Bebeto Matthews/The Associated Press
During the onset of the COVID-19 pandemic, the general line of thinking was that urban, densely populated areas would suffer more than sparsely populated rural areas due to the virus’s high transmissibility in areas where people are in close proximity. According to the CDC, however, COVID-19 infection rates in noncore or micropolitan areas – statistical areas that most laypeople would consider to be rural – began outpacing infection rates in large central metropolitan areas by mid-August 2020 and were almost double the large metropolitan rate in November (2020). A variety of social factors, such as the political leanings and socioeconomic status of rural Americans, have been proposed to explain the gap. One undeniable result of this disparity, however, is that rural Americans are getting sicker. This exacerbates a larger, less-obvious epidemic that has bedeviled rural America for a longer time: the decline of rural healthcare services. Simply put, rural healthcare is at a crisis point, and decisive action is needed to fix it.
The roots of the rural healthcare system’s decline lie in a number of factors. First, the United States healthcare network is provided by a patchwork of public and private healthcare systems that provide service to millions of Americans, paid for through a byzantine mix of private health insurance, government-funded healthcare plans such as Medicare and Medicaid, and direct payment. These two realities already burden rural healthcare centers with considerable disadvantages. Rural hospitals have to cover patients over a wider area; although fewer people live in rural areas, the Census Bureau estimates that these areas cover 3.69 million square miles, or 97.3 percent of the nation’s land (2016). To cover this, there are just 1,821 rural hospitals, with each one covering an average service area of 2,000 square miles (American Hospital Association [AHA], 2019). In addition to the distances rural people must travel to receive care, there is also the condition of the population. Americans living in non-metropolitan areas are more likely to die from every one of the top five causes of death in the United States than their metropolitan counterparts. In particular, rural Americans suffer from higher rates of unintentional injury, high blood pressure, hypertension and obesity (Centers for Disease Control and Prevention [CDC], 2017). They are faced with higher rates of heart disease and other chronic diseases (Simpson and Simpson, 1994). These trends are linked to both lifestyle choices such as cigarette smoking and lower rate of physical activity, and socioeconomic factors, including poverty or being uncovered by health insurance – factors that make them less likely to compensate healthcare facilities for the care they may receive. For many racial and ethnic minorities, histories of systemic racism as well as existing prejudices further contribute to these disparities. For example, James et al. found that non-white and non-Asian racial and ethnic minority persons in rural areas were more likely to rate their health as only fair or poor, and less likely to have a primary health care provider or see a doctor due to cost (2017). Black Americans living in rural America are at greater risk, as they are two to three times more likely to die of diabetes or hypertension-related causes compared to their white counterparts (Melillo, 2021). While these factors do not diminish the responsibility of these facilities to care for them, it does raise the operating costs, squeezing budget margins and leaving these hospitals dangerously reliant on Medicare patients and others that can pay to make ends meet.
Figure 1: Mean deaths per 100,000 Americans for the top five causes of deaths in metropolitan and non-metropolitan areas between 1999 and 2014. (Garcia et al., 2017) While metropolitan areas include both urban and suburban areas, non-metropolitan areas are solely rural.
In addition, these issues are exacerbated by a fundamental truth of rural America: its share of the population is both low and diminishing. According to the USDA, non-metro counties have grown on average just once in the last seven years, and that growth was a mere 0.02 percent – hardly a population boom, falling far behind an urban population growth rate that is 30 times higher (Cromartie et al., 2020). All of these primary factors contribute to other problems that stem from a needy population that may not be able to pay. Aging infrastructure is common in hospitals and healthcare systems that lack the capital or financial backers to modernize, while geography and patient-related factors (including a lack of health literacy and poverty) make accessing healthcare difficult. To make matters worse, rural hospitals and rural healthcare providers in general have struggled to find healthcare workers willing to work in these parts of the country. From a healthcare worker’s perspective, working in a rural environment may be one that is not as glamorous or rewarding as working in a major city or world-renowned hospital. Patients require more healthcare services overall, and more general care in particular – a marked difference from the national trend towards more specialized care. Additionally, the educational and career pathways for many physicians do not run through rural areas. Reduced educational opportunities and attainment earlier in life, as well as a dearth of residency positions in rural areas, reduce the number of physicians or healthcare professionals who were raised in rural areas or trained there. This leads to fewer healthcare professionals who have experience with rural patient populations or the willingness to treat them. As a result, rural counties have struggled to find medical professionals to staff their hospitals and set up family practices of the sort that used to provide medical care for a town’s citizens from cradle to grave. In fact, of the 218 counties in America that lack a single doctor, virtually all of them are rural, with only one having more than 15,000 inhabitants (McIntyre, 2020). These counties have tried to compensate doctors with various perks. Both state and federal incentives have been set up. These schemes, however, have not been entirely successful. In 2010, 27 of Texas’s 254 counties did not have a single physician and 16 more had only one physician in the entire county (Ramshaw, 2010). Despite incentivization to work in rural areas, 33 counties in Texas lacked a physician in 2018 – an increase that underlines the difficulty in replacing these medical professionals that provide vital care to rural communities.
While the decline of rural healthcare has been a slow slope, the pace has accelerated considerably over the past decade due to a number of events. First, the passage of the Patient Protection and Affordable Care Act (also known as Obamacare) enacted reforms that had a positive impact on rural healthcare. Expansions of Medicaid via federal grants by some states led to increased revenue and lower rates of
Figure 2: A graph and map detailing the closure of rural hospitals between 2005 and 2020 (University of North Carolina, 2020). On this map, hospitals that closed in 2020 are marked as yellow dots on the map, while blue dots are used on the map to denote hospitals that closed between 2005 and 2019.
uncompensated care in rural hospitals compared to similar hospitals in states that did not expand Medicaid eligibility (Kaufman et al., 2016). Rural patients were signing up for the subsidized health insurance offered by the ACA’s marketplaces as well, further decreasing the number of uninsured patients in these areas (Benitez and Seiber, 2018). The ACA also paid for a number of services, including mammograms, flu vaccines and well-child visits, allowing patients to pay nothing for these services. On the other side of the coin, however, rural hospitals were damaged by relatively low Medicare and Medicaid reimbursement rates, mandated technological upgrades that sapped otherwise needed funds, penalties stemming from new regulations, and high-deductible plans that shifted a higher portion of the bill onto insured patients. To exacerbate this problem, a number of predominantly rural states refused to expand Medicaid, which caused even more financial damage as hospitals bore many of the adverse effects of the ACA without many of the benefits. For example, reduced reimbursement rates for uninsured patients, as noted by researchers at George Washington University, severely affected hospitals in states that refused to expand Medicaid coverage, including North Carolina, Texas and Tennessee (2020). The patients who would have received that insurance were unable to pay their bills instead, passing the costs back to the hospital. The increased financial load was too much for many hospitals to bear. A report from Georgetown University’s Health Policy Institute found that the six states with five or more rural hospital closures were all states that refused to expand Medicaid (Searing, 2018). In these cases, the refusal of the state governments to expand Medicaid almost certainly led to the failure of those hospitals in the new healthcare industry created by the ACA’s passage.
As financial troubles and barriers to care have made rural health care delivery difficult, recent health crises and events have only accelerated the degradation of the rural health care system. The opioid crisis has savaged rural America, with opioid-related deaths increasing by over 700 percent in non-core metro areas over the last 20 years, with the lack of addiction treatment services and less specialized providers contributing to the increased death toll (Rigg et al., 2018). Policy changes undertaken by the Trump administration are also responsible for a more desperate situation, primarily through the attempts of the 45th President’s to repeal and replace the ACA. Under Trump, the mandate requiring Americans to have health insurance was effectively gutted, and states were allowed to place work requirements on Medicaid benefits – two moves that ultimately made health insurance more expensive for patients obtaining coverage through Medicare, Medicaid or the ACA’s health insurance exchanges. These changes undid many of the benefits of the ACA for rural healthcare providers while leaving many of the drawbacks – reduced benefits for treating uninsured patients, high-deductible plans and decreased Medicare payments. This last consequence, in particular, hurt rural hospitals badly, to the point where it was credited by the Government Accountability Office as one of the major reasons why rural hospitals closed down from 2010 to 2019 (2018).
Ultimately, the problems facing rural hospitals prior to 2020 were dwarfed by the emergence of the COVID-19 pandemic, which has sickened over 33 million Americans and killed almost 600,000. Under the CDC’s Social Vulnerability Guidelines, many rural communities were – and still are – considered “highly vulnerable” to COVID-19 (2021). A paper written by Dr. David Peters, a sociology professor at Iowa State University, supports these assertions. Peters notes rural communities often lack easy access to the resources and infrastructure needed to combat a pandemic, including testing materials and laboratories. Additionally, the patient populations of these communities are far more vulnerable to COVID-19. As noted by Peters, an estimate of up to 33 percent of rural counties – defined as having no town with a population greater than 2,500 – are considered “at-risk” in terms of the patient population’s medical condition (2020). Many of these at-risk people live in nursing homes or other long-term care facilities, which proved especially vulnerable to the threat of the coronavirus. Others lived in multi-generation homes with family members who are essential workers, exposing them to another potential route of infection. One example is meatpacking plants in micropolitan settings, which Peters cites as a notable indicator for increased COVID-19 infection rates (2020). These small towns, with a large workforce from the surrounding area working in close proximity, saw major outbreaks emerge from these centers of economic production, as workers became sick at the plant and transmitted the virus to family members at home. This chain of events was particularly devastating to Black and Latinx communities, who are overrepresented in the counties where these plants are located (Taylor et al., 2020). In semi-rural settings, meanwhile, factors from both micropolitan and rural settings put members at risk. Large institutions such as meatpacking plants and long-term care homes, as well as patient populations with considerable health conditions overall, drove infection rates in these settings, ensuring that less densely populated regions of America, regardless of the classification from micropolitan to rural, were inherently at risk from COVID-19.
Figure 3: A breakdown of COVID-19 cases and deaths in rural counties over a span of four months by proximity to livestock plants. (Taylor et al., 2021) The authors analyzed data from counties with livestock plants in 41 states, and categorized each rural county by its proximity to the nearest livestock plant.
In addition to the health risks directly posed by the COVID-19 pandemic, rural areas were challenged by additional factors that negatively impacted their collective health and the state of their healthcare system, and the economic fallout of the pandemic was one of the major stressors on both individuals and the system as a whole. Rural patients are often poorer and less likely to have health insurance, with Black and Latinx people again facing a significant gap in healthcare coverage compared to other racial or ethnic groups (Melillo, 2021). This compounded the effects of the lockdowns ordered to halt the community spread of the virus, which particularly hurt small businesses that needed a steady stream of income to remain viable. While farming and other essential occupations employ a sizable part of the rural labor force, these industries remain vulnerable to local outbreaks as well as constantly shifting supply chains that lead to millions of tons of food and other rural products going to waste unsold. Furthermore, even more rural areas rely on businesses in the outdoor recreation, tourism, and factory work sectors – all affected initially by the pandemic (Mueller, 2021). The financial strain compounded by the stress of living through a pandemic, also led to an increase in both stress and worsening mental health across all Americans, especially among those rural Americans, according to a survey conducted by the American Psychological Association (2020). Rural dwellers often lack access to the mental health and substance addiction services easily accessed in suburban and urban settings, a fact also noted by Peters (2020). These effects led to a backlash in some rural areas, with residents protesting public health measures they viewed as unnecessarily damaging to their local economies and hurting their mental wellbeing, over a virus that may have not reached their town or county. Many people in rural areas distrusted public health information about the pandemic due to a dearth of nonpartisan news sources, a concentration of media control in the hands of ideologically polarized entities, and the distortion of information by these networks to mislead rural Americans (Molinaro and Spjeldnes, 2021). Additionally, many rural Americans – as many as 60 percent in a Washington Post/Kaiser Family Foundation poll – feel as though they are overlooked by national media and that such news sources cannot be trusted wholly.
On top of these concerns, the politicization of the pandemic further muddied the waters. In Kentucky, where Donald Trump won the 2020 general election by over 25 percent, some rural residents initially believed it to be a hoax perpetrated to discredit the Trump administration, while others dismissed it as a “mild” disease that warranted no precautions (Rayes, 2020). This misinformation was particularly problematic in rural areas without access to high-speed internet broadband or other avenues through which verified, scientific information could reach people. The increasing use of social media has played a role in the spread of disinformation in some rural areas, as seen in the case of Morgan County, Colorado (Estes, 2020). There, a local Facebook group became a source of division and disinformation about a number of topics, including the coronavirus, causing discord among residents while also limiting the effectiveness of high quality scientific information. Rural communities often rely on social media sites such as Facebook to conduct business, stay in touch with others, and receive news. In this instance, however, social media was a negative influence on the community, as it led to a spread of disinformation that was repeated across many rural communities during the pandemic. In Illinois, for example, officials in McLean County were forced to refute rumors that the pandemic is a hoax or that COVID-19 had infected residents in late 2019 (Spangler, 2020). These factors have led to a pandemic that has stricken a long-ailing system, leaving it even closer to a catastrophic collapse that would endanger the lives of millions of Americans.
Solving the problems facing rural healthcare and rural hospitals will not be an easy fix, but it is necessary to ensure the survival of a system that too many people depend upon. There is little agreement on how to bring rural healthcare up to the standards of its urban counterpart, however. One train of thought, primarily championed by American conservatives, involves improving rural healthcare services through innovation, private enterprise and many of the mechanisms that drive advancement in other fields. This school of thought eschews large-scale reforms such as a full reorganization of government healthcare systems in rural areas. Instead, the Republican Party’s platform in 2016 (which was adopted again without edits in 2020 due to the coronavirus pandemic) centered on repealing the ACA. In its place, Republicans proposed a draft of measures aimed at the entire healthcare sector, which can be broadly grouped into four areas. On the insurance front, the platform calls for insurance regulation to be devolved to the states, with the federal government reducing its role. Most notably, it calls for the use of block grants for Medicaid, a provision that allows states to set eligibility requirements for Medicaid instead of enrolling all eligible persons in the program. As for private insurance, the platform advocated for insurance portability, arguing that lower insurance costs across state lines would breed competition and lower prices. For individual consumers, the Republican platform endorsed the repeal of the ACA’s mandate on health insurance ownership, transparent pricing for medical procedures, and the repeal of legislation that limited lawsuits against insurance providers. Furthermore, the party vowed to cap damages in medical malpractice suits for medical professionals, a problem that they credited with the declining number of physicians and other healthcare professionals in rural America. Finally, Republicans promised to promote public and private investment in new medical technologies (Republican National Committee [RNC], 2020). A notable exception here is the absence of any language or directive regarding the health disparities that exist along racial and ethnic lines, although the platform did acknowledge elder abuse and age-related discrimination. In any event, the majority of these policy goals had not been achieved by the Trump administration; the American Health Care Act proposed by the Republican Party failed in the Senate, and little legislation of note was subsequently passed. Instead, the policy changes that most affected rural health care came from executive orders, with many being issued in response to the COVID-19 pandemic. An executive order signed in August 2020 expanded telehealth services and improved rural broadband connections while supporting existing rural healthcare services, and Operation Warp Speed – arguably the most successful aspect of the Trump administration’s COVID-19 response – was a private-public partnership of the type envisioned by Republicans in their platform (Association of American Medical Colleges, 2020). Overall, the Trump administration failed to achieve its stated goals to reform the American healthcare system, while also failing to contain the pandemic in both urban and rural settings.
Jeremy Hogan / Echoes Wire / Barcroft Media via Getty Images
If the conservative approach is to favor specific improvements on existing policy while leaving significant reform and improvements to the private sector, the alternative offered by American liberals is a vague promise to do better, with few details to illustrate policy. The Democratic Party’s 2020 platform specifically highlights rural areas as a priority when it comes to incentivizing primary care physicians, registered nurses, and other badly needed health care workers. In addition, the platform makes promises to address the opioid epidemic, expand access to mental health and substance abuse services, and address the socioeconomic circumstances negatively impacting rural people’s health, particularly among groups that have poorer outcomes such as rural Black and Latinx Americans (Democratic National Committee, 2020) However, it lacks substantial detail as to how the party will accomplish these goals or how they can be achieved. Furthermore, there is debate among scholars as to the effects of a single-payer healthcare system – often known as “Medicare for All” – on rural healthcare providers. A number of rural hospital administrators stated that such a system would reduce their revenue due to the loss of private insurers who pay more for services, while the Congressional Budget Office found that revenue for rural hospitals would actually increase (O’Dowd, 2021). With President Joe Biden in office, the reforms that he and a Democrat-controlled Congress plan to make have been sidelined by the urgency of the pandemic. The American Rescue Plan Act, President Biden’s response to the crisis, includes USD 500 million in grants earmarked for “need-based grants to facilities that primarily serve rural areas.”(Fry et al. 2021) While this represents a considerable investment, it represents less than 0.03 percent of the relief package’s estimated USD 1.9 trillion price tag. While there are other appropriations that affect rural residents, including USD 47.8 billion for COVID-19 testing and mitigation efforts and USD 7.66 billion to improve local and state public health apparatuses, the priorities of this bill do not include plans to rebuild the rural healthcare system that millions of Americans depend on. Another piece of legislation would be needed to address the issue – one that would most likely face significant hurdles in a deeply partisan Congress where some of the more economically and fiscally liberal proposals would be shot down by conservatives and centrist Democrats alike. In this environment – and with a number of more politically pressing issues facing the new administration, the Democratic Party appears as if it will struggle to do more than roll back the previous administration’s efforts to defund Medicare and break down the Affordable Care Act when it comes to repairing the rural healthcare system.
The rural healthcare crisis is one that has silently impacted millions of Americans. A combination of risk factors among the populations, chronic financial instability, governmental neglect and rising challenges that went unmet created a situation that deteriorated rapidly in the face of the largest pandemic since the Spanish Flu. The results have been devastating, with a recent report by the consulting firm McKinsey & Company estimating that the rural mortality rate now exceeds that of urban areas in the United States by almost 16 percent (Bradford et al. 2021). In the ashes of the pandemic, however, there is a chance for significant reform. Both sides of the political aisle have shown some support for investing in rural healthcare initiatives, and the present administration is in a strong position to use its political capital to push such proposals in future legislation. The only question that remains is whether change in the form of increased investment in new technologies, improved healthcare infrastructure, or an overall restructuring of the American health care system will come to America’s rural hospitals, clinics, nursing homes, and other healthcare facilities. The toll of the prior inaction is a sobering reminder of how much is at stake and what could be lost without an honest effort to serve a population often forgotten yet no less deserving of the quality health care that other Americans enjoy.
American Hospital Association. (2021, January). Fast Facts on U.S. Hospitals, 2021. https://www.aha.org/statistics/fast-facts-us-hospitals
American Psychological Association. (2020, October 20). Stress in America 2020 Survey Signals a Growing National Mental Health Crisis. https://www.apa.org/news/press/releases/2020/10/stress-mental-health-crisis
Association of American Medical Colleges. (2020, August 7). Trump Signs Executive Order on Improving Rural Health and Telehealth Access. https://www.aamc.org/advocacy-policy/washington-highlights/trump-signs-executive-order-improving-rural-health-and-telehealth-access
Benitez, J. A., & Seiber, E. E. (2018). US Health Care Reform and Rural America: Results From the ACA's Medicaid Expansions. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association, 34(2), 213–222. https://doi.org/10.1111/jrh.12284
Bradford, J., Coe, E., Enomoto, K., & White, M. (2021, March 10). COVID-19 and rural communities: Protecting rural lives and health. McKinsey and Company Healthcare Systems and Services. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/covid-19-and-rural-communities-protecting-rural-lives-and-health
Centers for Disease Control and Prevention. (2017, August). About Rural Health. https://www.cdc.gov/ruralhealth/about.html
Centers for Disease Control and Prevention. (2020, November 20). COVID-19 Stats: COVID-19 Incidence, by Urban-Rural Classification — United States, January 22–October 31, 2020. Morbidity and Mortality Weekly Report (MMWR). DOI: http://dx.doi.org/10.15585/mmwr.mm6946a6
Centers for Disease Control and Prevention. (2021, May 4). Rural Communities. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/other-at-risk-populations/rural-communities.html
Democratic National Convention (49nd : 2020 : Milwaukee, Wisconsin). (2020). 2020 Democratic Party Platform. https://www.demconvention.com/wp-content/uploads/2020/08/2020-07-31-Democratic-Party-Platform-For-Distribution.pdf
Estes, C. (2020, March 17). How the COVID-19 Coronavirus Pandemic is Impacting Rural America. Forbes https://www.forbes.com/sites/claryestes/2020/03/17/coronavirus-and-rural-america/?sh=40fc2a36e108
Fry, T., Kennan, S., Marty, K. M., Ray, A., & Timmerman, A. (2021, March 2). U.S. House Passes American Rescue Plan -- 15 Provisions for Health Care Providers. JDSUPRA. https://www.jdsupra.com/legalnews/u-s-house-passes-american-rescue-plan-1846138/
George Washington University School of Business. (2020, November 5). How the Affordable Care Act is Impacting Communities. https://healthcaremba.gwu.edu/blog/how-the-affordable-care-act-is-impacting-communities/
James C. V., Moonesinghe R., Wilson-Frederick S. M., Hall J. E., Penman-Aguilar A., & Bouye K. (2017, November 17). Racial/Ethnic Health Disparities Among Rural Adults — United States, 2012–2015. MMWR Surveill Summ 2017, 66(No. SS-23), 1–9. DOI: http://dx.doi.org/10.15585/mmwr.ss6623a1
Kaufman, B.G., Reiter, K.L., Pink, G.H., and Thomas, G.M. (2016, September). Medicaid Expansion Affects Rural And Urban Hospitals Differently. Health Affairs, 35 (9). https://doi.org/10.1377/hlthaff.2016.0357
McIntyre, D. A. (2020, April 23). Amid coronavirus pandemic, these 218 mainly rural communities do not have a single doctor. USA Today. https://www.usatoday.com/story/money/2020/04/23/coronavirus-pandemic-218-us-rural-counties-without-a-single-doctor/111582818/
Melillo, G. (2021, March 15). 20-Year Data Highlight Little Progress in Rural Racial Health Disparities. American Journal of Managed Care. https://www.ajmc.com/view/20-year-data-highlight-little-progress-in-rural-racial-health-disparities
Molinaro, J., & Spjeldnes, S. (2021, February 1). The Electoral College and the Rural-Urban Divide. Aspen Institute. https://www.aspeninstitute.org/blog-posts/the-electoral-college-and-the-rural-urban-divide/
Moy E., Garcia M.C., Bastian B., Rossen, L.M., Ingram, D.D., Faul, M., Massetti, G.M., Thomas, C.C., Hong, Y., Yoon, P.W., & Iademarco, M.F. (2017, January). Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014. MMWR Surveill, 66(No. SS-1), 1–8. DOI:http://dx.doi.org/10.15585/mmwr.ss6601a1.
Mueller, J.T., McConnell, K., Burow, P.B., Pofahl, K., Merdjanoff, A. A., & Farrell, J. (2021, January 5). Impacts of the COVID-19 pandemic on rural America. Proceedings of the National Academy of Sciences, 118 (1). DOI: 10.1073/pnas.2019378118
O’ Dowd, P. (2019, August 16). Rural Hospitals Say ‘Medicare for All’ Would End Up ‘Closing Our Doors’. WBUR. https://www.wbur.org/hereandnow/2019/08/16/rural-hospitals-medicare-for-all-health-care
Peters, D. J. (2020, May 19). Community Susceptibility and Resiliency to COVID-19 Across the Rural-Urban Continuum in the US. Journal of Rural Health, 36(3), 446-456. https://doi.org/10.1111/jrh.12477
Ramshaw, E. (2010, January 7). No Country for Health Care, Part 4: Rural Recruitment. Texas Tribune. https://www.texastribune.org/2010/01/07/tough-to-recruit-doctors-in-rural-texas/
Rayes. A (2020, September 8). During the pandemic, social media can be an information lifeline for rural communities. Marketplace. https://www.marketplace.org/shows/marketplace-tech/during-the-pandemic-social-media-can-be-an-information-lifeline-for-rural-communities/
Republican National Convention (42nd : 2020 : Charlotte, North Carolina). (2020). Platform of the Republican Party, 2020. https://prod-cdn-static.gop.com/docs/Resolution_Platform_2020.pdf
Rigg, K. K., Monnat, S. M., & Chavez, M. N. (2018). Opioid-related mortality in rural America: Geographic heterogeneity and intervention strategies. The International journal on drug policy, 57, 119–129. https://doi.org/10.1016/j.drugpo.2018.04.011
Searing, A. (2018, October 29). More Rural Hospitals Closing in States that Refuse Medicaid Coverage Expansion. Georgetown University Health Policy Institute Center for Children and Families. https://ccf.georgetown.edu/2018/10/29/more-rural-hospitals-closing-in-states-refusing-medicaid-coverage-expansion/
Simpson, C., & Simpson, M. (2014, June) Complexity of the healthcare crisis in rural America. Journal of Osteopathic Medicine, 94(6), 502-508. file:///C:/Users/guhan/Downloads/502.pdf
Spangler, H. (2020). Are rural areas abandoning COVID-19? Corn and Soybean Digest. https://ezproxy.bu.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Ftrade-journals%2Fare-rural-areas-abandoning-covid-19%2Fdocview%2F2416835994%2Fse-2%3Faccountid%3D9676
Taylor, C. A., Boulos, C. & Almond, D. (2020, December 15.). Livestock Plants and COVID-19 Transmission. Proceedings of the National Academy of Sciences of the United States of America, 117(50), 31706-31715. https://doi.org/10.1073/pnas.2010115117
United States Census Bureau. (2016, December). New Census Data Show Differences Between Urban and Rural Populations. https://www.census.gov/newsroom/press-releases/2016/cb16-210.html
United States Department of Agriculture Economic Research Bureau. (2020, December). Rural America at a Glance: 2020 Edition. https://www.ers.usda.gov/publications/pub-details/?pubid=100088
United States Government Accountability Office. (2018, August 29) Rural Hospital Closures: Number and Characteristics of Affected Hospitals and Contributing Factors. https://www.gao.gov/products/GAO-18-634#summary
University of North Carolina Cecil G. Sheps Center For Health Services Research. (2020). Rural Hospital Closures. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/