for Clay County. "The newspaper has been going for the last four years to every household in Clay County," she says. "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, suggests 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, and the website is dedicated to supporting health care and population health in rural communities. There you'll find health care 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 tells Health.
That's really where change begins: when money and resources are invested back into these communities, Stewart points out. The governor of Illinois recently 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; and expands the coverage of doula services, among other benefits. Stewart is also well on her way to having a bill passed for a new birthing center on the South Side.
Change is happening in rural communities, too. In just four years, both Mickens and Gardner have implemented influential programming within their counties thanks to the $100,000 allotted each year through the Two Georgias Initiative. Mickens was able to bring the OrganWise Guys curriculum to elementary schools in Appling County to educate kids on nutrition. He's also launching a pilot program for 50 low-income diabetics in the community to have their health levels monitored daily and enrolled in nutrition classes. In November, 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," Gardner says.
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," Gardner says. But this is just the beginning. Gardner hopes to continue sharing what she's done 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," Gardner says.