Rural U.S. health care is in a crisis. We went to a Georgia town to see how people there experience it
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Scenes from the Medical center of Elberton, in Elberton, Georgia, a clinic that serves a rural population.Claire Harbage / NPR -
Brooke McDowell of The Medical Center of ElbertonClaire Harbage / NPR -
Dr. Jonathan Poon sits in his office at the Medical Center of Elberton.Claire Harbage / NPR -
Kim Jones, the Executive director of NAMI, stands for a portrait in downtown Atlanta.Claire Harbage / NPR
Imagine you’re having a heart attack and the nearest hospital is almost an hour away.
What do you do?
That’s a situation some of the 46 million Americans who live in rural areas could find themselves in, according to the Centers for Disease Control and Prevention. They’re more likely to die than someone who lives in an urban area due to having limited access to emergency services and specialized care.
Morning Edition wanted to see first-hand what this challenge looks like, so we visited Elberton, Georgia, which bills itself as the “Granite Capital of the World.” The town with fewer than 5,000 people sits a couple of hours east of Atlanta near the South Carolina border.
Cicadas chirped loudly as we made our way inside the Medical Center of Elberton
Office manager Brooke McDowell said they don’t quiet down, not even at night.
The center is officially designated by the government as a Rural Health Clinic, which means it can get more money for treating people with Medicare and Medicaid. About 70% of the center’s patients fit that profile.
The clinic offers services like primary care, gynecology, X-rays and chronic disease management. Dr. Dan McAvoy, who sat with us for an interview, said the clinic has six physicians and two nurse practitioners.
“Probably the most common things we handle are hypertension, diabetes, heart disease, stroke,” McAvoy said.
If not for this clinic, he said, most people would have to go to cities that sit 30 to 40 miles away. That can be a barrier for some patients, McAvoy said, because they don’t have transportation available to them.
Beyond that, many rural hospitals have been closing across the country. From 2010 to 2019, 114 closed or cut key services across the U.S., according to health policy nonprofit KFF. Closures are concentrated in states like Georgia that haven’t expanded Medicaid, the joint state and federal program that provides health coverage to low-income people.
In Georgia specifically, 18 of its 30 rural hospitals are at risk of closing due to financial issues, according to a February 2024 report from health consulting firm Chartis. The report also found that about half of all rural hospitals in the U.S. are operating in the red.
For 72-year-old Sylvia Chapman, this clinic means access to health care near her home — and a chance to tell jokes
“Why do melons get married?” she asked us and waited for a guess. “Because they cantaloupe.”
Chapman retired after 34 and a half years in public service and moved to Elberton seven years ago. She’s been a patient at the clinic for six years and she likes it here. “They let me tell my jokes. They tolerate me, so that’s not bad,” she said.
She’s had a couple of strokes, and every now and then, she needs to see specialists. The medical center helps her with referrals, and she likes her doctor. She’s also able to visit the nearby Elbert Memorial Hospital.
Where would she go if this clinic wasn’t here?
Athens, Georgia, takes her about 50 minutes to get to, or the town of Anderson, which is slightly closer but across the state line into South Carolina.
Would she skip care if what she needed was farther away?
“It’s easier to come here,” she said, adding that she would travel farther if needed. But the headache would be her husband’s because she rarely does any of the driving. “Whenever I tell my husband I have an appointment, he says, ‘Where is it?’”
He’s relieved to hear when they’re in town.
“You need this. You don’t need to get rid of this place,” she said, of the Medical Center of Elberton. “You have too many people in the waiting room, so you know it's a needed place. Very convenient for the locals.”
The local need is highlighted in Dr. Jonathan Poon’s schedule: It’s early May and he’s already booked out until July
It’s not a good feeling, Poon said, because he doesn’t want to be inaccessible to his patients.
“We will see, you know, our patients walk in without appointments any day. We'll work them in,” Poon said. “But it's just not a good feeling when someone calls and they have to wait for a month or more for appointments.”
It's a balance, Poon said, because he wishes he could spend more time with patients.
“But the more time we spend with patients means the fewer patients you can spend time with,” Poon said.
“Maybe I can’t clone myself, but if we can have more providers to help see our patients who have the same passion we do, that would be a great start,” Poon said.
That will be a challenge the clinic will have to grapple with sooner than later.
“Particularly, as some of us are aging, there’s going to be a need in the next few years for more physicians,” McAvoy said.
But it’s difficult to get doctors to move out this way.
“We have to find someone who likes the lifestyle of living in a small community and enjoys outdoors things, such as fishing and hunting,” McAvoy said.
Poon told us that one of the medical services most lacking here is mental health care
Poon said he and other doctors here have noticed mental health needs have become more of an issue over the past few years, but the clinic is limited in what it can do.
“We just don't have really a stable mental health program here,” Poon said. “And so we'd like to, you know, ultimately offer that ourselves. But there's no real, kind of, direct way for rural health to offer that.”
Georgia ranked 49th in access to mental health care and first in prevalence of mental illness in the 2023 report from Mental Health America, a nonprofit that works to provide resources and advocates for more access.
In Atlanta, we asked Kim Jones, the executive director of the National Alliance on Mental Illness for Georgia, why access is such an issue here.
She said that federal law requires insurance companies to provide mental health care at the same level that they do for physical health. Her organization has found that isn’t happening in Georgia.
But it’s also something people are uncomfortable talking about.
“I think there's just this overall stigma that mental health is maybe more so based on your behavior and your beliefs and pull up your bootstraps and just get over it. Versus it truly being a physical chemical imbalance in your brain at times,” Jones said.
With access overall in Georgia already a challenge, Jones said rural towns and counties fare even worse.
“There are a significant number of counties here in Georgia that have no mental health providers at all,” she said. “And so, even when we look at trying to expand telehealth, we have areas that are not covered by the internet.”
Despite the challenge of accessing health care, Sylvia Chapman tells us why this small town life appeals to her.
“I don’t have to fight traffic in the metro areas,” she said. She’s enjoying her retirement, playing games and puzzles on her phone. She and her husband will celebrate 47 years of marriage later in August.
She’ll keep coming to this clinic for her health care
She’ll also be watching the November election.
As someone who spent her working life helping Georgians get Medicaid, she recognizes the importance of health care as an issue.
“People are deciding whether to buy groceries or buy medicines. And that's the same problem we had back in the seventies and eighties,” Chapman said, adding that how people vote in November will be “very important” in deciding if Americans continue to face that challenge.
Transcript
A MARTÍNEZ, HOST:
Imagine you're having a medical emergency -say, a heart attack - and live in a rural area of the United States. According to the Centers for Disease Control and Prevention, you'd be more likely to die than someone who lives in an urban area. Now that could apply to more than 46 million Americans. We wanted to see firsthand the challenges of accessing health care in rural America. Elberton, Ga., is a city of just under 5,000 people. It's a couple of hours east of Atlanta near the South Carolina border. It bills itself as the Granite Capital of the World. But recently when I went to visit, it felt like it was ground zero for something else.
I've never experienced cicadas before, so this is a little odd for me.
In the parking lot of the medical center of Elberton, we're surrounded by cicadas with some taking up residence on my producer, Milton Guevara and editor Adam Bearne.
ADAM BEARNE, BYLINE: Look, it's on your headphone, Gue.
MARTÍNEZ: So I was really ready to go inside the center, which is designated as a rural health clinic. Now, that allows it to get more money from the federal government for providing Medicare and Medicaid services. Office Manager Brooke McDowell shows us around.
BROOKE MCDOWELL: We have 25 rooms. Every room has a computer. That is where we do our documentation. Even though we're rural, we pride ourselves on having really great technology.
MARTÍNEZ: In one of those rooms was 72-year-old Sylvia Chapman, who chats with us while waiting to see the doctor.
SYLVIA CHAPMAN: So what do you want to know?
MARTÍNEZ: Well, I just want to know, like, if this place weren't here, where would you go? What would you do to get medical care?
CHAPMAN: I would probably have to go to Athens or even Anderson. So this is a great place.
MARTÍNEZ: How much of a burden would that be to have to go to Athens or somewhere else?
CHAPMAN: Well, I don't drive that much. So my husband does all the driving, and it's a pain in the tucus for him.
MARTÍNEZ: Athens, home to the University of Georgia, is about a 45-minute drive from here. Anderson, across the state line in South Carolina, isn't much closer. But beyond this clinic's convenience, Chapman just likes the people here.
CHAPMAN: They let me tell my jokes (laughter). They tolerate me, so that's not bad. If I need a specialist or something, they go in the computer and find one for me. And so they're working for me.
MARTÍNEZ: Even though she says she'd travel farther if she had to, Chapman says the clinic is critical for the community.
CHAPMAN: You had too many people in the waiting room. So you know it's a needed place - very convenient for the locals.
MARTÍNEZ: Sylvia became a local when she moved to Elberton with her husband in 2017, and before she let us go, she was desperate to tell us her joke for the day.
CHAPMAN: Why do melons get married?
MARTÍNEZ: Why? Why do melons get married?
CHAPMAN: Because they can't elope.
(LAUGHTER)
MARTÍNEZ: She nailed the delivery. Now, Sylvia's recovering from a couple of strokes that she's had since she moved here, and that's typical of the kind of medical issues the clinic helps people with. Here's managing partner, Dr. Dan McAvoy.
DAN MCAVOY: Probably the most common things we handle are hypertension, diabetes, heart disease, stroke. And we do a good many wellness exams.
MARTÍNEZ: Dr. McAvoy oversees a small staff, the scope of which becomes crystal clear when another physician, Dr. Jonathan Poon, tells us what his schedule looks like.
JONATHAN POON: My office staff just told me that I'm booked out until July, which is not a good feeling because I don't want to be inaccessible to my patients. And we do try to open up. We will see patients, you know, walk in without appointments any day. We'll work them in.
MARTÍNEZ: But do you just as a person feel stretched thin? Like it's - I mean, I'm sure you want to care for as many people as you can, but...
POON: Yeah.
MARTÍNEZ: ...You're also a human being...
POON: Yeah.
MARTÍNEZ: ...That gets tired.
POON: It's a balance because you want to spend more time with the patients. But the more time you spend with the patients means that the fewer patients you can spend time with. And so being able to fix that problem is something that, maybe I can't clean myself, but we can have more providers to help see patients who have the same passion we do. That would be a great start.
MARTÍNEZ: How easy is it to attract a physician?
POON: Very difficult. We have to find someone who likes the lifestyle of living in a small community and enjoys outdoors, things such as fishing and hunting and that kind of thing.
MARTÍNEZ: While the clinic can handle many of their patients' needs, there are some things they just can't deal with.
POON: If we have someone who comes in that we think is having a heart attack, we have to send them to Athens because we have no cardiology in town.
MARTÍNEZ: But for Dr. Poon, it's not just about being more equipped to handle medical emergencies. If he had his way...
POON: I'd love to see, you know, better access to mental health because we see how much it has become a problem over the past few years, and we just don't have really a stable, you know, mental health program here. And so we'd like to ultimately offer that ourselves, but there's no real kind of direct way for rural health to offer that.
MARTÍNEZ: Mental health care access isn't just hard to get in the rural areas of the state.
KIM JONES: Georgia unfortunately ranks almost last in access to care for mental health here in Georgia. We did move up from being 51st to 49th.
MARTÍNEZ: That's Kim Jones, executive director of the National Alliance on Mental Illness or NAMI in Georgia. We met at Woodruff Park in downtown Atlanta next to a fountain and across from a streetcar stop. Despite moving up to 49th in the nation in access to mental health care, it's still low, so I asked Jones why.
JONES: Parity is a federal law that requires insurance companies to provide care at the same level that they do for physical health. And one of the issues that we have found is that's not happening here in Georgia.
MARTÍNEZ: Is it because maybe people feel that physical ailments require, maybe deserve, more attention and funding and resources than mental health issues?
JONES: Yeah, I definitely think it's a stigma that mental health is maybe more so based on your behavior and your beliefs and pull up your bootstraps and just get over it versus it truly being a physical chemical imbalance in your brain at times.
MARTÍNEZ: And Jones also understands the challenges of providing mental health care in rural areas.
JONES: There are a significant number of counties here in Georgia that have no mental health providers at all. Also, even when we look at trying to expand telehealth, we have areas that are not covered by internet, so telehealth isn't even an option.
MARTÍNEZ: Where would resources toward mental health be best spent?
JONES: I think not only in Georgia, but actually just mental health in general is going to get better when everyone helps with mental health. We all have been trained in CPR and first aid. And often, when I give speeches or talk about this, I ask how many people have actually used what they learned for CPR and first aid. A couple of hands go up. When I ask people, how many of you have been trained on what to do when somebody is experiencing a mental health crisis. Very few hands go up. And then when I ask how many of you have been in a situation with a mental health crisis and could have used that training, almost every hand goes up.
MARTÍNEZ: And for this election year, Jones is hoping more lawmakers in Georgia and around the U.S. raise their hands to help fund access to mental health care. Transcript provided by NPR, Copyright NPR.
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