By Sameer S. Kadri, MD
The implications of a surge in COVID-19 cases due to the Delta variant of SARS-CoV-2 on rural areas of the US and its health care safety net warrant careful and prompt appraisal. In early July, 2 referral hospitals in Missouri that receive patients from the state’s predominantly rural southwestern region experienced a major surge in COVID-19 caseload. In the month since, hospitalization rates have increased sharply in several other states, especially those with largely unvaccinated and rural populations. Whether these increases in COVID-19 hospitalizations portend a 10-, 100-times, or greater hospital surge crisis nationwide will become clearer in the coming weeks. With half the US population fully vaccinated, and assuming the vaccines remain effective for preventing serious disease requiring hospitalization, the nation at large might not encounter another surge with mortality burden of similar magnitude to the third wave. However, the virus has been sufficiently unpredictable to base preparedness on aggregate observations alone.
Many rural counties report that less than 25% of residents are fully vaccinated, raising the likelihood of localized surges in these areas. Multiple small surges throughout rural areas could have important implications for rural populations and hospitals. Rural health care systems in the US have unique organizational, clinical, and financial vulnerabilities that make it more difficult for those hospitals to withstand surges in COVID-19 cases. These vulnerabilities affect care quality and delivery and further impede financial stability. This Viewpoint highlights key vulnerabilities, discusses implications they pose, and suggests potential solutions for institutions, governments, and society as they navigate this potentially rural-dominant Delta variant phase.
Organizational Factors Limiting Surge Readiness in Rural Areas
Among the 5141 nonfederal, short-stay hospitals in the US, 1805 (35%) are designated as rural.1 These rural hospitals are spread across 97% of US land area, yet account for only approximately 1% of all ICU beds in the US, necessitating ultraregionalized critical care. Patients hospitalized with COVID-19 can deteriorate rapidly, potentially stressing available personnel and clinical resources and capabilities, and may require long-distance transfers to other centers. But when the referral centers are overburdened with COVID-19 caseloads, smaller hospitals must care for patients they would normally transfer. Capacity expansion could become imperative even at non-ICU centers.
However, small rural hospitals generally maintain a low census; rapid, massive expansion especially involving seriously ill patients could pose challenges and risks for these hospitals. It is considerably easier to expand from 2 to 10 ventilator beds than it is from none to some, which would require new personnel, expertise, and protocols, not just having ventilators. Such issues are compounded by perennial staffing shortages at many rural hospitals. Organizational vulnerabilities are deep-seated and unlikely to be quickly eradicated by ad hoc rescue funding alone, emphasizing the value of avoiding a surge.
“Rural Excess” Mortality and Pandemic Surges
Hospital survival rates for COVID-19 exemplify what happens when rural health care systems are overstressed. Excess mortality rates in rural (vs urban) areas predate the pandemic, and this mortality difference has worsened in recent years.2 Obesity and poverty are more prevalent among rural populations; chronic diseases that worsen outcomes from COVID-19 are common. Although many rural US hospitals avoided earlier pandemic waves, these areas were affected during the third wave. The COVID-19 death rate peaked at higher levels in rural (vs large metropolitan) counties, with 14-day death rates of 1.39 vs 1.0 per 100 000 people, respectively (eFigure in the Supplement).
Under optimal conditions, the chances of surviving a COVID-19 hospitalization have improved. Nonetheless, a recent study3 of 558 US hospitals, including 112 rural, reported 1 in every 4 COVID-19 deaths attributable to hospitals strained by surging caseloads. This underscores the benefit of avoiding surges and extending support measures such as transferring patients, replenishing supplies, and deploying more staff well before hospitals reach capacity. COVID-19 vaccinations are essential for preventing cases and reducing hospitalizations and deaths, but vaccination must be widely applied for this strategy to be effective. Vaccine uptake has remained low in many rural communities. For example, of all 105 counties in Kansas, only 2 reported more than 50% of residents vaccinated as of July 28, and 50 had vaccination rates below 35%. Misinformation and skepticism around vaccines have been difficult to dispel and political influences underpinning refusal are strong.
Pandemic Stress Compounds Financial Struggles
A key factor determining the ability of a rural hospital to withstand a surge in Delta variant cases is the financial health trajectory of the hospital. Financial struggles are well known to rural hospitals. Most are small, low-occupancy centers that lack parent corporations to absorb losses and depend on government funding to remain operational. Medicare- and Medicaid-dependent hospitals are particularly vulnerable to reductions in reimbursement. Some states that have not participated in Medicaid expansion (a provision that has improved hospitals’ financial stability) also have large rural populations.4 Between 2005 and 2019, 160 rural hospitals closed.5 The pandemic contributed to financial problems in rural hospitals, with temporary suspension of elective procedures and added costs for personal protective equipment, testing, and surge staffing. Twenty-one more rural hospitals closed in 2020-2021, the highest in any year; the number of rural hospitals operating with financial deficits has grown further6 and several remain on the brink of closure.
Timely government funds have enabled some recovery, without which more rural hospitals would have closed. The 2020 Coronavirus Aid, Relief, and Economic Security Act earmarked graduated base payments of $1 to $3 million and 1.97% of operating expenses for each rural acute care hospital to compensate for lost revenue. However, initial allocation was proportional to hospitals’ share of Medicare fee-for-service payments in 2019, limiting how much smaller rural hospitals could receive. Insufficient clarity on spending guidelines early on precluded some hospitals from spending funds received out of fear of having to return them. Subsequent allocations were concentrated among centers with a higher percentage of patients with COVID-19, but as of May 5, at least $24 billion in overall relief funds for health care centers remained unallocated.7
The Delta variant situation in the US is dynamic; responses must be rapid, multipronged, and preemptive rather than reactive. Vaccination must continue to be encouraged as the most powerful means for personal and family protection and for prevention of COVID-19 surges. Vaccination barriers specific to rural areas should be identified. Countermeasures must be acceptable to rural populations; some states view door-to-door vaccine outreach as being coercive. Preventive measures should be championed by trusted community representatives such as primary care clinicians, faith leaders, and social and community health care workers. Promotoras are health educators who serve their Hispanic communities and are being leveraged to encourage vaccination8; this model could be extended to other groups. Younger unvaccinated people must be reminded that they are at risk for SARS-CoV-2 infection and death.
Hospital leaders and administrators in rural areas should ask for help sooner and involve frontline health care workers in that decision. Tertiary centers in neighboring regions could accept overflow patients during a surge and transfer recovering patients back to their originating hospitals, so those facilities could benefit from billing and reimbursement for longer-term care and rehabilitation. Extraordinary efforts might be needed to prevent critical access hospitals and centers that are principal sources of health care and jobs for a rural community from closing. These might include exemptions and deadline extensions on accounts payable and relaxing critical access eligibility criteria.
The federal government has deployed surge response teams to areas severely affected by COVID-19. But the size, composition, and role of these teams will need constant updating to match rapidly evolving surge distribution. If hospital surges worsen in intensity, load balancing (transferring patients so no one hospital is compromised) should be prioritized.3 A network of coordination cells9 of medical operations experts has been established on federal, state, and regional levels to aid this effort. Existing rural trauma transport infrastructure could be maximally leveraged to decompress severely affected and hard-to-reach areas. If hospital surges remain moderate but occur diffusely, more sensitive metrics of hospital strain might be needed to optimize help to smaller centers. One such metric, the surge index,3 in addition to patient counts, considers illness severity and supportive-care needs and the hospital’s baseline bed capacity.
During the pandemic, Congress allocated large sums in relief measures. The recently passed $1.9 trillion 2021 COVID-19 stimulus package10 earmarked $8.5 billion for rural health care centers (including $398 million for hospitals with <50 beds and critical access hospitals) but requires hospitals to apply for funds. Funding should be accompanied by greater clarity on how centers should report and access funds. State-based programs could help rural hospitals navigate these complexities and maximize utilization. Maintenance of bipartisanship in Congress on pandemic relief and ensuring federal and state administrations have a consistent approach around response measures will greatly benefit US residents. Hopefully, these rescue efforts will also pivot into opportunities to work on longer-term solutions. Investments in building rural health care infrastructure, increasing workforce resiliency and incentives, improving broadband access and telemedicine utilization, optimizing air ambulance capabilities, and payment reforms to bolster long-term financial stability of rural microcosms are among a few approaches that will benefit rural US areas well beyond the pandemic.