Laboring to Provide Medical Care
Rural medical care shortage places residents in harm’s way
By Julian Emerson
Communications Specialist, Wisconsin Farmers Union
As a licensed midwife providing home birth services, Katie Breitenmoser works to meet the needs of low-risk pregnant mothers and families, but when problems arise during pregnancies, she collaborates with hospital-based providers to ensure the best outcomes possible.
However, doing so in central and northern Wisconsin where she works has become increasingly difficult as fewer medical providers are providing birthing services. In some cases, Breitenmoser said, her patients must travel two hours or more to receive the care they and their babies need. In other instances, she said, when serious health issues arise, pregnant mothers must be rushed to the nearest provider, often a drive of 45 minutes or longer.
Periodically, she said, mothers’ and babies’ lives are in danger. In the worst cases, deaths could occur because rural families often live far from a hospital that offers obstetric care.
“With birth and other types of medical care, we are really talking about life and death here,” Breitenmoser said. “We have fewer and fewer providers, and it seems like we continue to lose them. This is a huge issue, and it needs to get more attention.”
Since 2010, more than a dozen medical providers in rural Wisconsin have discontinued birthing at their sites. And it’s not just lack of access to birthing centers that are imperiling medical care in rural Wisconsin, health care experts say. Fewer specialized health care services, such as cardiac care or chronic illnesses, in the state’s rural areas also mean longer drives for people who live far from specialized care.
Many rural communities in Wisconsin once had their own hospitals. But outdated facilities, financial challenges, and difficulties attracting medical staff to those locations has meant fewer providers and less specialty care.
Emergency Medical Services (EMS) providers also are in increasingly short supply in Wisconsin. Across the state EMS agencies, especially those that rely on volunteer paramedics, face staffing shortfalls, with some facing halting that service.
A labor shortage, financial models that no longer work and inflation that makes buying ambulances and other equipment increasingly expensive mean EMS services are struggling, leaving many in rural areas in peril. In cases of medical emergencies, long distances from hospitals and lack of EMS service can prove deadly, experts say.
In Manitowish Waters, a Vilas County town of fewer than 600 in northeast Wisconsin, Jessica Mabie is one of only two EMS staffers providing emergency coverage to the surrounding area. Attracting more volunteer staff has proven difficult in recent years, she said, a fact that delays care and in some cases puts people’s lives at risk.
The closest advanced life support care is 20 minutes from Manitowish Waters, Mabie said, and when one ambulance is busy, a backup can take 45 minutes or longer to respond.
“Less people means longer wait times for an ambulance, as it has to come from a different town,” Mabie said. “Sometimes, unfortunately, that can be the difference between life and death.”
As EMS training and certification requirements have increased in recent times, the number of people volunteering for those positions has dropped, said Mabie, an EMS volunteer for the past 17 years. Even full-time departments that offer pay and benefits are scrambling to find employees.
Additionally, Mabie said, grisly scenes that EMS workers sometimes respond to can be emotionally taxing. In small communities like where she lives, oftentimes EMS workers know the accident victims at the scenes they respond to.
“This job is not for everyone,” she said. “You see the worst of the worst.”
Access to health care and EMS services are in especially short supply in small communities like Manitowish Waters, where extremely limited budgets come on top of a declining population, fewer resources and changes in reimbursement for medical procedures combine to make services more difficult to provide.
As available medical options decline, Breitenmoser said some of her patients drive more than 100 miles one way to receive the care they need. “It’s really hard for people to go that far,” she said. “But in some cases, to get the care they need, they don’t have any other choice.”
‘Do More With Less’
Health care providers in rural parts of Wisconsin and elsewhere across the country have struggled for years to staff hospitals and clinics. In the past few years, exacerbated by the coronavirus pandemic, retaining employees has become increasingly difficult, officials say, and attracting them to rural places is as challenging as ever.
As old hospital buildings in rural Wisconsin have aged and costs to upgrade them to meet current medical standards have been prohibitive, rural hospitals have closed in many smaller communities. In some cases those facilities have been replaced by satellite clinics and hospitals of larger providers centered in urban locations. But in other instances those outdated hospitals have not been replaced and have simply shut down.
Marshfield Clinic Health System has expanded its reach by building hospitals and clinics in rural parts of central and northwest Wisconsin that have lost hospitals. While the need exists for more providers in those regions, growing further could prove challenging for numerous reasons, among them that staffing more health care facilities would prove difficult, said Dr. William Melms, Marshfield Clinic Health System chief medical officer.
Simply attracting medical staff to work in rural areas is especially challenging, Melms said, noting the vast majority of graduates seek to work in larger communities.
“One major problem is finding labor,” he said. “During the (coronavirus) pandemic, we saw people leaving, and many of them didn’t come back. That is a problem in both rural and urban markets, but in rural ones it is acutely problematic.”
Maintaining health care services in rural communities is growing more difficult as those regions lose people amid a longtime, ongoing population shift from rural sites to urban ones, where job opportunities are more plentiful.
From 2010 to 2020, Wisconsin’s population increased by 3.6%, to 5.9 million, U.S. Census figures show. However, among the nearly 30% of Wisconsin’s 72 counties that lost population during that time, most were rural.
A 2020 report by Madison-based Forward Analytics, an organization that measures population trends, found that two-thirds of Wisconsin’s rural counties lost population from 2010 to 2018. The number of counties losing people nearly doubled from the previous decade, the report found.
“Across both Wisconsin and the nation, populations are shifting from rural to urban areas,” the report states. “While this is a long-term phenomenon, it seems to have accelerated over the past 10 years.”
Keeping hospitals and medical clinics operating with a reduced population to pay bills is a challenge, medical providers say. Compounding the problem, they say, is the fact that patient populations in rural locations generally are more vulnerable and more expensive to care for. Mortality and suicide rates are higher in rural places than urban ones, along with opioid-related drug overdose deaths.
Even as rural patients are oftentimes more expensive to treat, their ability to pay for medical services may be less. More urban people tend to have better health insurance than their rural counterparts, resulting in lower payback to rural hospitals. In addition, efficiencies of scale available at larger urban hospitals and clinics often aren’t possible in rural settings.
“When you’re looking at health care in rural areas, we’re having to do more with less,” Melms said.
Broadband, Telehealth Are Key
The growth of mobile jobs that was accelerated greatly during the coronavirus pandemic could attract more people to rural parts of Wisconsin and the U.S., economists say. For that migration from urban to rural settings to happen, high-speed internet access must continue to expand in rural areas.
Studies show high-speed internet, commonly referred to as broadband, is lacking in much of rural Wisconsin. Gov. Tony Evers’ administration has directed significant dollars toward increasing broadband across the state, and the Republican-led state Legislature also has supported broadband funding.
“Broadband represents a very real opportunity to attract jobs and people to rural areas,” said Brittany Beyer, executive director of the Grow North Regional Economic Development Corporation in northern Wisconsin and a member of Gov. Tony Evers’ Task Force on Broadband Access. “This is a way rural areas can reverse the trend of losing people and jobs to urban ones.”
To reach patients in rural sites, health care providers increasingly are using the internet to connect virtually. Those efforts have proven successful in some areas, helping providers extend specialized medical care to smaller ones where staffing wouldn’t otherwise allow it. However, doing so remains challenging in locations where internet speeds are slow or nonexistent.
Breitenmoser, who is a Marathon County Farmers Union member and lives on her family’s dairy farm near Merrill, said she hopes broadband expansion does improve health care access for rural residents. However, in the meantime she worries that staffing shortages at rural hospitals and continued economic pressures could lead to reduced medical services and more hospital and clinic closures in Wisconsin’s countryside.
As an example, Mayo Clinic Health System announced on Sept. 1 that its Barron hospital had ceased labor and delivery services on Aug. 26, and that those services at its Menomonie hospital will end on Dec. 31. Those hospitals join more than a dozen statewide that have stopped providing births in recent years.
Providing birthing services is labor intensive, and staffing the Barron and Menomonie delivery sites had become increasingly difficult, Mayo officials said. “Mayo Clinic Health System has been aggressively recruiting for several open OB-GYN positions over the last two years,” the Sept. 1 release states. “These relentless efforts have been unsuccessful in filling these critical openings.”
Such service reductions will continue to leave her patients and other rural residents without readily available medical care, Breitenmoser said.
“So often in these situations, it is budget over services, and this seems like it is only going to go further downhill,” she said. “If we don’t make significant changes, I shudder to think of where we are headed.”