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Patients in some parts of Nevada face a 134-mile drive to the nearest emergency room. But it's not just being in a remote location that costs precious minutes on the way to the hospital. It's race, too, according to a new study.

People in rural areas with the proportionately least white population -- especially American Indian, Alaska Native, and Black rural communities -- live even further away from life-saving care, reported Jan M. Eberth, PhD, of the University of South Carolina in Columbia, and colleagues.

Among people living in rural ZIP codes, those in areas with a high proportion of minorities consistently had to travel father than those in predominantly-white ZIP codes and others without a high percentile of one or more minority -- for all hospital services studied.

"I think people incorrectly view rural as a white thing, rural equals white -- and that's not the case at all," said Eberth, director of the Rural and Minority Health Research Center.

The study, , analyzed distance to the nearest hospital offering emergency services, trauma care, obstetrics, outpatient surgery, intensive care, and cardiac care nationally. The researchers used geographical units of area by ZIP code, called ZCTAs, and as "rural" or "urban." Unlike counties, these areas exclude large bodies of water and national parks with no population.

The researchers also identified those ZCTAs with the largest representation of minority residents based on the American Community Survey's race data from 2015-2019.

A rural ZCTA was flagged as highly Hispanic, for example, if it was in the 95th percentile of all rural ZCTAs with Hispanic people. ZCTAs with more than one group in a high percentile was classified as having multiple minority groups.

The disparities were particularly pronounced for American Indian/Alaska Native ZCTAs, which often corresponded to tribal lands: 37.7% of rural areas with high American Indian/Alaska Native representation were more than 30 miles from emergency services compared with only 17.7% of highly white areas.

Rural predominantly-Black ZIP codes were also further from hospital services than rural highly-white ones. Trauma care was the most difficult to obtain in high-minority rural ZIP codes, with more than 60% of those with a high proportion of more than one minority group being more than 30 miles from the nearest trauma center.

The nearest ICU was often more than 30 miles for rural high-minority ZCTAs as well.

Racist policy throughout history, the researchers wrote, has led to the marked concentration of racialized and ethnic populations in specific places: in the South, the enslavement of Black people; in the West and along the border with Mexico, policies that incentivized Mexican workers to labor on U.S. farms; and on reservation land and states with higher American Indian/Alaska Native populations, forced migration. Housing policy further restricted where racial and ethnic minorities could live.

Eberth said the extent of the difference in distance to emergency and other services in American Indian/Alaska Native-high ZIP codes was striking. Although the Indian Health Service operates 28 hospitals, "when you begin to look at the services provided within those hospitals, they just weren't the same scope as what was provided in other hospitals that are privately owned, or for profit," she said. "So even though a hospital is there, the services they provide are less."

Another finding stood out: high-Black ZCTAs were actually closer to hospital services than high-White areas in urban settings. She said it made sense due in part to "white flight" in the 1950s to the suburbs away from urban centers where hospitals were. However, she added, the quality of these hospitals near urban Black populations should be researched further, as some in urban centers are likely to be older.

Also, actual travel time could differ despite nearness in miles, Eberth noted. A that compared rural and urban Black travel times for care found that, although those in rural areas might travel longer distances, they were just as likely as urban Black patients to travel more than 30 minutes.

and to care have analyzed travel time, more difficult to capture on a national scale than straight-line distance, and .

Distance is only one of many factors that contribute to what Brock Slabach, MPH, chief operations officer of the National Rural Health Association, calls "a growing crisis in rural America."

"The data confirms a lot of other details that we've been seeing historically across the United States, and this is something that we deal with all the time in our work," he added.

Slabach and Eberth's group both pointed to a series of policy changes, including for rural hospitals, that have contributed to the in the last decade. These set the stage for a cycle of defunding of rural hospitals and people in need left uninsured, who then get less medical care and develop more untreated illness, which uses up more of a rural hospital's already limited resources.

"The populations that hospitals are dealing with in rural areas are older, poorer and sicker, which makes a bad combination if [a hospital] is looking financially to be successful," said Slabach, especially if they rely on federal reimbursement from Medicaid and Medicare.

The decline of rural hospitals ends up hurting minority rural communities more. "We need to dedicate more resources to the most vulnerable. Usually that's not the funding equation," said Jennifer Bennet, senior advisor at the Mobile Healthcare Association. Health clinics on wheels often fill in with basic care, cancer screenings, and vaccinations where other medical options are hard to access, though Bennet noted that they aren't replacements for ICUs or emergency rooms. "They're oftentimes the people that are the costliest [to treat] because they aren't getting the care that they needed, through no fault of their own."

Minority groups in rural areas have of poverty than rural white people and may be less likely to qualify for Medicaid and Medicare if they live in one of 12 states that have not opted to expand Medicaid under the Affordable Care Act of 2014. In states like Texas, Florida, Mississippi, Alabama, Georgia, and South Dakota that didn't opt into Medicaid expansion, than $17,774 aren't covered.

The American Rescue Plan incentivizes more states to expand Medicaid by promising more Medicaid dollars, Eberth pointed out, but it can't compel them to expand it.

Bennet stressed policies that would increase for mobile clinics in grants or through Medicaid and Medicare, and would reduce the need for and in the first place. Slabach pointed to a that could help prevent more rural hospitals from closing. The study authors urged action to improve , ensuring insurance plans have broad enough in-network services that patients can physically access a range of providers.

Bennet recalled a colleague once saying that you have to ask people what they need to be healthy and give it to them. "It's not like people want to be unhealthy. We have created these barriers, and in this instance, it's a barrier of distance."

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