While national media outlets cover the novel coronavirus outbreak in urban hotspots, rural America is bracing for its own wave of the epidemic. Several mostly-rural states have not mandated statewide stay-at-home orders, including Arkansas, Iowa, Nebraska, North Dakota, South Dakota, Utah, and Wyoming. Experts say it's only a matter of time before the virus hits these areas—and hard.

Cheat sheet: The dire state of rural health care

Early hot-spots spell trouble for rural communities

There's evidence that the novel coronavirus has quietly spread through rural areas. More than two-thirds of rural counties nationwide had at least one confirmed coronavirus case, and one in ten are reporting deaths.

Sioux Falls, South Dakota, is home to one of the single largest coronavirus outbreaks in the country, where more than 300 workers in a pork processing plant fell sick. A similar story in Louisa County, Iowa, propelled the number of infections to 200 in the county. According to a New York Times analysis, rural areas like Blaine, Idaho, Randolph, Georgia, and Terrell, Georgia, have some of the highest numbers of coronavirus cases per resident, outpacing urban hotspots like Chicago and New Orleans. On April 2nd, the rural town Albany, Georgia, had a coronavirus death rate of 7.65%, while the New York-New Jersey-Massachusetts area's mortality rate was 1.4%.

While rural areas had hoped their geographic isolation and dispersed communities would protect them from the brunt of the virus, these emerging clusters of cases and high per capita mortality rates suggest that rural America is far from immune to Covid-19.

Rural populations at heightened risk if coronavirus hits

In fact, research suggests these communities are poised to face especially poor outcomes. A study from the University of New Hampshire found that more than half of rural counties experience Covid-19 mortality rates that are higher than the national average due to their older populations. Rural residents also experience more chronic conditions, leaving them at a higher risk for complications.

Rural residents are more likely to be considered essential workers—like those in the meatpacking plants in Sioux Falls and Louisa County—leaving them at greater risk for exposure.

Rural populations also face greater barriers to accessing care. Residents are more likely to be lower income, uninsured, or live in states that have not expanded Medicaid, making it harder for them to afford unexpected care if they get sick. Even if they do seek care, geographic isolation and the growing number of hospital closures exacerbate access challenges. Importantly, while urban and suburban providers are turning to telehealth as a way to meet demands for care and reduce the virus' spread, rural areas lack the basic infrastructure to support telehealth.

Coronavirus could spell financial ruin for already struggling rural hospitals

More than 120 rural hospitals have closed since 2010, and the remaining hospitals fight to stay open. For the 2,000 rural hospitals serving about 60 million Americans—or a fifth of the total population—Covid-19 poses a looming threat to a fragile system.

Razor thin (or often negative) margins mean these hospitals don’t have the flexibility to handle plummeting revenue and rising expenses. They already lack key resources such as personal protective equipment (PPE), ventilators, inpatient beds, and medical staff. If a Covid-19 surge hits a rural hospital, they likely cannot compete with urban giants to acquire these lifesaving supplies. And unlike other natural disasters, such as hurricanes, overburdened rural hospitals can't lean on big-city medical centers for help when those organizations are also struggling.

Making matters worse, the stimulus package excludes government-owned hospitals from receiving loans, and many of these organizations serve rural communities. This unintentional loophole leaves some of the most vulnerable rural hospitals at risk as Covid-19 heads toward them. On April 18th, nine senators urged HHS to review its methodology for distributing the next round of CARES Act funding to better reflect the unique needs of providers who serve rural and predominantly Medicaid patients.

"There is literally no room for error here," Alan Morgan, CEO of the National Rural Health Association told the Los Angeles Times. "Rural America is a tinderbox of a health care crisis for those most in need."

To stay up to date on how the pandemic is evolving in rural areas, review these additional resources:

• The Rural Health Hub has continuous coverage of the rural response to Covid-19.
• Find clusters of Covid-19 cases and county level data using University of Chicago’s Covid-19 map.
• The Washington Post created a calculator to assess whether hospitals in an area are at risk of being overwhelmed by Covid-19 patients.

Is your rural hospital implementing strategies to combat the impact of Covid-19? Email Darby Sullivan at sullivada@advisory.com to share your experience.