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These posts examine local, regional and national data that matter to the Fifth District economy and our communities.

Hospital Access in the Fifth District and COVID-19

Regional Matters
April 30, 2020
hospital emergency room entrance

One of the key concerns during the COVID-19 outbreak has been that emergency health care facilities might become overwhelmed by the number of patients infected with the novel coronavirus. Stay-at-home orders issued by governors throughout the country aim to slow the spread of the virus to ensure that hospitals are able to handle the inflow of patients requiring urgent care.

Even before the current crisis, however, hospital access has been a concern for residents in many rural counties. Over the last decade, 128 rural hospitals have closed, according to data collected by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina, Chapel Hill. As a recent article in the Richmond Fed’s Econ Focus magazine explains, two-thirds of these closures were in the South, which includes states in the Fifth Federal Reserve District. This post examines hospital capacity in the Fifth District and explores whether populations in counties with more limited capacity are also at greater risk of serious illness from COVID-19.

Measuring Rural Hospital Access

One way to measure hospital capacity while correcting for the size of the population they serve is to look at the number of hospital beds per capita in each county. The following map plots the share of beds per 1,000 residents for general acute care, chronic disease, critical access, and long-term care hospitals for counties in each Fifth District state.

Note: Hospitals include General Acute Care, Long Term Care, Chronic Disease and Critical Access facilities. Each county’s pop-up box includes the number of confirmed cases of COVID-19 from April 28, 2020. For updated numbers, see Credits below.

For mapped measure:
U.S. Census Bureau and U.S. Department of Homeland Security Infrastructure Foundation-Level Data (HIFLD) 

For COVID-19 Cases:
Government of the District of Columbia, Maryland Department of Health, North Carolina Department of Health and Human Services, South Carolina Department of Health and Environmental Control, Virginia Department of Health and West Virginia Department of Health and Human Resources.

By these measures, 8 percent of counties in Maryland, 25 percent in West Virginia, 50 percent in Virginia, 18 percent in North Carolina, and 15 percent in South Carolina do not have hospitals. On the whole, a third of rural counties in the Fifth District and 28 percent of urban counties lack hospitals. We consider counties rural if they are classified as a “5” or a “6” in the U.S. Department of Agriculture’s Rural-Urban Continuum Codes, which distinguishes counties by the population size of their metro area or by their degree of urbanization and adjacency to a metro area.

While separating counties into those with and without hospitals is one indicator of hospital access, it may not be the most reliable metric. Residents in counties without hospitals may be served by facilities in nearby neighboring counties. This is particularly important in the case of Virginia, where cities are independent of counties. For example, Henry County does not have a hospital, but the city of Martinsville (located within the county) does. An alternative way to assess hospital access is to measure the average distance between each census tract in a state to the nearest hospital.

Average distances to nearest hospital in the Fifth District


Number of census tracts

Average distance to nearest hospital

First quartile

Median distance to nearest hospital

Third quartile

Maximum distance to nearest hospital

Washington, D.C.


1.3 mi.

0.7 mi.

1.1 mi.

1.8 mi.

3.4 mi.



4.1 mi.

1.5 mi.

2.9 mi.

5.4 mi.

21.0 mi.

North Carolina


6.1 mi.

2.7 mi.

5.0 mi.

8.5 mi.

56.2 mi.

South Carolina


6.3 mi.

2.4 mi.

4.9 mi.

9.0 mi.

27.9 mi.



5.3 mi.

2.1 mi.

3.5 mi.

6.6 mi.

42.1 mi.

West Virginia


6.7 mi.

2.3 mi.

5.6 mi.

9.7 mi.

26.4 mi.

Source: Author's calculations using U.S. Department of Homeland Security Homeland Infrastructure Foundation-Level Data (HIFLD).
Note: “Distance” measures the center of each census tract to the nearest hospital. In some cases, the nearest hospital may be located outside of a Fifth District state.

For each state and Washington, D.C., we measured the distance from the center of each census tract to the nearest hospital (in the case of some census tracts, the nearest hospital may be in a state outside of the Fifth District). We then aggregated these measures to get a general idea of how far residents are from hospital care on average in each state. From these data, hospital access in Virginia does not look dissimilar from other states in the Fifth District. Of course, average distance to the nearest hospital may also be a somewhat misleading indicator of access. Densely populated census tracts within and around cities are in close proximity to many urban hospitals, bringing down the average travel distance for the state as a whole. We also break the distances down into quartiles for each state. Twenty-five percent of a state’s census tracts have distances below the first quartile value, and 75 percent are below the third quartile value. The maximum distance to nearest hospital reports the value for the census tract in each state that is farthest away from a hospital. For example, in Maryland, this distance is about 21 miles. In North Carolina, it is a little more than 56 miles. Residents in some parts of each state have to travel much farther to the nearest hospital than the average.

Risk Factors

It is clear that residents in some rural parts of the Fifth District do not have the same access to emergency care as those in cities and adjoining suburbs. This could be particularly problematic in the current outbreak if those same populations are also at higher risk of needing emergency care due to serious illness from COVID-19. The Centers for Disease Control (CDC) lists a number of factors that may put individuals at greater risk of serious illness from COVID-19. These are broken down into elderly patients (age 65 and older) and patients with pre-existing medical conditions, such as lung or heart disease.

According to the Census Bureau, about 15 percent of the U.S. population is 65 or older and therefore in a higher-risk category for COVID-19. Looking at the counties in each Fifth District state without hospitals, we find that the populations skew a bit older than the country as a whole. In West Virginia, Virginia, and the Carolinas, the average share of the population 65 and older in counties without hospitals is around 20 percent.

Individuals of all ages with health complications are also predisposed to severe illness from COVID-19. According to an analysis by the Kaiser Family Foundation that uses CDC data, about 38 percent of the adult population in the nation has a pre-existing condition that puts them into the “at-risk” group. In the Fifth District, that share ranges from 32 percent in Washington, D.C., to 49 percent in West Virginia. Although 17 percent of adults 18 to 65 are at increased risk in the United States, in West Virginia that share is 24 percent.

Rural areas have greater shares of people older than 65 and more premature deaths due to chronic illness, on average. On the one hand, these risk factors combined with reduced access to emergency care could be concerning for many rural communities during the current outbreak. On the other hand, many of these same counties currently have fewer confirmed cases of COVID-19 than densely populated urban centers with greater hospital capacity. On average, counties without hospitals in the Fifth District had between nine and 42 confirmed cases as of April 28. Thus, the risk of community spread in those places currently appears to be lower.

Impact of COVID-19 on Rural Hospitals Going Forward

In addition to straining existing hospital capacity today, the COVID-19 outbreak could have lasting impacts on rural hospital access in the future. Rural hospitals tend to be smaller and have tighter profit margins than hospitals in cities, making them more reliant on revenue from inpatient services. As part of the nationwide effort to free hospital capacity for treating COVID-19 patients, many states have temporarily suspended elective medical procedures. This may place greater strain on already tight rural hospital budgets. According to data from the Cecil G. Sheps Center, 10 rural hospitals have closed to date in 2020, and a recent report from consulting firm Guidehouse found that a quarter of all rural hospitals in America are at high risk of closing. In the Fifth District, 50 percent of rural hospitals in West Virginia and 44 percent of rural hospitals in South Carolina fell into this high-risk category. Depending how long the moratorium on elective procedures continues, hospital access for some counties in the Fifth District could diminish further.

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Views expressed are those of the authors and do not necessarily reflect those of the Federal Reserve Bank of Richmond or the Federal Reserve System.

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