Long drives, high costs stand between rural adults and safe surgery

Nearly one in three Americans may find themselves in a precarious position: They live more than an hour’s drive from a high quality hospital and their insurance plan may leave them paying more than they can afford out of their own pockets.

The situation is worse for Americans living in rural areas, according to a pair of studies from a University of Michigan team led by a surgeon who grew up in rural West Virginia.

And that means more time away from home and work for patients and their caregivers, more expense, or potentially less-safe operations with a higher risk of complications.

The studies, published in the Annals of Surgery and JAMA, document a troubling situation.

But they also set out a framework for researchers and policymakers to study and improve Americans’ access to high quality and affordable surgical care within a reasonable drive time, and for hospitals to understand and support the needs of patients who live far away.

Key findings

The Annals study reveals that 99 million Americans lacked access to timely, high quality and affordable surgical care in 2020, up from 98 million in 2015.

Residents of rural areas had the largest increase in lack of this kind of access, but non-rural residents experienced an increase too.

The researchers define such access as living within an hour’s drive of a hospital that offers surgical care and earned at least three stars from the Medicare quality rating system, and being able to afford the out-of-pocket costs of that operation after any insurance coverage. 

The JAMA study focuses on adults living in rural areas who underwent any one of 16 different operations in 2010 and 2020, both low risk and high risk surgical procedures.  

When we can look at these factors in concert, we can have a better understanding of the net effect of our complex policy environment on patients, who may delay getting surgery and see their condition worsen and become more complex."-Cody Mullens, M.D., M.P.H.

It finds that 44% of rural adults across the United States drove 60 minutes or more to get to the operating room in 2020, up from 37% in 2010.

The median drive time, which discounts the impact of extremely long drives such as ones that patients make from Michigan’s Upper Peninsula to the U-M medical campus in Ann Arbor, was 55 minutes.

Patients living in rural areas experienced a greater increase in median travel time than non-rural patients. 

Factors driving the change

“One of the big factors creating this situation is hospitals closing in rural areas, with more than 150 lost in the last 14 years, but we can also see indications of other factors related to the health policy environment,” said Cody Mullens, M.D., M.P.H., lead author of both studies. 

Mullens is a resident in the Department of Surgery at Michigan Medicine, U-M’s academic medical center, and a National Clinician Scholar at the U-M Institute for Healthcare Policy and Innovation.

“The number who lacked access due to not having insurance shrunk a lot, likely due to the Affordable Care Act, but the number who are underinsured, likely due to the growth in high deductible health insurance plans and other factors, grew. So did the number who had to drive further to reach any hospital, especially a three-star or higher hospital.”

Mullens and his colleagues, including associate professor of surgery Andrew Ibrahim, M.D., M.Sc., and former U-M surgeon John W. Scott, M.D., M.P.H., now at the University of Washington, married data from multiple sources to develop their index of surgical access and measure drive times.

Their approach goes beyond previous studies that examined specific aspects of barriers to surgical care, by combining data about those factors.

“When we can look at these factors in concert, we can have a better understanding of the net effect of our complex policy environment on patients, who may delay getting surgery and see their condition worsen and become more complex,” said Mullens.

He notes that while the surgical patient data they used came from Medicare, the findings apply to any adult needing surgery.

Rural hospitals and patients most at risk

Mullens and colleagues previously published an overview of findings about the impacts of rural hospital closures, and a JAMA Viewpoint on how to monitor the impacts of a 2023 policy change for rural hospitals.

It allowed them to get additional Medicare funding that could keep them open, in exchange for becoming Rural Emergency Hospitals that don’t offer inpatient care or any surgery that requires an overnight hospital stay.

The findings also reflect a trend toward centralization of more complicated operations to certain hospitals – driven by a need to increase quality and safety and reduce complications.

But the JAMA paper looks at eight operations that are not usually viewed in this light, such as those to remove an inflamed appendix or gallbladder, repair a hernia, or replace arthritic knees and hips.

“It’s not acceptable for that large a proportion of patients to drive that far for low risk surgery that can be performed safely and with high quality at smaller hospitals,” said Mullens.

When deciding which cases to take, or whether to offer telehealth options for pre-operative and post-operative appointments, surgeons may want to consider patients’ travel times.

As for underinsurance for surgical costs, Mullens and colleagues note that helping surgical candidates choose insurance plans based on total potential out-of-pocket cost, rather than just monthly premium cost, could improve affordability.

When someone knows that surgery may be in their future, choosing a Medicare, ACA Marketplace or employer-sponsored plan that does not have a high deductible, starting and adding funds to a tax-free health savings account or flexible spending account, and checking on which hospitals are considered in-network for surgery, can be very important.

Additional authors: In addition to Mullens and Scott, the authors of the Annals of Surgery paper are Nina Clark, M.D.; Nicholas Kunnath, M.S.; Joseph Dieleman, Ph.D.; and U-M Surgery chair Justin Dimick, M..D, M.P.H. In addition to Mullens and Ibrahim, the authors of the JAMA  research letter are Reagan A. Collins, BA, Kunnath, and Janice C. Probst, PhD.

Funding/disclosures: The studies were funded by the Agency for Healthcare Research and Quality (R01-HS028606-03) and the National Institutes of Health, and by U-M’s support for the National Clinician Scholars Program.

Papers cited:

“Trends in Timely Access to High quality and Affordable Surgical Care in the United States,” Annals of Surgery.  DOI: 10.1097/SLA.0000000000006586

"Trends in Travel Time to Obtain Surgical Care for Rural Patients,” JAMA. DOI:10.1001/jama.2025.0447