Rural residents' access to hospitals is already a problem. Coronavirus could make it worse.

When Timaree Koscik’s husband, Tom, fell off the couple's roof in Tonopah, Nevada, and shattered his heels, she knew what they had to do.

“It was just like, 'Well, put him in the car and take him to Bishop.' ” The closest hospital is in Bishop, California, 115 miles away.

“You just do what you have to do," she said.

The remoteness of Tonopah, population 2,200, now feels like a buffer against the coronavirus pandemic. It’s more than 200 miles from the flare-up of cases in Las Vegas. As of March 26, there was only one case in all of Nye County’s 18,000 square miles.

"Honestly, I think we're better off here in the middle of nowhere than in the cities," Koscik said.

But she knows it's a false sense of security. Anyone sickened by COVID-19 may be hundreds of miles from the nearest open hospital bed, ventilator or isolation room.

In Tonopah, patients would have to make the trip to Bishop, but only until that hospital’s 25 beds are full.

Across the United States, rural communities could be among the most vulnerable in an outbreak.

Urban and suburban Americans live, on average, roughly 5 miles from the nearest hospital, according to Pew Research Center data from 2018. For rural residents, it’s an average of 10.5 miles.

But many towns are twice as far as that or more.

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An analysis of rural communities nationwide by the Arizona Republic, part of the USA TODAY Network, shows 1.1 million people live in rural communities at least 20 miles from the nearest hospital. Of those residents, a quarter are age 60 or older, putting them in the highest-risk age groups for the disease.

A surge of severe cases in those small towns could require stabilizing and transporting patients, one by one, dozens or hundreds of miles.

For many of these communities, the risks have worsened in recent years, as their own local hospitals have closed. In some, though, nursing homes have remained, concentrating the most vulnerable far from the best care.

Those same small towns may be more skeptical of the coronavirus threat and more resistant to official calls to close businesses or halt activities to slow the threat.

Almost every state has at least one place more than 20 miles from acute care. But three western states — Texas, California and Arizona — account for nearly a third of Americans in communities without a nearby hospital.

In Morenci, Arizona, a hilltop townsite is home to employees of the country’s largest copper mine. There is no hospital in Morenci, its twin town of Clifton or anywhere in Greenlee County.

But to most of Morenci’s 1,500 residents, the red-roofed building atop the hill looks like a hospital, said Dr. Jonathan Manwaring, the clinic’s chief medical officer. It’s not. It’s a clinic to provide family medicine and all-night urgent care. The clinic's parent company, Gila Health Resources, also runs a five-unit ambulance system for the county.

It doesn’t have an emergency room or a single hospital bed. It owns no ventilators.

"We’re basically a large doctor’s office with a 24-hour urgent care that takes all comers, and stabilizes and transports,” Manwaring said.

The nearest hospital is in Safford, more than 40 miles away, with 49 beds.

On Monday, Arizona health officials confirmed the first case of COVID-19 in Greenlee County.

Losing hospitals for years

Long before the arrival of the new coronavirus, rural America was already in a slow-moving health care crisis.

Over the past 10 years, 126 rural hospitals have closed, according to the University of North Carolina’s Rural Health Research Program. The research cited a number of factors for the decline: shrinking rural populations, consolidation in the hospital industry, states foregoing Medicaid expansion under the Affordable Care Act and residents’ tendency to seek hospital care elsewhere.

“Long distances from anywhere, physically declining buildings, no doctors — it’s really tough to make a (rural) health care business financially viable,” said George Pink, a professor at the University of North Carolina at Chapel Hill who does research on rural hospitals.

And when a rural hospital closes, the effects are felt beyond the immediate community.

The March 2016 closure of Southeast Health Center of Reynolds County in Ellington, Missouri, population 925, left seven communities without a hospital within 20 miles. Each of those rural communities has a nursing home.

On Saturday, Ellington, nestled among the Ozarks Mountains in the 3-million-acre Mark Twain National Forest, saw its first positive test for the new coronavirus. Hours later, a second test in the county was confirmed as positive. Meanwhile, officials at the Reynolds County Health Department have been assembling supplies for an outbreak, and others are taking precautions to avoid spread of the disease.

The town’s nursing home has closed to visitors.

Paula Dement runs a senior nutrition center where meals are served weekdays and residents socialize over bluegrass performances and bingo. The center began curbside meal pickup this week.

“I did it for the safety of the seniors, they’re in a high-risk group,” Dement said. “Even though they can’t get out and socialize, we’re an hour away from any major hospital: Poplar Bluff is an hour away, Farmington is an hour away.”

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The financial burden of a coronavirus outbreak will put even more pressure on remaining rural hospitals, which some fear could lead to additional closures. More than 800 rural hospitals currently lose money.

Going into the COVID-19 crisis, Pink said he is more worried about the remaining 2,000 rural hospitals than communities where the hospital has already closed. Communities where hospitals closed have learned to adapt, unlike places that still have their hospital.

Congress passed a bill last week that includes $275 million for rural and critical access hospitals as well as telehealth, but after that funding is gone, the future of many rural hospitals remains uncertain.

In a letter to congressional leaders requesting help to weather the outbreak, the American Hospital Association said “some facilities and practices are able to absorb significant losses for a period of time, but others, such as rural facilities, are not.”

Tribal lands face 'state of inequity'

The Navajo Nation has seen its number of confirmed coronavirus cases rise to more than 100.

The epicenter of the outbreak is Chilchinbeto, a community of 900 people that sits about 25 miles from the nearest grocery store — and hospital.

Of the 74 communities on the 27,000-square-mile Navajo reservation, which touches parts of Arizona, New Mexico and Utah, half are more than 20 miles from the nearest hospital, according to The Republic’s analysis. Other Arizona tribes — Fort Apache, Havasupai, Hualapai, Tohono O’odham — all have communities that are far from hospitals.

In Supai, the Grand Canyon community that is home to the Havasupai Tribe, there’s one doctor, one nurse and no ventilators, tribal Councilwoman Ophelia Watahomigie-Corliss said. The tribe closed public access to its famous trail and waterfalls, but has a dilapidated clinic now being rebuilt.

“I doubt our tribe is alone in this state of inequity,” Watahomigie-Corliss said.

Nationally, 295 communities on tribal lands are farther than 20 miles from the nearest hospital.

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On South Dakota’s Cheyenne River Reservation, the Cheyenne River Hospital closed, leaving four communities without a nearby hospital.

In response to the outbreak on the Navajo Nation, tribal leaders swiftly issued a stay-at-home order and travel restrictions for the entire reservation. “Help beat the virus by staying at home,” Navajo Nation President Jonathan Nez said in a written statement. "To prevent a massive public health crisis, every person must remain at home unless you need food, medicine or other essentials."

Such measures could be critical. Across the Navajo Nation, there are just 13 ICU beds in the three large in-patient facilities run by the Indian Health Services, according to Dr. Loretta Christensen, the chief medical officer with the Navajo Area Indian Health Service.

Christensen said in a widespread outbreak that filled the ICU, the health agency would first use its more than 50 isolation beds, then convert health care clinics and smaller service units for patients who are more stable or at the end of their quarantine.

So far, patients with severe cases have been flown to hospitals in Phoenix; Albuquerque, New Mexico; and Flagstaff, Arizona. But Christensen said at some point, hospitals in those cities might reach capacity, and their system will too.

'Tendency' not to trust government

Other rural communities have been slow to adopt measures to stem the spread of the virus, even though they have minimal access to hospital care.

When Nevada Gov. Steve Sisolak called for all nonessential businesses statewide to close in an attempt to halt the spread of COVID-19, Reno was already in the middle of its own shutdown. Police and code enforcement officers in the mid-sized city sent out warnings about fines and license revocations for those that didn't comply. In Las Vegas, local officials were slower to act, but casinos began closing on the Strip even before the governor's order came down.

The state's rural counties were also less than receptive to the Democratic governor’s plea.

In White Pine County, home to about 9,700 people on the remote eastern edge of the state, the sheriff took to Facebook to tell business owners to ignore Sisolak. Sheriff Scott Henriod walked that back when Sisolak signed an executive order requiring the closures.

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In Elko County in the state’s northeast corner, Sheriff Aitor Narvaiza lambasted Sisolak on Facebook.

"Now due to the coronavirus, Las Vegas and Reno are loosing their ass in revenue," he wrote. "As far as I am concerned, Las Vegas gets what they deserve."

He has since deleted the post and also has promised to enforce Sisolak's shutdown order.

Neither sheriff responded to requests for comment.

Nicole Baldwin, White Pine County's clerk, acknowledged that many people in the rural town of Ely felt the shutdown orders were overkill.

"We are four hours from everywhere," Baldwin said. "And we're not on an interstate, so we do feel like we are on an island here. However, in the same breath, we recognize the seriousness of the virus, and it is spreading rapidly. We have vulnerable people we want to keep protected."

Scott Lewis, director of emergency management for Nye County, which includes Tonopah, acknowledged that a cultural aversion to government mandates in rural Nevada can complicate the response to the epidemic.

"In general terms, there can be a tendency not to have trust in government," he said. "But realizing this is a potentially serious issue for Nye County, you do see a cooperative spirit. We just have to be diligent in remembering to take all the necessary precautions."

The disease has already reached far-flung towns.

In Beatty, Nevada, another gas stop of a town on the way to Las Vegas, a man with no travel history and no known contact with anyone with coronavirus tested positive. As in Tonopah, the nearest hospital to Beatty is more than an hour away. Sixteen other rural Nevada residents have tested positive.

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"Wherever you live, you never know where that potential risk could be coming from," Lewis said.

As of March 20, only 119 of the 240 beds in rural acute care hospitals were open, according to data from the Nevada Hospital Association. Only eight of the 20 ICU rooms were available.

The good news on ventilators: All 33 in rural Nevada were available as of March 20. The bad news: They're scattered across a state more than twice the size of Pennsylvania.

Lewis said the absence of a hospital in Tonopah isn't a complicating factor in these early days of the spread. People who are experiencing coronavirus symptoms are asked to call their doctor and not visit the hospital.

But if coronavirus patients begin to experience the severe respiratory symptoms associated with the infection, they must rely on a volunteer ambulance service to get them to far-away hospitals.

The question now is whether a bed will even be available for them.

"We have advanced paramedics in town 365 days a year and they can assist and make the transport safe for the patient," said Karmin Greber, chairwoman of the Northern Nye County Hospital District. "But now it's all about finding a place to receive them."

Contributing: Alden Woods, The Arizona Republic. Follow Pamela Ren Larson and Anjeanette Damon on Twitter: @renLarson_ @AnjeanetteDamon

This article originally appeared on Arizona Republic: Coronavirus: Case surge in rural towns would leave many far from care