‘Beams of Light in a Dark World’: Rural Health Providers Care for Patients with Few Options

This story is part of a series on rural health in the United States and the organizations filling the gaps for patients. Part one of the series can be found here.

Dr. Rose Gillin said she always wanted to help people in places where there weren't enough resources.

"I wanted to go to a place where there were no doctors and be the doctor," she said.

Gillin, who grew up in Puerto Rico, planned to practice medicine overseas. However, she was called to stay in the Midwest as she became a wife and mother, and has practiced family medicine in a small town in Indiana for over three decades.

"When one member of the community is not healthy, it affects the whole community," she said. "Providing for one another helps us all."

Currently, Gillin is the medical director at Center for Healing and Hope, a charitable health clinic in Goshen, Indiana. The clinic doesn't accept insurance and provides healthcare services to a diverse patient population, some of whom are crossing state lines for care.

Goshen sits at the center of several rural, medically underserved areas from northern Indiana, far west to the Illinois state line, and up into southwest Michigan. The small town is home to the charitable clinic and a federally qualified health center that has a care partnership with the local hospital.

Local providers say they are known for their consistent and integrated approach to medicine. As financial constraints have forced partial hospital closures and prevented some providers from taking on vulnerable patients, providers in Goshen say they're committed to providing inclusive care.

In return, their patients travel the distance.

"I like to think of clinics like ours and Maple City Health Center as beams of light in a dark world that can bring hope to people," Gillin said.

Overcoming Barriers to Care

According to the providers, affordability remains the greatest barrier to care for residents in small towns and rural communities. Maternal and dental care incur the highest costs. While insurance and Medicaid can offset the costs of major medical needs, fewer people are expected to have access due to ongoing legislative changes.

Gillin began her career at Maple City Health Center nearly 35 years ago and spent two decades at the health center as a primary care provider. She left to open her own micro-practice where she took phone calls, checked vitals, and saw patients.

"I did everything myself," she said. And she didn't accept insurance.

The doctor said it was hard work. However, the lack of overhead and her decision to decline insurance meant she was able to work with patients who are traditionally excluded from medical care, patients who didn't have access to employer-paid health insurance or Medicaid.

"It's always challenging when people don't have the resources to do what needs to be done," Gillin said. "You need a CT scan, and you can't afford it, or you need medication, and you can't afford it. It's difficult to always be working around barriers and know that you can't provide the best for patients because there aren't enough resources."

Northern Indiana and lower southwestern Michigan towns are predominantly rural. They're home to major manufacturing employers and have fewer than 50,000 residents. About 15% of Goshen's 34,000 population was born outside the U.S., according to census data.

Gillin said that the current political climate has heightened fear among some communities. The medical director said there is greater hesitancy to seek care.

"People live with a lot of fear," Gillin said. "That limits what they're willing to do, or try to do, or places they're willing to go."

Language can also be a barrier to care. However, the Center for Healing and Hope has bilingual staff and interpreter services available. The medical director said that when she encounters vulnerable patients who struggle to communicate, it reminds her of a past trip to Nepal during medical school. At the time, she got lost and didn't know how to ask anyone for help.

"I remember standing in the middle of this busy city on the sidewalk, thinking 'I can't communicate with anybody here'," she said. "I was able to make my way back to where I was staying, but I never found the place I was supposed to go. That feeling of not being able to communicate really hit me hard that day…it filled something in me to do this work."

Missy Schrock, executive director at Center for Healing and Hope, said the clinic sees a large immigrant population.

Schrock said their patients often weigh the cost of traveling 40 or more miles each way for an appointment versus the cost of an emergency room visit. She said there aren't enough providers across the rural towns, and there aren't enough providers that offer affordable care.

The executive director said that creates impossible choices for patients with chronic conditions or who need consistent medical care.

"The issue is that the people who don't have insurance don't have access to providers that will treat them," Schrock said.

After a Closure, Providers Pivot

In 2019, a hospital in Sturgis, Michigan, shuttered its birthing center and oncology unit due to budget cuts. As a result. Sturgis, home to 11,000 people, had fewer alternatives for care.

Stacy Linihan, executive director at Covered Bridge Health Center, the nearest federally qualified health center to the hospital, said they also can't afford to maintain obstetric services for Sturgis or neighboring Three Rivers communities. Linihan said they make obstetrician referrals to Beacon Health, a not-for-profit provider headquartered in South Bend, Indiana.

Linihan said that when hospitals close or are converted in rural towns, health centers tend to pivot and do more to support patients.

"They have to kind of pivot and really do more urgent type (care) that maybe a regular doctor's office wouldn't do," she said.

According to research from the University of North Carolina, 87 rural hospitals have closed and 65 have converted since 2010.

In recent years, Michigan amended the Social Welfare Act to redefine what constitutes a rural emergency hospital from population areas of 165,000 or less to 195,000 or less. This expanded access to funding for rural health programs to include areas with larger populations.

In 2023, the Sturgis hospital became the first rural emergency hospital in Michigan, which allows the hospital to provide inpatient services and apply for federal financial support. The UNC data does not include rural emergency hospitals.

"Hospital closures are awful for communities in which they happen," said Paul Fast of Maple City Health Center in Goshen. "We're really blessed that it's not happening here. It makes good care really hard (to provide), both for the remaining providers and for the patients, because coordination gets really, really complicated."

Fast said that hospital closures are a casualty of a full spectrum of diminished services.

"We have the highest rate of moms participating in prenatal care within the first trimester across the state, (and) we're very proud of that," he said. "If we could do more deliveries, if we could grow the team, that'd be fantastic. We just don't have the resources or the staffing. We're capped at the ability to do well."

'Playing to Each Other's Strengths'

Maple City Health Center in Indiana serves nearly 12,000 patients from 32 counties-including Michigan residents. Fast, Maple City's executive director, said patients are willing to travel to their location because they offer accessible care.

"What does access mean?" Fast questioned. "Is this a place that you can actually afford? Is this a place that makes you feel welcome? Is this a place where you feel confident in the quality of care that offers the type of services that you need?"

Patients also visit Maple City for prenatal care. The health center employs a family health practitioner, an obstetrician, and secured joint commission accreditation to partner with the hospital for the birthing process.

Fast said prenatal care can get "ridiculously expensive" and that it is dependent upon the number of tests and diagnostics required throughout the prenatal process. While Maple City has proven successful in prenatal care, Fast said it's difficult to secure specialized physicians in rural areas due to a lack of resources. Additionally, he said the current political climate has increased the difficulties of employing obstetricians in Indiana.

"When you're dealing with something like prenatal care, that's a really sensitive time in people's lives," he said. "The fact that there is an OB clinic nearby doesn't mean they're accepting patients, (and) it doesn't mean they're accepting you."

Fast said he knows they aren't the only provider in northern Indiana or southwest Michigan who can provide prenatal care. However, he said, patients come to them because they are welcoming and inclusive.

"The local staff, they really do feel this sort of safety net responsibility to the community," he said. "And in this partnership, we're playing to each other's strengths."

Direct Relief is committed to providing medical aid and support to health centers across the United States, including those in rural areas. Over the past year, Direct Relief has sent over $4.8 million in medical aid to charitable clinics and federally qualified health centers in Goshen, Indiana .