The unique challenges of rural aging in America are close to home in Northern Iowa, where we live.

Rural Hospitals on the Brink

Nearby, Southwestern Minnesota recently lost a rural critical access hospital. Many more rural hospitals across flyover country are on the edge of bankruptcy. This is due to the combination of interrelated reasons. Inadequate Medicare payment rates for rural states top the list. Dire provider shortages exacerbate the challenge. Nineteen rural hospitals closed in 2019. 2019 Was a Rough Year for Rural Hospitals At risk are 430 more rural hospitals. Hospital Closures in Rural U.S. Reach a Crisis Point Blame the Centers for Medicare and Medicaid Services (CMS). CMS oversees the two big government healthcare programs. CMS assumes it is less expensive to deliver care in rural areas.

Since 2005, at least 163 rural hospitals have closed, more than 60% of them since 2012.

Pew charitable Trusts

Rural Healthcare is more expensive

The exact opposite is true. It costs more to deal with rural distances and low volume. And rural areas lack a large employer with high-income employees on which to shift costs. Modern providers expect a premium to practice away from urban medical centers. Providers enjoy all the toys in urban centers. And the clubby companionship of peers. It’s hard to give all that up for less pay in rural America. Frontier and Mountain states are even worse off than farm country.

Specialist Needed for Rural Aging often Hours or Days Away

The healthcare system focuses on sick-care. And not wellness or prevention. This wrong focus skews provider compensation towards specialist procedures. And funds access in favor of urban areas. For instance, look at mental health. We have entire mental health and legal systems built around psychiatrists. And yet psychiatrists might as well be mythical creatures in most rural communities. Other chimeras in rural healthcare? Emergency Room physicians, gerontologists, and cardiologists. Every medical specialist that matters to rural elderly are hours or days away. And the general practitioners? They are fading Cheshire cats. The long wait times for appointments make the urban VA hospitals look good.

Some States compound their problem

Low State Medicaid reimbursement rates and the scope of coverage also contribute to the problem. Many states did not expand Medicaid coverage under the ACA. But the people still need care. More Rural Hospitals Closing in States Refusing Medicaid Coverage Expansion

Medicare Coverage is often in Name Only for Rural America

The ACA (Affordable Care Act) didn’t help. The ACA seems more to have changed who lacks access and coverage rather than how many. It especially disadvantages rural, working poor. The rural working poor experience unaffordable high insurance deductibles. And continued runaway medical inflation. On top of poor access. Think it doesn’t matter to you? Do you like to eat? It matters. The rural elderly have more affordable Medicare coverage. But again, it’s coverage in name only without rural providers or practical access to care.

Low cost-of-living without healthcare?

Retiring Baby Boomer providers and patients are only going to make this gap worse. Welcome to the future.

It’s a factor to consider when planning future downsizing and/or geo arbitrage. Low cost-of-living isn’t everything. When choosing where to retire? Access to care and the cost of care as a retiree must also be considered.

The Future of Rural Health Care?

Emerging new technologies will help. But not overnight. Telehealth and big data predictive analytics promise improvement. Combine these with remote monitoring. The future will enable far better prevention and early intervention. New technology is essential to solving this dilemma. But technology demands CMS approve paying for new channels and modalities of care. And CMS must focus payments earlier in the care cycle. This is where the greatest opportunities are for better outcomes. Especially for rural Americans.


Rural Medical Students Make Up 4.3% of Future Docs, Study Finds (12/6/2019). A study shows decreases in the number of rural medical student applicants and matriculants from 2002 to 2017, leading to low representation and possible physician shortage issues. The finding may indicate “a growing mismatch between the qualifications of rural applicants and medical schools’ admissions priorities.” Because growing up in a rural setting is a strong predictor of future rural practice, underrepresentation of medical students from this background spells trouble for the physician-starved communities, researchers added.

Rural America’s Health Crisis Seizes States’ Attention — Pew Charitable Trusts (1/31/2020): Michael Ollove