Rural residents who are Black or American Indian or Alaska Native are more likely to live further from a hospital than white rural residents, according to a new study.
Researchers used ZIP code tabulation areas (ZCTAs) to determine areas with the highest rates of minority and white communities and relied on provider location data from the American Hospital Association (AHA) and the Centers for Medicare and Medicaid Services (CMS). Researchers then measured distances to the nearest emergency rooms, trauma care, obstetrics, outpatient surgery, intensive care and cardiac care.
The study was conducted by a research team at the University of South Carolina and led by Jan Eberth, Ph.D., associate professor and director of the rural and minority health research center. It appears in the February volume of Health Affairs, an issue that focuses on racism and healthcare.
There are clear spatial trends among Black communities in the South, Hispanic communities in Texas and the West and American Indian/Alaska Native communities in Oklahoma, the upper Midwest and West, the study found. Rural areas with high Black or American Indian/Alaska Native representation were significantly farther from healthcare services than rural areas with high White representation, the study authors wrote.
For areas with a large share of minoritized racial and ethnic populations, the longest distances to emergency and ICU care are concentrated along the northern border of Arizona, in southwest Alabama and in parts of South Dakota, New Mexico and Texas.
Rural areas high in minority groups in the Midwest have consistently longer median distances to all hospital services. Rural areas in the West, regardless of racial and ethnic groups, had the longest median distances to all service types, the study found.
However, the data also showed that urban areas high in minority groups had shorter distances to all services than those areas with a high white population. The median distance range for urban areas with a large representation of minority groups was between 3.8 and 6.4 miles, whereas the median distances in urban non-minoritized areas was between 7.4 and 11.5 miles.
In rural areas with a high population of minority groups, the median distances ranged from 16.2 miles for emergency services to 25.6 miles for trauma care, which is significantly farther than for rural areas with a high representation of white residents (medians of 13.4 and 23.6 miles, respectively). The authors acknowledged that median distances in urban areas may not be the most meaningful reflection of travel time, the authors noted.
“These patterns likely result from a combination of housing policies that restrict housing opportunities and federal health policies that are based on service provision rather than community need,” the authors wrote in the study. Leaving the details of Medicaid to states, like whether or not to expand the program, has adversely affected people of color, the study said.
The findings also illustrate the difficulty of using a single metric—distance—to investigate access to care on a national scale, the study authors said.
Rural minority communities are also more likely to experience and be affected by hospital closures, the study noted. With each closure, existing healthcare disparities are exacerbated.
Areas with large American Indian/Alaska Native communities see the longest median distance from services; more than half of these areas have distances greater than 30 miles to intensive or cardiac care. Rural areas high in a Black population also have longer distances to hospital services than their white counterparts. Trauma care was the hardest to obtain in rural areas.
The authors suggested multi-pronged approaches to equity, including addressing and preventing gaps in care created by hospital closure or relocation and the use of telehealth services.
In the short run, access to selected services associated with hospital presence can perhaps be enhanced through expanded use of telehealth options, the authors said.
"Telehealth approaches have the unique advantage of resolving access difficulties both for rural populations and for urban residents facing transportation barriers," the authors wrote.
The federal government also has multiple policy avenues to pursue in efforts to enhance equity of access to hospital services, Eberth wrote. For instance, CMS could ensure that geographic equity in access to care, as measured through network adequacy standards and other metrics, is addressed in state Medicaid waivers.
"Changing a health care infrastructure that has been built within the context of discrimination against minoritized racial and ethnic populations is not a one-and-done effort. Dedicated policy and advocacy, coupled with geographically informed research, are needed to isolate and remedy current service shortfalls," the authors wrote.