Taylor Walker is wiping down tables after the lunch rush at the Bunkhouse Bar and Grill in remote Arthur, Nebraska, a tiny dot of a town ringed by cattle ranches.

The 25-year-old has her young son in tow, and she is expecting another baby in August.

“I was just having some terrible pain with this pregnancy and I couldn’t get in with my doctor,” she says.

Visiting her obstetrician in North Platte is a four-hour, round-trip endeavor that usually means missing a day of work. She arrived to a recent visit only to learn that another doctor was on call and hers wasn’t available.

“So then we had to make three trips down there just to get into my regular doctor,” Walker says.

This inconvenience is part of life in Arthur County, a 700-square-mile slice of western Nebraska prairie that’s home to only 465 people. According to census figures, it’s the fifth least-populated county in the nation.

It’s always been a chore to get to a doctor out here, and the situation is getting worse by some measures — here, and in many rural places. A new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that one out of every four people living in rural areas said they couldn’t get the health care they needed recently. And about a quarter of those said the reason was that their health care location was too far or difficult to get to.

Rural hospitals are in decline. Over 100 have closed since 2010 and hundreds more are vulnerable. As of December 2018, there were more than 7,000 areas in the U.S. with health professional shortages, nearly 60 percent of which were in rural areas.

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In Arthur County, it’s a common refrain to hear residents talk about riding out illnesses or going without care unless the situation is dire or life-threatening. Folks will also give you an earful about what happens when they do visit a clinic or hospital. Because of high turnover, doctors don’t know them or their family histories and every visit is like starting all over again, they say.

“It’d be nice to have some doctors stay and get to know their patients,” says Theresa Bowlin, the lone staffer working at the Arthur County courthouse.

Arthur’s population has been in a slow decline for decades. No one knows for sure, but it’s likely the town hasn’t had a full time doctor since the 1930s, though there was a mobile health clinic that used to park on the highway once a week up until the 1990s. But it got too expensive.

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Bowlin says it’s a perennial challenge to find a doctor who knows the community and understands the cowboy mentality about health care common here.

“The younger doctors coming in, they really don’t know how a cowboy can go that long with pain and not come to the doctor until he absolutely has to,” she says.

A generational shift

There’s a changing of the guard going on in the health care industry, and its effects may be most apparent in rural America. As baby boomer doctors retire, independent family practices are closing, especially in small towns. Only 1% of doctors in their final year of medical school say they want to live in communities under 10,000; only 2% were wanted to live in towns of 25,000 or fewer.

Taking over a small-town practice is too expensive, or in some cases, too time-consuming for younger, millennial physicians. And a lot of the newly minted doctors out of medical training are opting to work at hospitals, rather than opening their own practices.

The nearest hospital to Arthur is 40 miles south in the town of Ogallala. Christopher Wong, 36, is one of just two family practice obstetricians at Ogallala Community Hospital, which serves a vast area of some 15,000 people spread across several counties.

Wong grew up in suburban Denver, about a three-hour drive away, but world’s apart from western Nebraska

“Most of the people I take care of out here are ranchers and farmers,” Wong says.

Wong first got interested in rural health care during med school, doing volunteer work in rural Louisiana after Hurricane Katrina. Still, working full time in a small town in rural Nebraska has been an adjustment.

One day, he did rounds at the hospital, saw dozens of patients at the clinic and signed a birth certificate for a baby he’d just delivered. He and the mother had to get a little creative, Wong recalled. She had a history of going into labor fast, but lives more than an hour’s drive from the hospital. Plus it’s calving season on her ranch. And she wasn’t sure her husband would be nearby — or available — to drive her to the hospital.

“So we brought her into the hospital when she was 39 weeks so we could induce her,” Wong says.

Being a doctor in a small town, you’re always on, even when you’re not. It’s not like you can just clock out and leave work. Wong will bump into a patient at the grocery store who politely asks about this ailment or that problem. Everyone knows him and there’s no anonymity. He’s also on call every other weekend.

“It’s very hard to get away,” Wong says. “It’s hard to separate it all.”

He has a girlfriend in Denver and tries to get down there when he can. But it’s a tough sell to convince a partner to move to rural Nebraska where there are few other young professionals or opportunities.

“I think that’s why it’s also hard to get physicians into rural practice because it’s hard to maintain a personal life.”

Burnout is high. Wong is approaching three years on the job in Ogallala and has no plans to leave. But it’s a constant worry for hospital administrators.

“Work-life balance is a big piece, they want to go home at some time,” says Drew Dostal, CEO of Ogallala Community.

Doctors like Wong, who do both family practice and obstetrics are already in high demand. Dostal even offers $100,000 signing bonuses to help ease their debt burden. It may get them out here for a few years, he says, but they’re usually lured away by other offers and rarely become fully part of the community.

“Physicians who have to move on to help get their debt paid off …[that] challenges patients as well,” Dostal says. “They want to know [their doctor], they want them to stay forever, but it just isn’t a reality in today’s health care.”

Social matchmakers

Dostal is currently looking for a third family practice doctor and could probably hire a fourth. Retaining doctors is key to keeping critical access hospitals like this one open. In the NPR poll, close to one out of every ten respondents said their small town hospital had recently closed.

Recruiting and retaining doctors is so pressing that hospital officials even try to become social matchmakers. If a doctor likes sports, for example, administrators may suggest they volunteer as team physician at the high school; or if they are an arts lover, they could volunteer on the planning committee for the local arts festival.

“If we don’t do a better job of doing that, there is a risk for rural places to lose their hospital, or lose their providers that are in that hospital,” says Dr. Jeffrey Bacon, the chief medical officer for three Banner Health hospitals in northeast Colorado and western Nebraska, including in Ogallala.

Bacon and other hospital officials say a more effective solution than social matchmaking or signing bonuses might be if medical schools did more active recruiting in small towns.

In January, Ogallala Community was thrilled to hire Jessica Leibhart to join Wong as a second family practice OB-GYN. Leibhart, 36, grew up in Imperial, Neb., about fifty miles south of Ogallala.

“I was looking to get back to my roots,” Leibhart says. “This was really close and looked like the right fit for us.”

Leibhart relocated from the Omaha area and her family already had contacts in Ogallala, so the transition has been smooth. She knows that in a small town it’s virtually impossible to escape your job.

“If we’re at Walmart or my husband and I will be out for dinner and then pretty soon someone stops by, but that’s part of it,” Leibhart says. “And that truly is becoming part of the community and part of the family that the small town is.”

Finding doctors who want to be part of the small town family, may be one solution to addressing the worsening doctor shortage in rural America, and the growing urban-rural divide.

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Polling by NPR finds that while rural Americans are mostly satisfied with life, there is a strong undercurrent of financial insecurity that can create very serious problems for many people living in rural communities.

The findings come from two surveys NPR has done with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health on day-to-day life and health in rural America.

After a major poll we did last fall found that a majority (55%) of rural Americans rate their local economy as only fair or poor, we undertook a second survey early this year to find out more about economic insecurity and health. The poll looked beyond the known factors of job loss and the decades-long flight of young people to more urban areas.

Several findings stand out: A substantial number (40%) of rural Americans struggle with routine medical bills, food and housing. And about half (49%) say they could not afford to pay an unexpected $1,000 expense of any type.

Access to health care

One-quarter of respondents (26%) said they have not been able to get health care when they needed it at some point in recent years. That’s despite the fact that nearly 9 in 10 (87%) have health insurance of some sort — a level of coverage that is higher now than a decade ago, in large part owing to the Affordable Care Act and the expansion of Medicaid in many states.

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“At a time when we thought we had made major progress in reducing barriers to needed health care, the fact that 1 in 4 still face these barriers is an issue of national concern,” says Robert J. Blendon, co-director of the survey and professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health. “Either it is still not affordable for them or the insurance they have doesn’t work — or they can’t get care from the health providers that are in their community.”

Of those not able to get health care when they needed it, the poll found that 45% could not afford it, 23% said the health care location was too far or difficult to get to, and 22% could not get an appointment during the hours needed.

Dee Davis, president and founder of the Center for Rural Strategies in Whitesburg, Ky., says poverty and ill health are endemic where he lives. “People in this congressional district have the shortest life span in the United States; we also are the poorest,” Davis says. “We’re poor and we’re sicker.”

But, he adds, the Affordable Care Act — which in Kentucky brought an expansion of Medicaid to many previously uninsured residents — went a long way in helping many rural communities take care of recurring problems. “We’re not out of the woods yet but the ACA certainly changed the landscape,” Davis says.

Lots of rural people benefited from the ACA, he adds, and if that progress were to be lost, he says: “We’re in trouble.”

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For purposes of this poll, “rural” was defined as areas that are not part of a Metropolitan Statistical Area, as used in the 2016 National Exit Poll. The NPR poll was conducted in English and Spanish using random-digit dialing Jan. 31-March 2 among a nationally representative, probability-based sample of 1,405 adults ages 18 or older living in the rural U.S. The margin of error for the total respondents is plus or minus 3.5 percentage points at the 95% confidence level.

Financial insecurity

One measure of financial security is the ability to meet unexpected expenses like a car repair or a medical problem or fixing something that has gone wrong in the house. It’s not unusual for these expenses to run $1,000 or more, so we asked whether that would be a problem.

Overall, nearly half (49%) said they wouldn’t be able to afford that. And more than 6 in 10 rural black and Latinx Americans said they would have a problem paying that off (blacks, 68%; Latinx, 62%), compared with 45% of rural whites.

“When you’re living close to the edge, sometimes you fall off,” says Davis. “If half the people in rural America can’t deal with a $1,000 bill, that’s rough.”

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It would be an issue for 72-year-old Leitha Dollarhyde, a retired caregiver who lives near Whitesburg, Ky., a rural town of under 2,000 people. She was born about 4 miles from where she lives today.

Her answer, when asked if she could afford an unexpected $1,000 expense? “No. There’s no way. My savings account is zero.”

Dollarhyde worked all her life, but the jobs just didn’t pay enough for her to put anything aside. She raised four children. Today her income — Social Security and Supplemental Security Income — adds up to $790 a month.

“With that income, you watch every penny,” she says.

Strong social networks

Yet even with the high levels of financial insecurity that we found, there is abundant optimism and satisfaction with the quality of life in rural America. Almost three-quarters (73%) of rural Americans rate the overall quality of life in their local community as excellent or good. And a majority (62%) are optimistic that people like them can make an impact on their local community.

Davis says that is what he observes in rural Kentucky. “People may be living a more hardscrabble existence than folks in the suburbs or a lot of the folks in cities, but it doesn’t mean they’re not living a decent life,” he says. “Most people are pretty happy with it; they’ve got friends and neighbors they rely on and they’re where they want to be.”

Still, social isolation and loneliness are a concern in rural America. We found nearly 4 in 10 (38%) said “many people” in their community feel lonely or isolated, with almost 1 in 5 (18%) saying they “always” or “often” feel either isolated or lonely. People with disabilities (31%) more frequently said they feel lonely or isolated from others compared with those without disabilities (12%).

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A majority of rural Americans say they participate in civic and social activities, including volunteering and service, political activities, community meetings and membership in a variety of groups. The most frequently cited activity was volunteering their time to an organization working to make their local community a healthier place to live (49%).

Whitesburg community activist Nell Fields says that when her husband was recently hospitalized, her neighbors were extraordinary.

“My neighbors come and mow my grass, feed cattle, get eggs every day for the last few weeks,” she says. “That says so much to me. [It] makes me feel the emotion now of what it feels like to have such warm, wonderful support and I know that’s the blessing of living in rural America.”

Declining hospitals

Since 2010, 106 rural hospitals have closed in rural America. As many as 673 more are at risk of closure, according to a 2016 report from iVantage Health Analytics. Currently, there are approximately 1,860 rural hospitals in the U.S.

Eight percent of rural adults polled say hospitals in their local communities have closed down in the past few years. About two-thirds (67%) say the closures were a problem, including 38% who say they were a major problem.

“It means people have to travel greater distances to receive care, and distance can be a barrier to timely and appropriate access to services,” says Brock Slabach of the National Rural Health Assembly in Leawood, Kan. “Delayed care can often lead to tragic consequences. This can be a huge barrier for many living in rural areas.”

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As an example, he points to the small town of Tonopah, Nev., population 2,478, that is more than three hours away from the nearest hospital by road. The community’s hospital closed in 2015 and the ambulance service in town was left to deal with all kinds of medical problems that it is not situated to handle, Slabach says.

In areas where higher-speed Internet access is available, people are turning to telehealth instead of going to a doctor or clinic. But broadband access is a perennial issue in many parts of rural America, with 1 in 5 (21%) saying that accessing high-speed Internet is a problem for their family. Among those who do use the Internet, a majority say they do so to obtain health information (68%).

The medical purposes for using telehealth vary, as a majority of rural telehealth patients (53%) say they have received at least one prescription from their doctor or other health professional using telehealth, while 25% have received a diagnosis or treatment for a chronic condition, 16% have received a diagnosis or treatment for an emergency, and 9% have received a diagnosis or treatment for an infectious disease.

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