By Tulsi Patel
Nefertiti Byrd, a business owner in the rural town of Warrenton, NC, speaks about how her physician wasn’t “somebody that you grew up with or somebody in your family that you knew” (Byrd 0:19:24). Regardless, she continued to place her trust in the rural healthcare system. Other residents of Warrenton opposed Byrd’s belief, choosing herbalists over physicians. Home remedies seemed to grow in popularity, as Byrd recounts seeing more flyers for herbal medicine (Byrd 0:15:43). As a consequence of the lack of Medicaid expansion, this divide between allopathic healthcare and home remedies is seen across rural North Carolina. The lack of Medicaid expansion caused rural hospital closures, patient distrust, and a transportation burden, ultimately leading people to turn toward home remedies.
Since Medicaid was not expanded in North Carolina, uninsured people avoid hospital visits in fear of high medical costs, leading to hospital closures and a lack of resources in remaining hospitals. Uninsured patients who do visit the hospital prevent the hospital from being compensated. As a result, large numbers of hospitals in NC are closing, mainly in rural regions (Malone, 2020). In 2019, the US had its “worst year for rural hospital closures” in the South (Heath, 2021). Since the COVID-19 pandemic began, 25 percent of rural healthcare organizations are in danger of closing (Heath, 2021). These hospital closures prevent vulnerable rural populations from accessing care. Rural hospitals that have not been closed suffer from a lack of resources. More than 40 percent of rural hospitals in North Carolina are in negative margins (Paschal, 2020). While these negative margins cannot force the hospitals to close, it creates a financial strain that “makes it hard to pay staff, keep pace with changing technology” (Paschal, 2020). This instability discourages clinicians from working in rural hospitals. In counties with hospital closures, the median of clinicians per 100,000 patients dropped from 71.2 to 59.7, whereas counties without closures had a decrease of 87.5 to 86.3 clinicians per 100,000 residents (Heath, 2021). Clinicians avoid working in rural hospitals and cause closures, further discouraging rural clinicians and creating a vicious cycle. Hospital closures magnify the lack of medical facilities and professionals across rural NC, decreasing healthcare access and changing people’s beliefs about rural hospitals.
The lack of resources in rural hospitals and the general fragility surrounding rural healthcare create distrust among communities toward these hospitals. Darlene Spencer-Harris, a community organizer from Rocky Mount, NC, spoke about how she “will hear a lot of people say, ‘I don’t go to the doctor in Rocky Mount. I go to Raleigh or Greenville where I know I’m going to get the best of care’”(Spencer-Harris 1:14:51-1:20:51). This distrust is exacerbated by the dwindling numbers of rural physicians. Spencer-Harris demonstrates the importance of continuity of care to patients. She continues to visit her physician because she has known him for a long period of time, despite him not accepting her insurance (Spencer-Harris 1:14:51-1:20:51). Other rural residents do not receive this continuity of care “because every time [they] turn around, a doctor is leaving” (Spencer-Harris 1:14:51-1:20:51). Strong patient-doctor relationships cannot be built during this instability, decreasing access to care. Rural hospital closures, due to the lack of Medicaid expansion, cause people to lose trust in the remaining rural hospitals.
Alongside increasing patient distrust, rural hospital closures decrease access to healthcare by increasing travel times. Areas with rural hospital closures saw an increase of 20 miles for the median travel distance between 2012 and 2018 (Heath, 2021). Rural areas do not provide modes of transportation as readily as urban areas. Rural counties do not typically host public transportation, such as buses, or private transportation, such as Uber. Stephanie Atkinson, a nurse in Dunn, NC, describes the latter by saying “nobody is sitting around waiting for somebody to need a ride because it’s such a rural setting” (Atkinson 0:26:45-0:28:45). While Medicaid does provide transportation, the lack of Medicaid expansion in NC prevents people from having that resource. Examples of distressing consequences of this transportation barrier in other states can be applied to NC. In Fairmont, West Virginia, a woman was forced to take a 25-minute-long ambulance ride to a hospital in a different county because the medical center in her town closed (Paschal, 2020). As Atkinson mentions, “transportation is one of the biggest barriers [rural communities] face” (Atkinson 0:26:45-0:28:45).
The lack of Medicaid expansion in NC has led to increased distrust and travel times for rural populations, causing patients to turn toward home remedies and local herbalists. Ana Marie Deaver, a nurse in Dunn, NC, explains how her family relied strictly on home remedies because they weren’t “privileged enough to go to the doctor” (Deaver 0:17:02). If she had a cold, her mother would prepare a mixture of castor oil, honey, and garlic (Deaver 0:17:02). Many families, similar to Deaver’s, don’t attempt to receive allopathic care due to their lack of health insurance. They cannot rely on rural healthcare systems and choose to treat themselves. Home remedies, like Deaver’s castor oil mixture, are not typically harmful. Many have served as reliable preventative measures for generations. Increasing people’s access to healthcare would not make herbal medicine practices go extinct but allow people the option of allopathic medicine that they otherwise would not have.
Medicaid expansion would greatly increase access to care in rural populations by decreasing travel times, increasing patient trust, and providing the opportunity to receive allopathic treatments. Expanding Medicaid would allow rural hospitals to be compensated, preventing further closures and opening new hospitals. Having hospitals in close proximity would relieve rural residents of their transportation burden. The growth of the rural healthcare system would encourage clinicians to work in these hospitals, creating continuity of care and causing patients to place more trust in rural hospitals. Medicaid expansion would reduce the home remedy-allopathy divide present in Byrd’s town because North Carolinians would have access to both types of treatment. To ensure that allopathy does not overpower home remedies, rural clinicians must be aware of the cultural significance of herbal medicine. Alongside diminishing the transportation burden and instilling patient trust, Medicaid expansion would create a middle ground between herbal and allopathic treatments.
Atkinson, Stephanie. Interview with Maddy Kameny. 25 June 2018 (Y-0003). Southern Oral History Program Collection (#4007), Southern History Collection, Wilson Library, University of North Carolina at Chapel Hill.
Byrd, Nefertiti. Interview with Anna Freeman. 14 July 2018 (Y-0012). Southern Oral History Program Collection (#4007), Southern History Collection, Wilson Library, University of North Carolina at Chapel Hill.
Deaver, Ana Marie. Interview with Maddy Kamey. 28 June 2018 (Y-0020). Southern Oral History Program Collection (#4007), Southern History Collection, Wilson Library, University of North Carolina at Chapel Hill.
Heath, Sara. Rural Hospital Closures a Hit to Patient Care Access, Outcomes. 26 Jan. 2021, patientengagementhit.com/news/rural-hospital-closures-at-hit-to-patient-care-access-outcomes.
Malone T, Kirk D, Randolph R, Reiter R. Association of CMS‐HCC Risk Scores with Health Care Utilization among Rural and Urban Medicare Beneficiaries. NC Rural Health Research Program, UNC Sheps Center. December 2020. FB 169.
Paschal, Olivia. Experts are Warning that the “sky is falling” for rural healthcare in the South. Louisianaweekly.com, The Louisiana Weekly, 18 May 2020, www.louisianaweekly.com/experts-are-warning-that-the-sky-is-falling-for-rural-health-care-in-the-south/.
Spencer-Harris, Darlene. Interview with Lauren Frey. 26 June 2019 (Y-0129). Southern Oral History Program Collection (#4007), Southern History Collection, Wilson Library, University of North Carolina at Chapel Hill.