Rural Americans are especially vulnerable to the coronavirus pandemic due to higher prevalence of pre-existing conditions, lower coverage rates, and other barriers to accessing health care. As the virus has spread, rural communities are now facing severe outbreaks, overwhelming hospitals that were already vulnerable before the pandemic. Through his failed coronavirus response and attacks on the Affordable Care Act (ACA) and Medicaid, President Trump is only fueling this crisis in rural America. 

Rural Health: By The Numbers

  • More Than 120 Rural Hospitals Have Closed Since 2010. A record 18 rural hospitals closed in 2019, and 14 closures have been reported so far in 2020. The vast majority closed in states that had not expanded Medicaid at the time of the hospital closure.
  • 430 Rural Hospitals Were Already At A High Financial Risk Of Closing Before The Pandemic. This represents roughly 21 percent of the country’s rural hospitals. 
  • More Than Half Of All Rural Low-income Communities In The U.S. Have Zero ICU Beds. A study published in Health Affairs found that on average, even the poorest urban areas had more ICU beds per capita than the wealthiest rural areas.
  • Rural Hospital Closures Are Associated With A 6 Percent Increase In Death Rates In Surrounding Counties. Rural hospital closures were associated with a 5.9 percent increase in death rates in surrounding counties according to researchers from the University of Washington. The study was published before the pandemic. 
  • Rural Hospitals In Medicaid Expansion States Are 62 Percent Less Likely To Close. 75 percent of vulnerable rural hospitals are in non-expansion states. 
  • The Affordable Care Act Led To A $12 Billion Reduction In Uncompensated Care Costs. Between 2013 and 2015, hospitals’ uncompensated care costs decreased by $12 billion, or roughly 30 percent. The majority of this reduction was concentrated in states that chose to expand Medicaid. 
  • Medicaid Covers Nearly One In Four Rural Americans. Medicaid covers nearly 24 percent of rural Americans, 45 percent of rural children, 15 percent of rural seniors, and pays for 51 percent of rural births. 
  • Nearly 1.7 Million Rural Americans Gained Coverage Through Medicaid Expansion. Thanks to the ACA, nearly 1.7 million rural Americans gained Medicaid coverage. The uninsured rate for low-income adults dropped from 35 percent to 16 percent in rural areas and small towns in states that expanded Medicaid. 
  • In 2017, Nearly 1 In 5 Marketplace Enrollees Lived In Rural Areas. 1.6 million enrolled in ACA coverage lived in rural areas in 2017. 
  • 1 In 3 Rural Adults Report Issues Affording Medical Bills. A survey published in January 2020 found that 32 percent of rural adults reported problems paying medical bills even before the pandemic. 

How Trump and His Republican Allies Are Failing Rural Communities

Rural Hospitals Got Shortchanged In Initial Round Of Relief Funds. Even before the pandemic, hundreds of rural hospitals were on the brink of closing. The situation became more dire as rural hospitals needed to quickly obtain supplies and personal protective equipment to fight the pandemic — all while they lost significant revenue from elective procedures. By basing hospital relief on its Medicare payments, federal relief funds initially excluded many rural hospitals. After receiving widespread criticism, Trump’s HHS announced in late April that it would carve out $10 billion for rural health clinics and hospitals, but these funds are running out. Additional aid came in the form of Medicare loans, but rural health providers fear they could be on the hook for paying back the money even as cases and hospitalizations rise in rural communities. 

Trump And GOP Senators Are Refusing To Pass Additional Relief. In May, the House passed the Heroes Act, landmark legislation that provides more than $1 trillion to state, local, territorial and tribal governments to pay vital workers like first responders, health workers, and teachers. Additionally, the legislation allocates $75 billion in funding for testing and contact tracing, including provisions to specifically serve rural communities. Heroes also guarantees free coronavirus treatment without cost-sharing, opens a special enrollment period for the uninsured to gain coverage through the ACA marketplace and increases in federal funds to support state Medicaid programs. Months later, Senate Republicans have refused to negotiate and failed to vote on this essential relief. 

Trump Has Continued His War On Medicaid. The Trump administration has worked tirelessly to dismantle Medicaid, particularly through his efforts to impose enrollment barriers and red tape. After Arkansas imposed the nation’s first so-called work requirements program, more than 18,000 residents lost Medicaid coverage. While these state efforts have been blocked by a federal judge several times, the Trump administration keeps fighting to impose work reporting requirements in Medicaid, appealing federal court rulings that blocked such requirements because they are illegal. Meanwhile, a recent GAO report found that the administrative costs to implement the failed work requirement programs in five states topped $400 million. Additionally, Trump has repeatedly sought cuts to the program, most recently in his 2021 budget, which called for more than $1 trillion in cuts to the ACA and Medicaid. 

Red States Have Blocked Medicaid Expansion. As the nation faces this unprecedented health care crisis, Medicaid expansion is especially important for reducing uncompensated care costs and protecting rural hospitals from financial peril. Medicaid expansion is a critical part of our response to coronavirus, but Republicans in 12 states have rejected expansion, blocking an estimated two to four million people from gaining Medicaid coverage. All of these states are in the southern and midwest regions with significant rural populations. While Democrats have proposed incentivizing these holdout states to expand Medicaid in response to the pandemic, these efforts have been blocked by Senate Republicans. 

Trump Is Still Trying To Overturn The ACA. Trump notoriously tried and failed multiple times to repeal the Affordable Care Act. All of the repeal bills that went through Congress would have caused millions of Americans to lose their health coverage and raised costs for millions more. Now the Trump administration has thrown its full support behind a lawsuit that would do the same. If the Republican lawsuit is successful, more than 20 million Americans will lose their coverage and more than 135 million people will lose protections for pre-existing conditions, including the millions of Americans who contracted the coronavirus. The lawsuit would also terminate Medicaid expansion, which covers 15 million people and provides important funding for already-struggling rural hospitals during the pandemic. The lawsuit will be heard one week after the election.

President Trump’s Failure to Control Coronavirus Allowed It To Spread To Rural Communities, Overwhelming Already-Vulnerable Hospitals

The Third Wave Of Coronavirus Has Hit Rural Areas Especially Hard. In contrast to the spring, when the virus was spreading rapidly in urban areas, rural counties are now bearing the brunt of the pandemic. America’s most rural areas are currently seeing twice as many new cases per-capita as the nation’s biggest cities, while about one in four COVID-19 deaths are occuring in rural areas. Rural hospitals are especially ill-prepared for surges in patients, as they have little staff and specialized equipment like ventilators. More than half of hospitals in rural areas have no ICUs. Hospitals are easily becoming overwhelmed, and critically ill patients are being forced to travel miles, sometimes out of state, to receive care. Rural areas also have populations that are older and sicker, meaning that a higher proportion of people who contract the virus will end up in the hospital.

  • The Virus’ Resurgence In Texas Is Stranding Acutely Ill Patients In Rural Areas. As large hospitals in Texas cities like Lubbock and El Paso are becoming overwhelmed by coronavirus patients, smaller rural facilities have nowhere to transfer those who are critically sick. Hospitalizations in Texas are up more than 75 percent since the beginning of October. Bigger facilities are out of staff and beds — so rural hospitals have nowhere to send patients experiencing other life-threatening emergencies, like heart attacks or strokes. Rural hospitals’ emergency rooms have also been stretched so thin that patients with COVID-19 are waiting in their cars. 
  • Rural Areas In The Midwest Are Being Ravaged By COVID-19. On October 29, Illinois, Minnesota, North Dakota and Ohio all reported record highs for new cases in a day. Rural areas in Minnesota are “lit up with cases.” Since the beginning of October, the 10 Minnesota counties with the biggest increase in cases are all in rural parts of the state. Wisconsin is on track to run out of ICU beds, and nurse capacity, in “as little as two weeks.”

Shortages Of Cash And Supplies Make It Harder For Rural Areas To Respond To The Crisis. According to Stateline, “forty-eight percent of rural hospitals have negative operating margins, and the median number of days of cash on hand for all rural hospitals is less than 33.” Many facilities also lost revenue during the first wave of the virus when they were forced to cancel elective procedures. As the administration failed to ramp up supplies of tests and PPE, rural hospitals on shoe-string budgets had to compete with larger health systems and states for access to protective supplies. This problem persists: with the virus still raging, the propensity of larger systems to stockpile this gear has meant that rural clinics are desperate for supplies. Meanwhile, rural hospitals have struggled to ramp up testing. Many can’t afford their own testing labs, so they’ve been forced to send samples to commercial labs that are experiencing delays. Amid the constant financial problems that plague rural facilities, at least 15 rural hospitals have closed in 2020.

Rural Residents Are Experiencing Serious Financial And Health Hardships As A Result Of The Pandemic. More than 40 percent of rural families have reported that, since the pandemic broke out, at least one person in their family had lost a job, been furloughed, or had wages or hours reduced. More than half of rural families have reported having a hard time caring for their children. Meanwhile, one in four rural households have been able to get medical care for serious health problems amid the pandemic, while half of those have reported that a family member experienced serious consequences as a result.