RALLS — On a map, this small Southern Plains town looks 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 departments.
But being close to a larger city makes getting health care more difficult. As Lubbock rapidly grew and reached, the city inadvertently drained patients, doctors, and businesses from nearby towns.
The result: everyone in Ralls finds themselves driving 34 minutes to the nearest hospital in Lubbock if they’re sick, injured or dying.
“My mom is going to be 83 years old and she can’t drive anymore,” said Ralls resident Kathleen Sedgwick, who retired to care for her mother. “She has a regular doctor, a doctor for her gallbladder problems, a doctor for her liver and a cardiologist.”
They are all in Lubbock.
Sedgwick drives his mother and blind mother-in-law to Lubbock at least once a week. Sometimes it can be three times a week.
People living in the far reaches of Texas have good reason to be disappointed. At best, drives like these are time-consuming and destructive. At worst, they are the difference between life and death.
As other small-town hospitals struggle to keep the lights on, their services, doctors and patients end up heading to the nearest urban medical district. Rural-to-urban resource migration is often due to various factors that push rural residents out, such as a lack of economic benefits or job and education opportunities.
Don McBeath, a rural health expert in Lubbock, calls this phenomenon the “doughnut effect” and said it’s happening 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 center in Texas and bypass it, the hospitals in that range may be losing patients to the major medical center.”
In the 10 counties surrounding Lubbock, four of them have critical access hospitals — clinics that were hospitals before the cutbacks — five of them have limited services and one has no hospital at all.
“Rural hospitals are often the biggest economic driver for many rural communities,” said Adrian Billings, an Odessa physician with the Texas Tech University Health Sciences Center. “So when one closes, the doctors and other staff will move to another community that has a hospital.”
It’s a ripple effect from there, Billings said: As rural doctors move away, they take their children out of the local school and affect state funding. Local businesses have fewer people spending money in their stores, and it becomes harder for the city to attract new businesses.
Muleshoe is a primarily 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 to Lubbock.
As is the case with many rural communities, Muleshoe’s population has declined. According to the U.S. Census, the city lost 1.2 percent of its population from 2020 to 2021. This is part of a statewide trend, as more than half of all Texas counties lost population between 2010 and 2010. and 2020. All of them are exclusively in rural Texas.
Erin Gonzalez somewhat follows that lead as a nurse practitioner. She grew up in her mother’s Muleshoe Clinic before moving when she was 18 to several small towns in West Texas, then New Mexico. She moved back home a few years ago when her mother was ready to retire.
Working in rural medicine is a unique experience. The people Gonzalez grew up with now sit on the table in her exam room. Her commitments range from visiting someone’s child to checking on their great-grandmother later that day. She already knows that next Sunday she will see her patients at church.
Inevitably, her patients begin to feel like family. Which makes it hard for her to see their community wasting resources.
“When hospitals close and health facilities start to conglomerate, that’s the corporatization of medicine,” Gonzalez explained. “It’s getting 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 many.”
Working in rural healthcare can be daunting at times. During the COVID-19 pandemic, she was prescribing medications that Muleshoe pharmacies could not fill and had to fill in Lubbock instead. Even in the case of a broken arm or leg, Muleshoe’s providers can only stabilize and send patients — in an hour and 15 minutes — to an orthopedic surgeon in Lubbock who can set the bone.
“We have patients who have needs but are without vehicles,” Gonzalez said. “So if you ask someone to drive 30 miles to see a specialist, they’re going to have to pay for a ride or ask someone to borrow a car.”
While Gonzalez can see the impact of the donut effect through the hospital’s services, Billings, who is also Texas Tech’s associate academic dean, can see it through work. A study highlights how geographic diversity is an indicator of where a medical student will end up working. From 2002 to 2017, students from rural backgrounds in medical school decreased by 28%, while students from urban areas increased by 35%.
He said rural health care students are most likely to be the ones to return to their hometowns or another small town when they graduate.
It’s harder, Billings said, to recruit urban students to live a rural lifestyle. City students are used to certain luxuries, such as 24-hour shopping and international airports. A young student choosing to leave a bustling city with entertainment around every corner and go to a quiet small town that doesn’t have a movie theater can happen. But it’s rare.
“Take an urban student and ask them to go to a place like Presidio where they’re 150 miles from the nearest Walmart, that’s a tough ask,” Billings said.
“Now if we can give a student born and raised in the Presidio the opportunity to achieve academic success at the university level [and] then the professional level, they are the ones most likely to come back home to practice there,” he said.
McBeath, who is retiring from the Texas Association of Rural and Community Hospitals in 2021, said a big part of the problem is that rural hospitals’ expenses often exceed revenue. Because rural populations are often elderly or low-income, rural hospital patients are typically uninsured or reliant on Medicaid. Both options could leave hospitals running in the red and at risk of closing.
There’s also what McBeath considers a misconception — the idea that one can get better health care in an urban facility than in a rural one. McBeath said this puts off people in rural communities who have a choice of where to go.
“You always hear cities say, ‘Shop local first,’ and that applies to health care and hospitals,” McBeath said. “If you can’t get service at your local hospital, that’s one thing. But if you can get it locally and get around it, it will hurt the local hospital and if enough happens, it might not be there after a while.
No rural hospitals have closed in Texas since March 2020, which health experts attribute to federal funding serving as a safety net during the pandemic. However, that funding is ending soon, leaving some worried about the next step.
“If we don’t make a huge investment to continue treating people in rural areas, we’re going to become obsolete,” Gonzalez said. “It’s going to be impossible to stay open.”