Why health care is still hard to access in rural towns near Texas’ bigger cities

Main Street in downtown Ralls on Sept. 1, 2022. (Mark Rogers For The Texas Tribune, Mark Rogers For The Texas Tribune)

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RALLS — On a map, this small town in the South Plains seems well positioned for residents to find health care. With nearly 1,700 residents, Ralls is nestled between Crosbyton, about 10 miles away, and Lubbock, about 30 miles away, both of which have hospitals and emergency rooms.

But being neighbors with a larger city has made getting health care harder. With Lubbock quickly growing and in reach, the city has inadvertently sapped patients, physicians and businesses from nearby towns.

The result: Everyone in Ralls finds themselves driving 34 minutes to the closest Lubbock hospital if they are sick, injured or dying.

“My mom is about to be 83 and can’t drive anymore,” said Kathylynn Sedgwick, a Ralls resident who retired to take care of her mother. “She’s got a regular doctor, a doctor for her gallbladder problems, a doctor for her liver and a cardiologist.”

All of them are in Lubbock.

Sedgwick drives her mother, and her blind mother-in-law, to Lubbock at least once a week. Sometimes it can be three times a week.

People living in the far-flung corners of Texas have a good reason to be frustrated. At best, drives like these are time-consuming and disruptive. At worst, they are the difference between life and death.

As other small-town hospitals struggle to keep the lights on, their services, physicians and patients eventually drift into the nearest urban medical district. The rural-urban migration of resources is often due to various factors pushing rural residents out, such as a lack of economic benefits or job and education opportunities.

Don McBeath, a rural health care expert in Lubbock, calls this phenomenon the “doughnut effect,” and said it happens all over Texas.

“If you have a rural hospital located within 30 to 60 miles of an urban area with a major medical center, that rural hospital is basically competing,” McBeath said. “If you take any major medical hub in Texas and do a doughnut around it, hospitals in that range could be losing patients to the major medical center.”

In the 10 of the counties surrounding Lubbock, four of them have critical access hospitals, five of them have limited services, and one doesn’t have a hospital at all.

“Rural hospitals are often the biggest economic driver for many rural communities,” said Adrian Billings, an Odessa doctor with the Texas Tech University Health Sciences Center. “So when one closes, doctors and other employees will move to another community that does have a hospital.”

It’s a ripple effect from there, Billings said: As rural physicians move away, they take their children out of the local school and affect state funding. Local businesses have less people spending money at their stores, and it becomes harder for the town to attract new businesses.

Muleshoe is a predominantly farming and ranching community nestled in Bailey County. The small town of nearly 5,100 people is closer to the New Mexico border — about a 20-minute drive — than it is to Lubbock.

As is the case with many rural communities, Muleshoe has had population decline. According to the U.S. census, the town lost 1.2% of its population from 2020 to 2021. This is part of a trend seen statewide, as more than half of all Texas counties have lost population between 2010 and 2020. All of them are exclusively in rural Texas.

Erin Gonzales somewhat followed that track as a nurse practitioner. She grew up in her mother’s Muleshoe clinic before moving when she was 18 to a few small towns in West Texas, then to New Mexico. She moved back home a few years ago, when her mother was ready to retire.

Erin Gonzales works as a nurse practitioner at the Sudan Medical Clinic Monday, March. 6, 2023, in Muleshoe, Texas.

Erin Gonzales, a nurse practitioner at the Sudan Medical Clinic, in Muleshoe on March 6, 2023. “If we don’t make a huge investment to keep treating people in rural areas, we will become obsolete,” Gonzales said. “It will be impossible for us to stay open.” Credit: Justin Rex for The Texas Tribune

Cars pass through downtown Muleshoe, Texas, Monday, March. 6, 2023. (Justin Rex for The Texas Tribune)

Cars pass through downtown Muleshoe on March. 6, 2023. Credit: Contributor

Buildings sit vacant Monday, March. 6, 2023, in Muleshoe, Texas.

Vacant buildings in Muleshoe on March. 6, 2023. As with many small Texas towns, Muleshoe's population is declining. Credit: Justin Rex for The Texas Tribune

First: Cars pass through downtown Muleshoe on March 6, 2023. Last: Vacant buildings in Muleshoe. Credit: Justin Rex for The Texas Tribune

Working in rural medicine is a unique experience. People Gonzales knew growing up are now sitting on her exam room table. Her appointments range from seeing someone’s child to checking their great-grandmother later the same day. She already knows she will see her patients at church the following Sunday.

It’s inevitable that her patients would start to feel like family. Which makes it difficult for her to see their community lose resources.

“When hospitals close and health care facilities start to conglomerate, that’s the corporatization of medicine,” Gonzales explained. “It’s to a point where it’s easier for us, as providers, to not run private practices or keep our doors open because you need so much.”

It can be disheartening at times to work in rural health care. During the COVID-19 pandemic, she would prescribe medicine that Muleshoe’s pharmacies could not fill, and instead had to be filled in Lubbock. Even in the case of a broken arm or leg, Muleshoe providers can only stabilize and send patients off — an hour and 15 minutes away — to a Lubbock orthopedic surgeon who can set the bone.

A truck passes a county road in Bailey Co. on March. 6, 2023.

A truck passes a county road in Bailey County. Credit: Justin Rex for The Texas Tribune

“We have patients who have needs but who are vehicle destitute,” Gonzales said. “So if you’re asking somebody to drive 30 miles to see a specialist, they’re going to have to pay for a ride or ask somebody to borrow a car.”

While Gonzales can see the impacts of the doughnut effect through the hospital’s services, Billings, who is also an associate academic dean for Texas Tech, can see it through employment. A study highlighted how geographic diversity is an indicator on where a medical student will eventually work. From 2002 to 2017, students with rural backgrounds in medical school declined by 28%, while students from urban areas increased by 35%.

He said rural health care students are most likely to be the ones to go back to their hometowns or another small town when they graduate.

It’s harder, Billings said, to recruit urban students to live a rural lifestyle. Urban students are accustomed to certain luxuries, such as 24-hour stores and international airports. A young student choosing to leave a lively city with entertainment around every corner to a quiet small town that doesn’t have a movie theater can happen. But it’s rare.

“You take an urban student and ask them to go to a place like Presidio where they are 150 miles away from the nearest Walmart, it’s a hard ask,” Billings said.

“Now, if we can enable a Presidio-born-and-raised student for academic success at the university level [and] then the professional level, they are the ones most likely to return home to practice there,” he said.

McBeath, who retired from the Texas Organization of Rural and Community Hospitals in 2021, said a big part of the problem is that rural hospital expenses often exceed the revenue. Since rural populations are often elderly or low income, rural hospital patients are typically uninsured or rely on Medicaid. Both options can leave hospitals operating in the red and at risk of closing.

Then there’s what McBeath considers a misconception — the idea that a person can get better-quality health care at an urban facility than at a rural one. McBeath said that is driving away people in rural communities who do have a choice on where to go.

“You always hear towns say, ‘Shop local first,’ and that applies to health care and hospitals too,” McBeath said. “If you can’t get service at the local hospital, that’s one thing. But if you could get it locally and bypass it, that’s harming the local hospital, and if it happens enough, it may not be there after a while.”

No rural hospitals have closed in Texas since March 2020, which health care experts have credited to federal funding that served as a safety net during the pandemic. However, that funding is ending soon, making some worry about the next step.

“If we don’t make a huge investment to keep treating people in rural areas, we will become obsolete,” Gonzales said. “It will be impossible for us to stay open.”

A truck drives down Highway 84 towards Muleshoe. The town is closer to New Mexico than it is to Lubbock, the nearest city.

A truck drives down Highway 84 toward Muleshoe. The town is closer to New Mexico than it is to Lubbock, the nearest city. Credit: Justin Rex for The Texas Tribune

Disclosure: Texas Tech University and Texas Tech University Health Sciences Center have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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