We have seen hospitals filled, high daily death tolls, and exhausted healthcare workers in large cities, like New York and Seattle. How will COVID-19 affect rural America? 
While initially many rural Americans felt protected by nature of their location, they are now feeling the effects of COVID-19 close to home. Small towns may serve as safe havens at the beginning of a pandemic. However, their residents are often disproportionally affected later in terms of access to medical care, geographical isolation, health equity, and slightly higher rates of some harmful health behaviors (such as higher smoking rates). In fact, most Americans living in these areas are older and less healthy than Americans in urban areas. The combination of these comorbidities and less access could be detrimental to rural communities in the face of a pandemic.
What are the risks?
According to the CDC, rural citizens have higher rates of high blood pressure, obesity, and cigarette smoking – all of which have been correlated with poor clinical outcomes or death when coupled with COVID-19 infection. In conjunction with common comorbidities of this population, the average age of a rural American is 73.3 years [pdf]. Those with advanced age have shown to have significantly higher mortality rates compared to younger people, as the elderly accounted for nearly 80% of fatalities in China and the U.S.
Access to medical care in rural areas is a barrier that ultimately deprives small communities of adequate healthcare, including care necessary to treat and prevent infectious diseases like COVID-19. Patients may have to travel long distances to seek care from a healthcare provider or an emergency room. Before the pandemic, many rural hospitals were already struggling to stay afloat, both in terms of finances and resources. Rural health facilities already have fewer healthcare workers, medical supplies, and tests before hitting their projected COVID-19 peak. These pre-existing shortages may lead to fewer replacements for healthcare professionals who become sick and undiagnosed cases amongst community members. Some of these shortages are already being felt in areas like Idaho, Wyoming, and South Dakota.
What can we do?
Forty-one states have enacted state-wide shelter-in-place orders or state closures in hopes of decreasing community transmission. The remaining nine states have resisted such closures and are all predominately rural states in the Midwest. One such state’s governor justified the decision to not mandate closures by stating it is a one-size-fits-all approach. As a result, Midwest residents have noticed out of state travelers in their state often seeking refuge or shopping at stores that remain open. Some tribal governments, like the Oglala Sioux Tribe in South Dakota, have heeded other states’ warnings and issued travel bans of their own, despite their state remaining open.
So how can rural Americans protect themselves during this pandemic? The Department of Health and Human Services has relaxed some patient privacy laws to make telemedicine more accessible to Americans, particularly in rural and frontier communities. Certain facility types that provide care to the most vulnerable, like Federally Qualified Health Centers and Medicare-certified Rural Health Clinics, should note that regulatory and billing variations exist in the delivery of telehealth services [pdf]. The use of telemedicine will be paramount to these rural areas, as it will reduce the need for patients to travel or risk unnecessary exposures. Healthy individuals should take extra care to ensure the most vulnerable rural populations – the elderly and those with multiple comorbidities – are given the utmost protection by ensuring they do not come into contact with anyone who is sick. Because local governments haven’t been unanimous in the decision to issue closures, it is important for everyone to take personal responsibility so our hospitals do not become overrun as a result. Those living in rural areas can protect their health and the health of their communities by following CDC guidelines, staying at home, and practicing social distancing.
Note: This post was edited after publication to provide updated policy information on telemedicine reimbursements for some providers.
Tiffany Johnson