By Brystana G. Kaufman, PhD
By Rebecca Whitaker, PhD
By George Pink, PhD
By G. Mark Holmes, PhD
First published: 30 June 2020
During the COVID‐19 epidemic, it is critical to understand how the
need for hospital care in rural areas aligns with the capacity across states.
Methods
We analyzed data from the 2018 Behavioral Risk Factor Surveillance
System to estimate the number of adults who have an elevated risk of serious
illness if they are infected with coronavirus in metropolitan, micropolitan,
and rural areas for each state. Study data included 430,949 survey responses
representing over 255.2 million noninstitutionalized US adults. For data on
hospital beds, aggregate survey data were linked to data from the 2017 Area
Health Resource Files by state and metropolitan status.
Findings
About 50% of rural residents are at high risk for hospitalization
and serious illness if they are infected with COVID‐19, compared to 46.9% and
40.0% in micropolitan and metropolitan areas, respectively. In 19 states, more
than 50% of rural populations are at high risk for serious illness if infected.
Rural residents will generate an estimated 10% more hospitalizations for
COVID‐19 per capita than urban residents given equal infection rates.
Conclusion
More than half of rural residents are at increased risk of
hospitalization and death if infected with COVID‐19. Experts expect COVID‐19
burden to outpace hospital capacity across the country, and rural areas are no
exception. Policy makers need to consider supply chain modifications,
regulatory changes, and financial assistance policies to assist rural
communities in caring for people affected by COVID‐19.
In the United States, rural populations are older and sicker than
urban populations, and thus at greater risk of hospitalization and death during
the COVID‐19 pandemic. The response to the epidemic in the United States has
been hampered because of limited capability to test and identify positive cases
of the virus, and this has increased the opportunity for community spread.
Epidemiologists estimate the novel COVID‐19 will infect between 30% and 70% of
the population, and it is critical to understand how the need for hospital care
in rural areas aligns with the capacity across states.
The US coronavirus epidemic originated in cities, and the early news
coverage of “hot spots” has highlighted experiences in metropolitan areas and
large health systems. As a result, rural residents may feel the threat is
distant and less relevant for their communities. Communicable diseases often
have a larger impact in urban areas due to the population density, social
lifestyles, and use of mass transit. To some extent, social distancing is a way
of life for many rural families given the landscape and geography, as well as
personal choice. President Trump has said, “You go out to the Midwest, you go
out to other locations, and they're watching it on television but they don't
have the same problems. They don't have by any means the same problem."1
Despite this, cases are growing in rural areas. In North Carolina
and Oklahoma, early instances of community spread were in rural counties.2-4
Even in low‐density populations, the spread of COVID‐19 infections across
communities occurs very quickly for multiple reasons: (1) as a novel virus,
there is no prior immunity in the population; (2) people may be infectious
before they experience symptoms; and (3) the virus transmits easily even
without person‐to‐person contact.5, 6 Grocery stores, pharmacies, and gas
stations, wherever visitors and locals pass through, may be opportunities for
the spread of the virus in rural communities.7
Rural communities need to prepare for the impact COVID‐19 will
have on their residents and health infrastructure. We present nationally
representative data on the population at risk of serious illness due to
infection, estimated infection numbers, and health system capacity for
inpatient care in metropolitan, micropolitan, and rural areas for each state.
Methods
We analyzed data from the 2018 Behavioral Risk Factor Surveillance
System (BRFSS) to estimate the total number of adults who have an elevated risk
of serious illness if they are infected with coronavirus in metropolitan,
micropolitan, and rural areas for each state.8 BRFSS is an ongoing,
state‐based, random‐digit‐dialed telephone survey of noninstitutionalized
civilian adults. BRFSS uses the National Center for Health Statistics (NCHS)
Urban‐Rural Classification scheme (URC) for counties to define metropolitan
(URC <5; over 50,000 population), micropolitan (URC = 5; 10,000 to 50,000
population), and rural (URC = 6; less than 10,000 population). The 4 urban
categories were combined into the metropolitan category for linkage to the 2017
Area Health Resource Files for data on hospital beds (defined as staffed acute
inpatient or swing beds), aggregated by state and metropolitan status.
We recognize the list of known risk factors will continue to
evolve as the Centers for Disease Control and Prevention gains more data about the
outcomes of the disease in different populations. Similar to other recent
studies, our definition of high risk includes older adults (ages 60 or older)
and younger adults between the ages of 18 and 59 with heart disease, cancer
(excluding skin cancer), chronic obstructive pulmonary disease (COPD), or
diabetes.9, 10 Current evidence has not confirmed asthma to be a risk factor.11
We were unable to include hypertension as a risk factor because it is not
tracked by the survey. Data represent adults who report ever being told by a
doctor that they have one of the listed conditions. The survey weighted number
and proportions at high risk were aggregated to summarize metropolitan,
micropolitan, and rural subgroup data for each state.
Estimates of the eventual infection rate of COVID‐19 range from
30%‐70%, reflecting a high degree of uncertainty.12, 13 We present estimates
for low (30%) and high (70%) spread scenarios. Hospitalizations were calculated
as the product of the infection rate, the hospitalization rate among infected,
and the population. We assumed hospitalization rates of 10% and 30% for those
infected who are at low or high risk for serious illness, respectively.14, 15
We assumed the average COVID‐19 hospital stay to be 11 days.16
Results
Study data included 430,949 survey responses representing over
255.2 million noninstitutionalized US adults in 50 states. Rural respondents
represented 16.7 million rural residents nationally. We included 7 states that
had no rural respondents (Connecticut, Delaware, Hawaii, Massachusetts, New
Hampshire, New Jersey, and Rhode Island) because they do have metropolitan and
micropolitan observations.
Among rural residents, 50.0% (95% confidence interval [CI] =
49.1%‐51.0%) of noninstitutionalized adults are at high risk for
hospitalization and serious illness if they are infected with COVID‐19,
compared to 46.9% (CI = 46.0%‐47.7%) and 40.0% (CI = 39.6%‐40.3%) in
micropolitan and metropolitan areas, respectively (Figure 1). Compared to
metropolitan areas nationally, rural and micropolitan areas have higher
proportions of patients at high risk due to health conditions and being over
age 60. About one‐third (32.0%, CI = 31.1%‐32.8%) of rural residents are at
high risk due to health conditions and 37.3% (CI = 36.5%‐38.2%) are at high
risk to due age over 60 (19.3% being high risk for both factors).
Figure 1
Open in figure viewer PowerPoint
Mean Proportion of Residents at High Risk Nationally Due to
COVID‐19 by Metropolitan Status.
Source: Authors’ analysis of 2018 Behavioral Risk Factor
Surveillance System data.
Variation exists in the portion of the population at risk across
states’ rural and micropolitan areas (Figure 2). Between 20%‐40% of rural
populations have health conditions associated with increased risk, 25%‐45% are
over age 60, and 40%‐60% total are at high risk of serious illness if infected
with COVID‐19 due to age or health conditions. State micropolitan distributions
are similar to rural, although rural populations have a greater prevalence of
health conditions. In 7 states, more than 50% of both rural and micropolitan
populations are at high risk for serious illness if infected (Alabama,
Kentucky, North Carolina, South Carolina, Tennessee, Virginia, and West
Virginia), all in the South Census region. In another 12 states, more than 50%
of the rural population is at high risk for serious illness if infected
(Arkansas, Florida, Illinois, Louisiana, Maine, Michigan, Missouri, Montana,
New Mexico, Oklahoma, Oregon, and Pennsylvania), representing all 4 Census
regions (Figure 3).
Figure 2
Open in figure viewer PowerPoint
Proportion of States’ Residents at Risk of Serious Illness Due to
COVID‐19 in Metropolitan, Micropolitan, and Rural Areas.
Source: Authors’ analysis of 2018 Behavioral Risk Factor
Surveillance System data.
Figure 3
Open in figure viewerPowerPoint
Percent of Rural Residents at High Risk of Serious Illness Due to
COVID‐19.
Source: Authors’ analysis of 2018 Behavioral Risk Factor
Surveillance System data.
The COVID‐19 hospitalization rate per capita is estimated to be
higher in rural than micropolitan and metropolitan populations given equal
infection rate of the virus. On the low estimate of spread (30%),
hospitalization rates per capita are estimated at 5.4, 5.7, and 6.0 per 100 in
metropolitan, micropolitan, and rural populations, assuming 10% of low‐risk and
30% of high‐risk infected individuals are hospitalized. On the high end of
spread estimates (70%), hospitalization rates per capita are estimated at 12.6,
13.5, and 13.9 per 100 in metropolitan, micropolitan, and rural populations. In
the low spread scenario, metropolitan areas have 7.7 hospital beds on average
for every 100 COVID‐19 hospitalizations compared to 6.3 in micropolitan areas
and 5.4 in rural areas (Figure 4).
Figure 4
Open in figure viewerPowerPoint
Number of Hospital Beds Compared to Estimated COVID‐19
Hospitalizations for State Metropolitan, Micropolitan, and Rural Populations.
Source: Authors’ analysis of 2018 Behavioral Risk Factor
Surveillance System and 2017 Area Health Resource File data. Truncated to show
observations with state high‐risk population less than a half million people.
Assumes 30% of high‐ and low‐risk populations are infected with COVID‐19 and
assumes a 10% hospitalization rate in low‐risk populations and 30%
hospitalization rate in high‐risk populations.
Policy Implications
More than half of rural residents are at increased risk of
hospitalization and death if infected with COVID‐19. Due to the higher
percentage at high risk of hospitalization, rural residents will generate an
estimated 10% more hospitalizations per capita than urban residents given equal
spread. The need for care may be particularly devastating in the South Census
region, where the percent of rural population that is high‐risk exceeds 50% for
10 states. In addition, rural hospital closures further exacerbate the capacity
to treat seriously ill patients with COVID‐19 in rural areas. Since 2017, 40
rural hospitals have closed and others have reduced their number of beds,
further reducing capacity for COVID‐19 care even below the estimates presented
in this study.17 Additionally, rural access to intensive care and ventilators,
key aspects of care needed for the 5% of critically ill COVID‐19 patients, is
limited.18 As a result, many rural residents may travel or be transferred to
urban hospitals for care. Transfers require precious time that can affect
outcomes in critical situations, even under normal conditions. Transfers during
the wave of COVID‐19 infections in cities may present additional challenges if
the receiving hospital is also overwhelmed. As a result, the preparedness of
urban hospitals will impact care for some rural residents as well.
Supply Chain Modifications
Resources for combating this epidemic are limited, and rural areas
need financing and supplies to strengthen their response to COVID‐19. Some
hospital vendors have rationed orders for personal protective equipment and
other supplies according to ordering history. As a result, rural hospitals that
have been tightly controlling expenses may be limited to those small supply
stocks, leaving them unprepared to handle the surge during the epidemic. The
national stockpile is intended to be a safety net but is insufficient for a
crisis of this magnitude. Policy makers should consider how national resources
are distributed according to projected need in both low‐ and high‐density
areas. Structural urbanism may lead to disproportionate distribution of supplies
as they become available, with rural areas getting fewer supplies and equipment
per capita.19 Senate lawmakers are urging the Federal Emergency Management
Agency to coordinate with the Department of Agriculture and Department of the
Interior efforts to support the rural COVID‐19 response.20
Regulatory Changes
In response to COVID‐19, the Centers for Medicare & Medicaid
Services (CMS) is waiving certain regulations to give providers more
flexibility and reduce reporting burden.21 For example, CMS waived bed
restrictions and length of stay limitations for Critical Access Hospitals.
However, reimbursement for the cost of caring for COVID‐19 patients is a
concern for rural providers who care for uninsured or underinsured patients.
Although providers are not charged for the COVID‐19 test, they are charged for
the flu and respiratory syncytial virus infection (RSV) tests, which are
required prior to receiving the COVID‐19 test. As the need for testing grows,
unreimbursed expenses may become prohibitive for some rural providers to
continue providing care, particularly for uninsured or underinsured patients.
Financial Assistance
Many rural hospitals remain at high risk of financial distress,
and the additional costs associated with epidemic preparation may force more
hospitals to close or fail to meet the needs of their community.22 Cash supply
and short‐term financing for rural hospitals may not be sufficient to support
the up‐front costs of care and preparation during a high‐volume period, like an
epidemic.23 Advance payments prior to and during the surge would support rural
hospitals’ efforts to prepare for the epidemic and provide necessary care. CMS
implemented a 20% reimbursement increase for COVID‐19 patients through the
Inpatient Prospective Payment System, but these changes do not benefit the
majority of rural hospitals because they receive cost‐based reimbursement.24
On May 1, 2020, the Department of Health and Human Services (HHS)
announced that it is distributing $10 billion from the Provider Relief Fund to
rural providers in support of the national response to COVID‐19.25 Rural Health
Clinics and Community Health Centers will receive a minimum level of support no
less than $100,000, with additional payment based on operating expenses. Rural
acute care general hospitals and Critical Access Hospitals will receive a
minimum level of support of no less than $1,000,000, with additional payment
based on operating expenses.
Limitations
This limited, descriptive analysis presents a best‐case scenario
where spread of COVID‐19 is 30%. We assumed only 10% of people at low risk
would require hospital care, but there is little evidence about the actual rate
of hospitalization in this population because many mild cases go undetected.
Though recent data suggest the infection rate is not lower in rural areas,
there is substantial uncertainty in these preliminary estimates.26 This
estimate of bed capacity does not consider current occupancy rates. Rural
hospitals typically have lower average daily census than urban hospitals, but
they will still be responsible for injuries and other acute illnesses that
occur during the pandemic, reducing capacity for COVID‐19 care.
Institutionalized adults are a group that may be at high risk of serious
illness if infected with COVID‐19, but this group is not captured in the BRFSS
responses. As a result, our data may underestimate the total number at high
risk during the pandemic.
Conclusion
Experts expect COVID‐19 burden to stress hospital capacity across
the country, and rural areas are no exception. This analysis represents a
conservative estimate of the number of people at risk of serious illness from
COVID‐19 and the ability of rural hospitals to meet demand for COVID treatment.
The $10 billion distribution will augment the cash of rural hospitals and
providers for several weeks. However, policy makers need to consider supply
chain modifications, regulatory changes, and ongoing financial assistance to
support rural communities in caring for people affected by COVID‐19.
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