Imagine you are in Washington, D.C., and have a sudden onset of severe chest pain radiating to your left arm, diaphoresis, dyspnea, and nausea—you are having an acute myocardial infarction. You call 911, but the nearest hospital to you is in Baltimore, more than 40 miles away. The only emergency medical services (EMS) unit available is transporting a victim from a motor vehicle collision to the trauma center an hour away. EMS will not be able to respond for at least an hour, if not longer. Welcome to the dilemma faced by many rural Americans when their local hospitals have closed.

Ezekiel Emanuel, one of the architects of the Affordable Care Act, predicts that one in five hospitals will close by 2020. In his book Reinventing American Health Care, he wrote, “Long live fewer hospitals. Welcome to the new age of digital medicine.”¹ He also predicted that the first to close would be smaller hospitals, which I interpret as being mainly rural hospitals. It may be the cynic in me, but predictions often come true when they are self-fulfilling prophesies of a well-designed plan.

Trend in Rural Hospital Closures

Whether this is the inevitable fate of rural hospitals or part of a deliberate plan to cut federal spending, the rural hospital closure trend has started. In 2013, 14 rural hospitals closed nationwide, leaving whole communities without sufficient access to emergency care. In Georgia, where I live, four of the state’s 65 rural hospitals have closed over the past two years, with at least 15 more at risk, according to HomeTown Health, an association representing rural Georgia hospitals. The main reasons are financial, due to stressed budgets, shrinking revenue, growing expenditures, and gossamer-thin reimbursements.

When a rural hospital closes, it worsens access. Almost one in five Americans lives in a rural area. For the most part, these people are older, less educated, have more chronic illness, and are uninsured or underinsured. They have less access to specialist care and often must travel long distances to receive it. Sometimes travel out of town is difficult, unaffordable, unavailable, or impossible for them.

These barriers are not just inconveniences; they impact lives. For example, a study from California showed that when distance to the hospital increased, so did death from injury and time-sensitive conditions such as acute myocardial infarction.² Another study from Canada documented increased adverse perinatal outcomes when local hospitals close and travel distances increase.³

Access is not only an issue for local residents. When you travel across the country on our highways to visit families for holidays, take children to college, or visit remote recreation areas, access to care changes along the way and is variable depending upon your destination.

Hospital closures are not just a health care problem. There are economic impacts as well. In addition to providing health care services, rural hospitals contribute to local economies. They bring outside dollars into rural communities and stimulate local purchasing power. They also help attract industry and, in some locations, a steady flow of retirees.

Crucial Importance of Rural Areas

Rural America is not just “flyover country.” Everyone, even those in large metropolitan areas, benefits from the fuel, fiber, and food that America produces. It has been estimated that without rural America’s contributions, you would be paying at least 15 percent more for these products. What would you do without that extra 15 percent in you pocket? Failing to invest in rural America, ignoring the importance of rural America, and disregarding its significance to everyone in the country is foolish and based on ignorance, if not arrogance.

The federal government has historically supported rural hospitals. Since 1997, it designated many as critical access facilities, recognizing that their small size limited their scope of service. Such hospitals received extra federal funding to focus on critical medical services.

Last year, the US Department of Health & Human Services Office of Inspector General recommended that the federal government tighten rules on critical access hospitals to save money. Such a move would likely reduce the number of such facilities by two-thirds.

Funding for the poorest Americans is also changing, with the Affordable Care Act having cut payments for indigent care in anticipation that the impoverished and uninsured would move to Medicaid. However, 23 states have not expanded their Medicaid programs in fear of escalating financial burden. In those states, a gap in federal support for the poor has emerged. Surprisingly, poverty is a greater burden in rural than urban areas, and the ability of small hospitals to absorb losses is far less. Urban and larger facilities can cost shift and offer other services to offset losses, or they may tap local governments for financial support for indigent care. Rural and smaller facilities don’t enjoy the same options or support.

The application of telemedicine to rural emergency care should be explored, developed, and tested, particularly in remote and rural areas. Issues with fair payment and licensure requirements for telemedicine services need to be resolved.

Georgia’s governor, Nathan Deal, is concerned that further hospital closures will cause significant issues with access to care. For this reason, he has created a Rural Hospital Stabilization Committee to explore options. One proposed idea is to allow rural facilities to convert to freestanding EDs. This would allow access to emergency care and treatment for time-sensitive conditions without requiring the presence of a hospital. The hospitals would maintain their Certificate of Need (CON) and could reopen should conditions improve.

This seems a rational option and is worth consideration and our involvement. An emergency physician who is an ACEP member sits on the governor’s committee, and the Georgia College of Emergency Physicians is engaged as well.

Emergency Physicians Need to Be Part of the Discussion

EMTALA, sufficient reimbursement, alternative sources of care, follow-up care, access to specialty consultation, EMS, workforce, and telemedicine are all part of the discussion. It is irrational for us to sit on our hands and await solutions from others without our input. The emergency medicine community should consider access to rural emergency care as a priority advocacy agenda item.

I do agree with Mr. Emanuel on one point: this is an opportunity for telemedicine. The application of telemedicine to rural emergency care should be explored, developed, and tested, particularly in remote and rural areas. Issues with fair payment and licensure requirements for telemedicine services need to be resolved. The ACEP Telemedicine Section was formed in 2011 during the ACEP Scientific Assembly in San Francisco. It is maturing, growing, and working to shape emergency telemedicine for the future.

It seems to me that EMS also plays a heavy role in rural emergency care delivery. How can it be leveraged to improve access? What limitations does it face, and how can these barriers be overcome?

I know emergency physicians care about people and do so regardless of race, gender, age, ability to pay, and wherever they may happen to live. It is our (ACEP’s) obligation to advocate for access to care for rural and remote areas.

We should be aware that public-policy developments may have unintended consequences impacting rural hospitals and our ability to deliver emergency care. Policy makers need to be fully educated about the unique issues and problems faced by rural hospitals and their importance not only to the health of their populations but to the economic vitality of their communities. The value of rural America to the rest of the country must be recognized, and all Americans deserve the same access to emergency care, recognizing emergency medicine as an essential public service.

Dr. Rogers is co–emergency department medical director at Coliseum Health System in Macon, Georgia, and ACEP secretary-treasurer.

References

1. Emanuel E. Reinventing American Health Care. New York, N.Y.: Public Affairs; 2014.
2. Buchmueller TC, Jacobson M, Wold C. How far to the hospital? The effect of closures on access to care. J Health Econ. 2006;740-761
3. Gryzbowski S, Stofl K, Jude Kornelsen J. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Serv Res. 2011;11:147