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In some parts of the rural United States, accessing in-person health care can feel impossible. Local emergency rooms and specialists might be nonexistent, and a trip to the clinic can take hours.
Telehealth has changed the game. Stephen Martin, a family physician and addiction medicine specialist, has witnessed how the recent influx of virtual appointments has increased access to medical care for rural patients from his practice in Barre, Mass. People seeking long-term addiction treatment who may have shied away from health care in the past because of stigma in a small town or lack of transportation can now receive substantive treatment.
But no one knows how long telehealth will remain a viable option for many people on Medicare. Policies introduced during the COVID-19 pandemic made it easier for people in rural America to access virtual care, but some of these programs are set to expire at the end of the year.
Recent research suggests that expanded access to telehealth has an indispensable place in post-pandemic healthcare. While bipartisan support for the extensions remains, legislation that could implement them long-term is currently in limbo, caught up in Congress’ battle to extend government funding into 2025. If a bill to extend these services isn’t passed before December 31, many people living in rural America will face renewed hurdles to accessible care.
Health care in rural areas can be hard to access
Physician shortages, hospital closures and the shuttering of critical services, such as labor and delivery care, have made it increasingly difficult to find reliable health care in rural areas (SN: 12/11/24). According to the Center for Healthcare Quality and Payment Reform, almost 200 rural hospitals have closed since 2005, leaving millions of people without emergency care or inpatient services in their communities. Late insurance payments and tight profit margins have left 360 more rural hospitals at risk of immediate closure. As of this year, there are about 1,200 rural hospitals throughout the country.
When these hospitals vanish, the patients they leave behind still fall ill and require care. People living in rural areas across the United States are more likely to die from heart disease, cancer, chronic lower respiratory disease and stroke than their urban counterparts, researchers reported in May in Morbidity and Mortality Weekly Report. Sixty-five percent of nonmetropolitan counties across the country lack a psychiatrist, and rural patients have higher rates of suicide and depression than urban residents, other studies have found.
If you don’t get along with the only doctor in town, Martin says, you’re in a tough spot. “You’re left to the idiosyncrasies and vantage points of any small number of practitioners in that area. So if those practitioners aren’t interested in addiction, you won’t have addiction care. If they’re not interested in mental health, you won’t have mental health care.”
Unsurprisingly, transportation to different providers is often a limiting factor for rural patients. For the millions of people living in rural parts of the country, it can take nearly twice as long to reach a hospital than it does for urban residents. Numbers vary wildly, but the average car travel time to the nearest hospital for someone in a rural area is 17 minutes; the average urban dweller needs just about 10 minutes. For people living in remote, hard-to-reach areas, it can take hours to reach in-person care.
There are patients who “literally have to take off an entire day of work to come and see us,” says U.S. Representative Gregory Murphy, a urologist who represents North Carolina’s 3rd District. “So many of the areas, sadly enough, in eastern North Carolina are rural and impoverished areas. So for people to lose half a day or a full day of work, it is a lot of lost wages.”
Telehealth legislation has been a boon for rural residents
In March 2020, isolation, quarantine and fear of COVID-19 kept people away from health care centers. In response, Congress passed several temporary acts that expanded Medicare’s coverage of virtual care — for instance, patients could receive mental or behavioral telehealth care without visiting in-person after an initial appointment. Telehealth use boomed. In-person appointments shifted to virtual ones. The number of telehealth users has since dropped but remains higher than pre-pandemic levels.
Telehealth takeoff
Telehealth use among Medicare users skyrocketed during the first year of the COVID-19 pandemic, then dropped, according to data from the Centers for Medicare & Medicaid Services. But use remains nearly twice as high as it was before the pandemic.
Initially set to expire at the end of the U.S. COVID-19 public health emergency in May 2023, the telehealth flexibilities were extended to December 31, 2024 (SN: 5/4/23). Some members of Congress want these expansions made permanent. Legislators have introduced several such bills this year, like the Telehealth Modernization Act of 2024. Despite pushback from insurance company lobbyists, expanded telehealth access “enjoys great bipartisan support,” says Murphy, who believes there is a “very good chance” the bill is added to Congress’ end-of-year package.
If the telehealth provisions aren’t extended, rural patients may soon find they have fewer options for health care.
“This is going to harm a lot of folks,” says Andy Seaman, a harm reductionist and addiction medicine specialist based in Calais, Vt., where they are the head of Substance Use Disorder Programs at Better Life Partners. “I think it’s a huge barrier when you require people to come in person, especially for rural Americans.”
Seaman treats many patients who are homeless and injecting methamphetamines or opioids. These patients might not have transportation, social support or available childcare, they say. Patients might be experiencing intimate partner violence, which can restrict their ability to attend in-person visits.
“Telemedicine is critical for access,” Seaman says. Finding a primary care doctor, a specialist to help manage chronic conditions, and a mental health practitioner might be a tall order in some rural counties.
As the data roll in, scientists are learning that telehealth has the power to facilitate a diverse array of treatments. For example, doctors can virtually rehabilitate patients with chronic obstructive pulmonary disease, a lung disease with high prevalence in rural areas, and virtual mental health care can reduce depression symptoms and improve quality of life.
And for patients with opioid use disorder, virtual care can actually boost treatment retention, researchers reported in the December Journal of Substance Use and Addiction Treatment. Patients will stay and seek care for longer when the barriers are fewer.
“It is understandably very difficult for people to access relatively public resources like health care when they’re likely to know someone who works at their front desk or the nurse who’s helping them,” says Martin, who works at Boulder Care and the University of Massachusetts Chan Medical School in Worcester, and virtually treats patients with opioid use disorder. “It’s very difficult to make yourself vulnerable to bias and prejudice because of an addiction. People told us over and over again, ‘I just couldn’t do this in my own town.’’’
Telehealth isn’t a panacea for health care access
While telehealth can be an incredible resource for mental health care, addiction treatment and chronic symptom management, it can’t address every health issue.
“If you need someone to come in and … do screenings for diabetes and cancer and all of those things, they still need to happen in a clinical setting,” says Yendelela Cuffee, a social epidemiologist at the University of Delaware in Newark.
But she has seen more and more hospitals and federally qualified health centers close over the years. “There is a vast need to have those [facilities],” Cuffee says.
Additionally, many people living in rural America might lack the technology necessary to chat over video. In 2020, the Federal Communications Commission reported that about 22 percent of rural Americans and 28 percent of people on what the agency classifies as Tribal Lands lacked broadband coverage, which is internet access quick enough to accomplish basic web-browsing tasks.
Researchers, policy makers and health care workers have also shared concerns about telehealth’s impact on the quality of care. Some argue that technical difficulties during the pandemic inhibited certain care routines. Others argue that communication is impacted due to loss of nonverbal cues from patients and clinicians.
A growing number of studies are beginning to clarify how effective telehealth is when used to treat patients. For instance, the expansion of telehealth wasn’t associated with an increase or decrease in low-value care for Medicare patients in Michigan, researchers reported November 7 in JAMA Network Open. Low-value care encompasses services that are pricy, wasteful or even harmful to patients, like repeat lab tests or unnecessary prescriptions.
“I think in general, policy makers are worried that because telehealth makes things more convenient, we might actually see more low-value care,” says Terrence Liu, a primary care physician and health services researcher at the University of Michigan in Ann Arbor. His team’s finding “does provide some reassurance that we aren’t seeing a rise in low-value care when primary care practices use more telehealth.”
The next few weeks will determine how telehealth will integrate into post-pandemic health care. Researchers and physicians agree: Telehealth, while limited in ability, can bridge an increasingly large divide between rural patients and practitioners. For many patients, like those Martin and Seaman treat, telehealth can protect privacy, provide medication and pave the way for long-term recovery.
“It’s not telehealth by itself. It’s telehealth that’s done with the best evidence, in the most humane way,” Martin says. “And it turns out that you never need to meet someone in the flesh to really have an incredibly moving experience that helps you get well.”
