By Charlotte Huff for KFF Health News.
Broadcast version by Freda Ross for Texas News Service reporting for the KFF Health News-Public News Service Collaboration

The night before her chemotherapy, Herlinda Sanchez sets out her clothes and checks that she has everything she needs: a blanket, medications, an iPad and chargers, a small Bible and rosary, fuzzy socks, and snacks for the road.

After the 36-year-old was diagnosed with stage 3 breast cancer in December, she learned that there weren't any cancer services in her community of Del Rio, a town of 35,000 near the Texas-Mexico border.

To get treatment, she and her husband, Manuel, must drive nearly three hours east to San Antonio. So they set an alarm for 4 a.m., which allows for just enough time to roll out of bed, brush their teeth, and begin the long drive navigating dark roads while watching for deer.

About an hour before they arrive at the cancer clinic, the couple pulls over to quickly eat fast food in the car. The break gives Herlinda time to apply ointment on the port where the needle for her chemotherapy will be inserted.

"It numbs the area, so when I get to the infusion room the needle won't hurt," she said.

For rural patients, getting cancer treatment close to home has always been difficult. But in recent years, chemotherapy deserts have expanded across the United States, with 382 rural hospitals halting services from 2014 to 2022, according to a report published this year by Chartis, a health analytics and consulting firm.

Texas led that list, with 57 rural hospitals - nearly half of those statewide that had offered chemotherapy - cutting the service by 2022, according to the analysis. Rural hospitals in states like Texas, which hasn't expanded Medicaid, have been more likely to close, according to data from the Cecil G. Sheps Center for Health Services Research.

To keep the doors open, financially strapped facilities in small communities nationwide continue to shed basic health care services, like obstetrics and chemotherapy, said Michael Topchik, executive director of the Chartis Center for Rural Health.

"The data are staggering," Topchik said. "Can you imagine feeling that sick, and having to drive an hour in each direction, or maybe more each direction, several times a week?"

Loss of chemotherapy services can signal other gaps in cancer care, such as a shortage of local specialty physicians and nurses, which is bad news for patients, said Marquita Lewis-Thames, an assistant professor at Northwestern University in Chicago whose research covers rural cancer care.

Rural patients are less likely to survive at least five years after a cancer diagnosis compared with their urban counterparts, concluded a study co-authored by Lewis-Thames and published in JAMA Network Open in 2022. While the rural-urban survival gap narrowed over the nearly 40 years researchers studied, the disparity persisted across most racial and ethnic groups, with only a few exceptions, she said.

Many cancer drugs are now given orally and can be taken at home, but some treatments for breast, colon, and other common cancers must still be administered intravenously inside a medical facility. Even distances of an hour or two each way can strain patients who already may be coping with nausea, diarrhea, and other side effects, physicians and patient advocates said.

"It's pretty uncomfortable for some of these patients who may have bone metastases or have significant muscular pain and have to sit in the car that long and hit road bumps," said Shivum Agarwal, a family physician who practices in rural communities an hour west of Fort Worth, Texas.

Plus, travel can cost much more than filling the gas tank.

"Usually it requires an able-bodied family member taking off a whole day or at least half a day from work," Agarwal said. "So, there's a big economic cost for the family."

In this sense, the Sanchez family is fortunate. Herlinda's mother drives four hours from Abilene to Del Rio to watch the couple's youngest children, their 2-year-old twins.

Cancer infusions can last as long as eight hours on top of the travel time, causing significant financial and logistical challenges, said Erin Ercoline, executive director of the San Antonio-based ThriveWell Cancer Foundation. The nonprofit provides adult patients with financial assistance, including for gaps in insurance and transportation-related costs. It has helped cover gasoline for Sanchez, who received her final round of chemotherapy in late June. The financial assistance will also pay for her hotel when she travels for breast surgery this month.

Not all rural hospitals are ending chemotherapy. Childress Regional Medical Center, a 39-bed hospital in West Texas, is constructing a 6,000-square-foot center for patients who need infusions for cancer and other diagnoses, including multiple sclerosis and rheumatology.

The infusion area, which started with two chairs in 2013 and now has four, will grow to 10 chairs and have more patient privacy when it opens next year. The next-nearest infusion center in this sprawling region is an hour or more away, which discourages some patients from seeking care, said Childress' CEO, Holly Holcomb.

"We've had a handful of patients say, 'If you can't do it here, I'm not doing it,'" Holcomb said. She credits the federal 340B drug discount program for enabling the remote hospital to provide infusion drugs.

Hospitals that qualify for 340B can buy outpatient drugs at steep discounts. The program provides "a huge kickstand for rural hospitals," said Topchik, of Chartis Center. Hospitals can use the savings to buoy or expand services provided to the community, he said.

But some patients are not daunted by long drives and travel costs.

"I'm from the country, so small is better - it's just more personable," said Dennis Woodward, 69, who lives in Woodson, Texas. He has a type of non-Hodgkin lymphoma and chooses to make a two-hour drive to Childress. He had first visited an oncology clinic in Abilene about an hour away. The clinicians were nice, but "I felt like a number," he said.

After his first appointment at Childress this year, his oncologist, Fred Hardwicke, walked him over to meet the nurses who would administer the medicine, Woodward recalled.

Most Fridays during Herlinda Sanchez's chemotherapy, Manuel would nap in the car. But during her final treatment in June, he stayed nearby, counting down the hours.

Several family members joined Herlinda when she rang the bell later that afternoon to signal the end of her treatment.

"I don't want to be in San Antonio no more," said Herlinda, a mother of four who does administrative work at Laughlin Air Force Base near Del Rio. "I'm looking forward to the break."


Charlotte Huff wrote this story for KFF Health News.

It is National Rural Health Day and experts are flagging research showing increasing health disparities between urban and rural places, including in South Dakota.

A new advisory from the American Heart Association shows between 2010 and 2022, cardiovascular death rates increased a whopping 21% among young adults in rural areas, especially after the onset of COVID-19. In urban areas, the rate increased only 3%.

Dr. Karen Joynt-Maddox, associate professor of medicine at Washington University, chairs the association's presidential advisory committee and said the change is due to a mixed bag of increased risk factors in rural areas.

"If you put that on top of a real problem with health care infrastructure and access in rural areas, you sort of have a perfect storm for worsening cardiovascular health."

Joynt-Maddox noted traditional risk factors include high blood pressure, diabetes and obesity, which have been increasing in rural areas over the last few decades. Other contributing factors, she said, include poverty, food insecurity, depression and substance use disorder.

Tim Nikolai, Midwest senior rural health director for the American Heart Association, said rural communities have less access to resources like health care and grocery stores with fresh produce. Even access to high speed internet contributes to health outcomes. Health care providers are stretched thin, Nikolai added.

"It stretched hospitals and health care providers to try to serve the needs of their community the best way they can," Nikolai observed. "And that's something we're trying to collaborate with them on, is how can they meet people where they are?"

Nikolai listed some work happening in South Dakota including offering blood pressure monitoring at local libraries, installing four new Public Health AmeriCorps members across the state and the town of Spearfish prioritizing public CPR training and AED access.

More than 38 million Americans live with diabetes, including nearly 1 million Georgians.

The Georgia Department of Public Health estimates another 230,000 people in the state may have diabetes but don't know it.

During National Diabetes Month, Dr. Griffin Rodgers - director of the National Institute of Diabetes, Digestive, and Kidney Diseases at the National Institutes of Health - emphasized the importance of managing diabetes early to prevent serious health complications.

"Diabetes can damage blood vessels and nerves," said Rodgers, "so the patients that have it have a higher risk of developing conditions like a heart attack or a stroke, diseases of the kidneys and the eyes and the teeth, as well as the lower extremities."

Between 2014 and 2018, diabetes led to over 100,000 hospitalizations and 154,000 emergency-room visits in Georgia.

But Rodgers said diabetes is preventable and manageable. He added that regular wellness visits - where blood sugar, blood pressure, and cholesterol are checked - are key to staying healthy.

Rodgers said a healthy diet is a major part of managing or preventing diabetes.

He suggested eating plenty of fresh produce, whole grains, and lean proteins like fish - and cutting back on sugary drinks by choosing water instead.

Regular exercise and seven to eight hours of sleep each night are also important.

"On the physical activity side, 30 minutes a day, five days a week for most adults is what's
generally recommended," said Rodgers. "Just walking. And if you can't do the 30 minutes all at one time, breaking it into either two 15, or three 10-minute intervals is sufficient."

Early signals that diabetes could be a problem include frequent urination, constant thirst or hunger, fatigue, blurry vision, nausea, unexpected weight loss, or tingling in your hands and feet.

Rodgers said managing diabetes can be as simple as focusing on "the A-B-Cs of care" - checking your A1C, blood pressure and cholesterol levels, and quitting smoking.




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California could be in for some big cuts to health care for low-income families under a second Trump administration, according to health experts.

Policy specialists at the nonprofit KFF said they are bracing for Trump allies in Congress to make major reductions to Medicaid expansion under the Affordable Care Act, in order to pay for big tax cuts promised by the president-elect.

Larry Levitt, executive vice president of health policy at KFF, said it would force states to backfill or raise costs.

"For the ACA, simply letting enhanced financial aid expire after next year would result in big out-of-pocket premium increases, reduced enrollment and more people uninsured," Levitt projected.

Robert F. Kennedy Jr., President-elect Trump's choice for Health and Human Services Secretary, did not say much on the campaign trail about funding for Medicaid or the Affordable Care Act, so his positions are unclear. Kennedy has expressed skepticism about vaccines and has said the U.S. should stop putting fluoride in drinking water.

Jennifer Kates, senior vice president and director of the Global Health and HIV Policy Program for KFF, said the Centers for Disease Control and Prevention cannot require states to follow its recommendations on vaccines and fluoridation.

"That's up to states and local governments," Kates explained. "But CDC can recommend, and if those recommendations are not being made or being watered down or changed, that sends a message to states, to schools, to parents."

Health advocates are also raising concerns DACA recipients could lose access to health plans sold on the state marketplaces created under the Affordable Care Act. Changes to so-called "public charge" rules could make families with mixed immigration status hesitant to use Medicaid benefits.


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