You can’t follow news about healthcare without seeing daily headlines about inequities in medical outcomes. Minority groups, whether divided by skin color, place of origin, religion, or legality of residence, are reported as having inferior health status and medical outcomes compared to majority white populations. There is an entire agency, Health Equity Education Center, devoted to studying these minority disparities.

Yet, there is a greater inequity in medical outcomes that gets little play in the press: the urban-rural disparity. NPR recently called this a “crisis.” And it is, just not acceptable headline material for most Washington-complicit media.

In 1960, the state of Texas had 325 rural hospitals, most were quite small with 25–50 beds. All had emergency rooms. Despite a population growth from 9.6 million in 1960 to 30.5 million today, Texas has fewer than 150 rural hospitals. Most have limited emergency facilities; many have none. Nationally, 136 rural hospitals closed from 2010 to 2021 adding these towns to the increasing number of “medical deserts.” Sporadically, there are solo physicians or nurse practitioners in these areas but no emergency facilities.

In Dallas, Texas, the average maximum wait time for a new patient appointment with a primary care physician in 2017 was 12 days. In a small city like Albany, NY, the maximum wait then was a medically unacceptable 122 days. Obviously in rural medical deserts, the wait time is, well, forever.

Washington and the complicit media don’t expend much airtime on the urban-rural inequity, probably because the federal government is largely responsible.

This unsung inequity stems from federal payments, what are called allowable reimbursement schedules. While these directly determine payments for Medicaid, Medicare, and Tricare enrollees, private insurance companies tend to follow these payment schedules or face the wrath of Washington and/or their shareholders. So, Washington effectively dictates all U.S. medical payments.

The payment for delivering care is generally less than the cost of doing business. With rural hospital annual financial losses of 9% to more than 20%, closures are inevitable and ongoing. Those that remain open despite ongoing losses of at least 5% do so through supplemental revenue from local taxes, bond issues, or state grants.

There are also the financial losses mandated by EMTALA (Emergency Medical Transport and Labor Act of 1986). Any person who enters a hospital that receives funds from Washington — virtually all U.S. hospitals, both rural and urban — and who needs urgent medical services must be given medical care, even if the hospital never gets paid for said care. Such persons are daily occurrences in U.S. hospitals.

The influx of more than seven million illegal migrants during the Biden administration has had an additional massive negative financial impact on communities located on or near the southern border. First, these individuals are usually in ill health and needing urgent care, exacerbating hospital losses. Second, they need social services such as food, housing, and education for children. This takes money from the tax base leaving no funds to supplement the hospitals.

Urban hospitals, especially large university medical centers, can survive the losses incurred by low payments for direct care while rural hospitals cannot, for two reasons. The large institutions have many expensive technologies such as MRI scanners and ultrasound machines where payment is considerably greater than cost. Without such advantages, rural hospitals have no profits from tests to make up for losses from care delivery.

Large urban hospitals have a second funding source unavailable to small rural institutions: research grants. Such grants are in the millions, even billions of dollars. NIH grants typically have a 40% overhead expense (sometimes higher) built into the grant. While some of this amount is necessary to pay for research lab overhead, much of it can be diverted to defray losses from care delivery. Washington never sees a report that shows a hospital did this.

The solution is obvious and politically radioactive given the power of numerous special interests through lobbyists with their campaign contributions.

Pay more for care delivery and less for fancy tests. Like that is going to happen!

So, rural Americans, in their millions, suffer death by queue — dying while waiting for technically possible care that never comes — while their urban brethren have general doctors, specialists, and subspecialists (like this pediatric cardiologist author) at their beck and call.

Deane Waldman, M.D., MBA is Professor Emeritus of Pediatrics, Pathology, and Decision Science; former Director of the Center for Healthcare Policy at Texas Public Policy Foundation; former Director, New Mexico Health Insurance Exchange; and author of 12 books including multi-award winning, Curing the Cancer in U.S. Healthcare: StatesCare and Market-Based Medicine.

Image: Free image, Pixabay license.