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.

California faces a big shortage in the health care workforce, so health centers in San Diego are taking matters into their own hands, launching a training program for medical assistants.

The Laura Rodriguez Medical Assistant Institute, part of the Family Health Centers of San Diego, has graduated dozens of new medical assistants since January of last year.

Pauline Lucatero, chief academic administrator for the institute, said multiple factors led to the shortage.

"This is just due to the aging population and retirement," Lucatero observed. "I also believe that trying to recover back from COVID, we lost a lot of professionals."

The program recruits students from the community. In fact, 65% of its graduates started out as a patient of the health centers. The Bureau of Labor Statistics projected jobs for medical assistants would grow 14% from 2022 to 2032. The training program was made possible by a $450,000 grant from the nonprofit Direct Relief.

Dr. Byron Scott, chief operating officer of Direct Relief, co-chairs the group's Fund for Health Equity.

"They live in this community," Scott pointed out. "They're learning this new skill and then they're able to stay within the community and support the community, not only providing health care, but there's other economic benefits, not only for the community, but for themselves."

The program costs about $7,200. Students can get a loan, which can be forgiven if they work for Family Health Centers of San Diego for three years. Students can do the training in four and a half months full-time or eight months part-time. The next full-time class starts Oct. 7.

Now that the Arkansas Supreme Court has denied a petition to put an abortion rights measure on the November ballot, proponents for women's reproductive rights say they are not giving up.

The case was sent to the high court after the Arkansas Secretary of State rejected the petition because members of Arkansans for Limited Government didn't submit required paperwork for paid workers who gathered signatures.

The group's communications director - Gennie Diaz - said they want to give Arkansans the right to choose, but legislators keep changing the rules.

"The constitution of Arkansas says that you need to gather signatures from 15 Arkansas counties out of the 75," said Diaz. "The legislature last session passed a law saying that they're bumping it up to 50, which is an extreme jump."

Under Arkansas' current law, abortions can only be performed if the mother's life is in danger.

The proposed amendment would have allowed abortion care up to 18 weeks after fertilization - and in cases of rape, incest, threats to the mother's life, or if it was believed the fetus wouldn't survive.

About 14,000 of the petition's signatures were collected by paid canvassers, but the secretary of state says those names couldn't be counted because of the missing paperwork.

Without those signatures the group didn't have the 90,000 names needed to have the issue placed on the ballot.

Diaz said proponents of a woman's right to choose can make their voices heard by voting.

"From city council, all the way to the state legislators and constitutional offices," said Diaz, "ask them their opinion on this petition, and if it was something you supported. I think that that should definitely weigh into what people decide at the ballot box. "

The measure faced heavy opposition from abortion opponents in the state.

The nonprofit Family Council Action Committee had vowed to challenge the proposed constitutional amendment in court if it made it onto the ballot.

Following the ruling, GOP Gov. Sarah Huckabee Sanders posted on the social media platform X that the far-left pro-abortion crowd in Arkansas showed they are both immoral and incompetent.




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County health officials in rural Iowa are using a new app to connect people to their doctors and cut down on missed appointments.

The Health Connector program provides transportation to and from medical appointments in Dallas County - and is geared toward people over 60, those with a disability, people who speak English as a second language, and veterans.

County Community Health Administrator Abigail Chihak said it will help reduce the number of missed appointments, that happen because people don't have a way to get to the doctor's office.

"It's an app that allows riders to schedule both their medical appointment and their transportation appointment at the same time," said Chihak. "So, while they are at the doctor's office scheduling a follow-up appointment, they can get that transportation for their follow up appointment set up before they even leave."

A one-way Health Connector trip countywide is $5, within the city limits it's $2.50.

The pilot project is funded by the U.S. Department of Transportation and could be expanded to other parts of the country if it's successful.

Chihak said using the Health Connector app is helpful to the patients who need to schedule their doctor's appointments and a ride to get there, but it will also help reduce costs and improve efficiencies for health care providers.

"This also helps our healthcare teams to know if their patients are on the way, and help them to assure that their patients are going to be able to get to their appointments," said Chihak, "to alleviate the number of no-shows that they have."

The app also has options for vision impaired users who can get GPS style directions from the bus all the way to the front door of their doctor's office, even if it's deep inside a complex medical suite.



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