Last February, a child with no prior history had a severe allergic reaction in a rural North Carolina middle school. EMS promptly responded and per the parent’s request, initiated transport to a large medical center in Durham, more than 30 minutes away. En route, the child’s vital signs crashed. A choice had to be made. Paramedics diverted to the closest hospital only minutes away in Roxboro. At our emergency department, she required multiple medications and supportive measures to save her life.
In a critical moment like this, time matters. In rural communities like mine, the local hospital is often the only place to turn in a medical emergency. But across the country, that lifeline is under growing strain.
More than 60 million Americans live in rural communities, many of whom face persistent challenges accessing primary care. This creates pressures on rural hospitals and the clinicians that serve patients. On any given shift, a small team may treat traumatic injuries, heart attacks, and complex medical conditions, often back-to-back. Clinicians wear many hats, caring for emergency patients, supporting inpatient care, and filling critical staffing gaps wherever they are needed.
The financial reality of rural healthcare is just as sobering. Rural hospitals must remain ready to treat emergencies around the clock, even when patient volumes are unpredictable and reimbursement continues to decline. Further, rural areas have higher uninsured rates and rely more heavily on Medicare and Medicaid, which reimburse at lower rates. Between 2005 and 2023, 146 hospitals in rural U.S. counties closed or were converted to non-acute care, a staggering loss for these communities, including 64 in the Southeast region.
These structural challenges directly affect patients. Many rural Americans delay care due to distance, cost, or lack of access to specialists or preventive services. As a result, rural Americans disproportionately suffer from higher rates of chronic disease and preventable illness. In 2022, potentially preventable deaths in rural America included 20,000 from heart disease and stroke, 6,000 from cancer, 10,000 from unintentional injuries, and nearly 6,000 from chronic lower respiratory disease. Patients arrive at the hospital sicker and later in the course of disease, consequences of a system stretched too thin for too long.
Rural health care is now at a crossroads. Last year, Congress approved $50 billion to strengthen rural care through the One Big Beautiful Bill Act, with funding aimed at stabilizing struggling hospitals, strengthening the healthcare workforce, expanding telehealth technology, and addressing chronic disease. These investments are important, but they come at an uncertain time. Affordable Care Act tax credits that help people maintain coverage are expiring, and Congress has adopted significant cuts to Medicare and Medicaid. As more people become uninsured, routine care will be delayed, increasing reliance on emergency departments.
Rural hospitals must adapt to this reality. In my work with a rural hospital in North Carolina and with TeamHealth, a national network of clinicians that supports hospitals, we have focused on making care delivery more efficient so clinicians can see more patients without compromising quality. We have expanded telehealth and adopted tools to help hospitals manage patient flow. These efforts to prioritize metrics that improve access, safety, and patient experience can serve as a template for rural healthcare leaders. Small but meaningful improvements in areas like door-to-provider time, length of stay, left without being seen rates, and patient satisfaction can make a real difference in the lives of rural patients.
I often think about the child whose life was saved, and the hundreds of children who require immediate, lifesaving care every day. For millions of Americans, the local hospital is not just a healthcare facility. It is a lifeline. Rural communities deserve reliable access to care. The future of rural healthcare will depend on the choices we make now. For the patients and communities who rely on these hospitals, those choices could not be more important.
Nadine McGraw is a physician assistant with nearly 20 years of experience across emergency medicine, hospital medicine, urgent care, and primary care currently serving as a facility medical director and advanced practice clinician director at TeamHealth.
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