The COVID-19 pandemic could be ‘devastating’ in rural areas

Workers load new respirators into a van at Columbus Covid2 Hospital on March 16, 2020 in Rome, Italy. Columbus Covid2 Hospital. (Photo by Marco Di Lauro/Getty Images.)

The COVID-19 pandemic is not hitting greater Minnesota as early or as hard as the metro yet, but rural health care systems may be ill-equipped to deal with the outbreak, with fewer health care workers and hospital beds than cities.

One-third of Minnesota counties — all of them rural — have fewer than about 25 hospital beds. Eight counties have none, according to preliminary state data from 2018.

The pandemic could be “devastating” to rural communities nationwide because of fewer hospitals, a smaller health care workforce and spotty broadband access, said Carrie Henning-Smith, deputy director of the University of Minnesota Rural Health Research Center. Although rural health care in Minnesota ranks highly in the U.S. by many measures, access to care is still limited across parts of greater Minnesota, an analysis of state hospital records shows.

Lower population density in rural areas means the virus is likely to spread more slowly in these communities than in the cities, Henning-Smith said. Cases of COVID-19 identified by the state so far bear that out, with 55 of the 89 confirmed cases in Hennepin and Ramsey counties.


But the pandemic will hit rural communities eventually, and many don’t have the health care infrastructure to handle an influx of patients, she said. Greater Minnesota’s aging population and higher rates of chronic illness also put them at higher risk for severe COVID-19. Nearly 45% of rural residents are over the age of 50, compared to 32% of urban residents.

Between 845,000 and 2.5 million Minnesotans could get sick during the pandemic, according to projections from from the Harvard Global Health Institute. The number of people requiring hospitalization statewide could drastically exceed the number of available hospital beds, even under the researchers’ most conservative projections of the virus’ effects. In a moderate scenario where 40% of residents fall ill, more than 350,000 people — 8% of the state’s population — will require hospitalization. Roughly 75,000 will need ICU treatment. 

Health care workforces are already limited in rural areas and will be even more strained when doctors and nurses get sick or need to self-quarantine. In Minnesota, 80% of licensed health care workers were in metro areas in 2019, whereas roughly 73% of the population lived in metro areas, according to the Minnesota Department of Health.

“Our bench players are not as deep. You’ve got your A team and your B team, but beyond that, you don’t have the depth to call up your C team and your D teams,” said Dr. Keith Stelter, president of the Minnesota Medical Association.


Moving providers between locations to meet patient need is also more difficult in rural areas, where hospitals are farther apart, Stelter said. For example, in the Twin Cities, a health care worker in the Fairview Health Services system could move from the system’s Edina hospital to the University of Minnesota Medical Center relatively easily. That’s not the case outstate, where hospitals can be separated by long drives.

Plus, rural regions tend to have lower hospital capacities for critical cases, exacerbated by decades of hospital closures, Henning-Smith said. More than 120 rural hospitals across the U.S. closed between 2005 and 2017, including at least two in Minnesota.

In Minnesota, health care providers are relatively well-distributed across the state, Stelter said. Rural facilities may have more space for COVID-19 patients under an executive order issued Thursday by Gov. Tim Walz that postpones all non-essential and elective surgeries that require protective gear for health care workers or ventilators.

Many rural hospitals are licensed for more beds than they reported were in use, according to state hospital data, suggesting they could ramp up capacity.

“I think we’re certainly better positioned than some other states, but it remains to be seen,” Stelter said. “That’s why it’s so crucial, what we’re doing now to tamp down on a surge of patients by [staying home and social distancing].”

Still, state data show a rural-urban disparity in hospital capacity. More than 40% of the state’s hospital beds are in Hennepin and Ramsey counties, compared to roughly 33% of Minnesota residents, according to preliminary 2018 data from the Minnesota Department of Health.

Nationally, just 1% of ICU beds are in rural areas, and 4% are in small cities like Owatonna and Alexandria, according to the Society of Critical Care Medicine. Henning-Smith said those numbers are “terrifying,” given that so many COVID-19 patients require intensive care.

The Minnesota Department of Health records don’t specify how many hospital beds are in intensive care units.
Henning-Smith said that in addition to her concerns about health care, she also worries about rural residents’ access to resources during quarantine. Services like curbside grocery pickup and meal delivery make it easier for people to stay at home — but only in cities.

“I maintain a little bit of hope from the fact that people in rural areas aren’t as densely packed together,” Henning-Smith said. “I do worry a lot about all the underlying risks. We just don’t have the health care and other infrastructure built up in rural places to support people during something like this.”

Rilyn Eischens
Rilyn Eischens is a data reporter with the Reformer. Rilyn is a Minnesota native and has worked in newsrooms in the Twin Cities, Iowa, Texas and most recently Virginia, where she covered education for The Staunton News Leader. She's an alumna of the Dow Jones News Fund data journalism program and the Minnesota Daily. When Rilyn isn't in the newsroom, she likes to read, add to her plant collection and try new recipes.