Rural Alabama

The Long Decline: Health Care Access Grows Difficult in Shrinking Rural Communities

Dr. Brittney Anderson poses for a portrait in an examination room at the Anderson Family Care clinic in Demopolis, Ala., Wednesday, Jan. 17, 2024. (Will McLelland for the Alabama Reflector)

Annie Hashaway, an 86-year-old cancer survivor, travels about 65 miles from Butler County to Montgomery for routine work related to her immune system.

She used to be able to drive herself. But that ended when she had two heart attacks a couple years ago.

“Half the time I couldn’t drive, and it was so hard to get somebody,” Hashaway said. “They would say they’re going to take me, then something comes up, and they weren’t able to take me.” 

She has few other options. After Montgomery, the next closest would be in Dothan, over 90 miles from Hashaway.

The lack of health care providers in rural Alabama is stark. Most of Alabama’s rural counties have significantly more people per primary care physician than urban counties. Butler County, where Hashaway lives, has just one primary care physician per 4,900 residents, according to data from County Health Rankings & Roadmaps (CHR&R), a University of Wisconsin Population Health Institute program.

The average in Alabama is 1,520 people per one physician.

By contrast, Jefferson County, Alabama’s most populous, has 875 people to every primary care physician, the most of all counties. Jefferson County had a population growth of about 2.5% in the last census while Shelby County, a suburban area next to Jefferson County had a population growth of 14.3%. Butler County’s population dropped over 9% between 2010 and 2020.

What loss means

As rural Alabama continues a decades-long population collapse, residents who remain — many of them older people — face increasing barriers to health care, a trend seen around the nation.

According to a case study by KFF, a San Francisco-based nonprofit that studies and reports on health policy, declining population was a factor in three hospital closures analyzed in Kentucky, South Carolina and Kansas, despite each state having moderate population growth overall.

The three hospitals that shuttered, one in each state, were in counties that lost population in the five years before closing. Other factors included an aging population (a product of population decline); high uninsured rates, low Medicare reimbursements and economic challenges.

Those trends are also present in Alabama. The last Alabama hospital to close, in 2020, was located in Pickens County, which experienced about a population decline of 3.16% over the last decade. A hospital in Butler near where Hashaway lives, shut down in 2019.

The J. Paul Jones Hospital in Wilcox County, whose population fell 9.2% between 2010 and 2020, shut its doors in 2017.

According to County Health Rankings, Alabama averaged one physician for every 1,520 residents in 2020. In Wilcox, it’s one for every 5,103 residents. And in Lowndes, it’s one for every 9,641 residents.

There are also significant differences between the rural and urban physician workforce. Primary care physicians made up a larger portion of the physician workforce in rural areas (49%) than in urban areas (30%). Conversely, specialists made up a smaller portion of the rural physician workforce (23% versus 37% in urban areas).

Lack of providers hinder access to care. With many Black Belt counties aging faster than the state as a whole, many have worse health outcomes than the state, which has some of the worst outcomes across the nation.

Life expectancy is lower in every Black Belt county than across Alabama overall (74.8 years). Wilcox County residents have a life expectancy of 69.8 years, five less years than the state average. According to the National Cancer Institute, 13 of the rural Black Belt’s 17 counties had higher cancer rates than the state of Alabama’s age-adjusted cancer incidence rate (44.1 per 10,000), with the highest being in Lowndes County (58.4 per 10,000).

A need for transportation

Losing access to healthcare services, especially those provided by hospitals, means more reliance on transportation. And that’s hard to come by in rural areas.

In a University of Minnesota study, respondents across all 50 states reported rural transportation challenges due to infrastructure followed by geography, funding, accessibility and political support and public awareness.

Lack of transportation delays medical care for millions of people across the U.S. every year, with this number nearing 6 million in 2017, according to a 2020 University of North Carolina at Chapel Hill study published in the American Journal of Public Health.

The study demonstrates a positive association between vehicle access and healthcare accessibility, particularly in rural areas where transportation options are limited. Rural residents report longer travel times to healthcare providers, especially specialists, potentially leading to missed or delayed non-emergency treatment.

Royal Brown, who lost his driver’s license due to having three strokes, had to see a specialist over 50 miles away in Tuscaloosa, but his insurance wouldn’t pay for it. Dr. Brittney Anderson, a family medicine doctor based in Demopolis in Marengo County and Brown’s primary care provider, arranged and paid for a round-trip ride.

“I need my license to get around,” Brown, a 52-year-old who lives in Linden, about 20 minutes south of Demopolis. “I got a car parked over at my uncle’s yard. I can drive it, but I don’t want to drive it without my license.”

Marengo County, where Linden is located, is one of the top 20 counties in Alabama for population loss. The county saw its population decline by about 8% from 2010 to 2020. Perry County saw the largest population decline, at nearly 20%.

Anderson said that transportation is probably the single biggest issue impacting patients in rural Alabama.

“It’s heartbreaking for one to know that there are specialists that are in Tuscaloosa even, but transportation is such an issue that our patients can’t get to them to get the care they need,” she said.

Adults with no vehicle at home and with poor public transit access (21%) were more likely to miss healthcare than those with good access to public transportation (9%), according to a 2023 policy brief from the Robert Wood Johnson Foundation and the Urban Institute.

While around 5% of nonelderly adults missed healthcare due to transportation, low-income adults (14%), disabled adults (17%), those on public insurance (12%), and vehicle-less households (13%) were more likely to miss an appointment because of transportation. Likewise, 91% of adults have a car, but it’s less common for Black adults (81%), low-income adults (78%), disabled adults (83%), and those on public insurance (79%) or without any (83%) to have a car.

What transportation means

Before the Cancer Wellness Foundation of Central Alabama started providing transportation assistance for Hashaway, she said that she missed many appointments. She’d often have to depend on friends, often having to pay them more than $50 for the round trip.

Insurance companies often have a limit on miles for healthcare appointments, and they also limit how many trips a patient can take in a year.

Brown’s lack of transportation makes getting to his much-needed medical appointments difficult.

If non-emergency transportation is available, and his insurance will pay for it, he can see Dr. Anderson every three months. He had to cancel an appointment recently due to his insurance being unable to provide transportation that day.

But it’s easy for individuals with chronic conditions to use up the mileage insurance will pay for. Cancer patients, for example, might reach their limit in a month.

“If they’re getting radiation, radiation is [needed] often and they may travel over two hours, several times a week, and that’s two hours here, their treatment and the two hours home, and there’s not a lot of insurance companies that are going to cover that,” said Carol Gunter, executive director of the Cancer Wellness Foundation of Central Alabama.

Aside from Montgomery, where the foundation is located, 18 of the 32 counties that the foundation serves experienced population decline in the last census, and about 47% of their patients in 2022 were located in those counties, despite lower population.

Dr. Anderson said that some specialists come to Demopolis on certain days of the week. That brings some specialized health care to areas with limited access. But rural residents may still have trouble accessing the services if they are only available one day a week.

“And there’s some specialists that we just don’t have access to, and there are some surgical procedures that just cannot be done and won’t be done in rural Alabama,” she said. “So there still is the need to get those patients to Tuscaloosa to Birmingham for that care.”

Brown said he enjoys living in Linden, a town of just under 2,000 people. He now lives in his late grandmother’s house, which had been sitting vacant for about 30 years before he moved in.

But Brown often has to rely on his neighbors even for basic transportation needs, such as going to the groceries. Even if he’s not sure which he likes more, he said he would move to a bigger city if it meant he could leave his house more often, even if there are more stressors associated with the cities.

“But at least you got something to do in the bigger cities. You won’t be sitting around bored. You can go to the gym, movies, or whatever,” he said.

Instead, he said he spends his days stuck at home, bored. If he had a vehicle, he’d have something to do, he said, like going to the gym.

“I just read on my phone, call my friends, family members or go across the street so I can have somebody to talk to, where I won’t go crazy,” he said.


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