Joyce and James Foster live in a bucolic slice of Texas hill country blanketed in oaks, jumping with deer and dotted with lakes. But a less welcome addition to their landscape has arrived: COVID-19.

Given their ages — she is 90 and he is 94 — the couple is particularly at risk, along with 36% of Llano County that is over 65.

“It scares me to death, of course,” says Joyce Foster, adding that she and her husband are social distancing, getting food delivered by their daughters and staying in touch with doctors who are 35 miles away in Fredericksburg. “Any right-minded person would be frightened if you look at what’s going on all over the world.”

The Fosters are right to be concerned about the potential havoc coronavirus could wreak on the 50 million Americans of retirement age. A March 18 report from the U.S. Centers for Disease Control and Prevention notes that 31% of cases, 45% of hospitalizations, 53% of ICU admissions and 80% of deaths associated with COVID-19 involve seniors.

Some parts of the U.S. are potentially poised to take a harder hit from the virus than others. A USA TODAY analysis found that in 341 counties — or 11% of all U.S. counties — at least 25% of residents are 65 or older. Nationwide, only 16% of the population is over 65, according to the census.

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When it comes to states that have high concentrations of seniors, Texas leads the nation with 27 of those 341 elderly-heavy counties, followed by Nebraska, Michigan, Montana, Florida and North Carolina.

Complicating matters, 83% of those graying counties are classified by the U.S. Census as rural, defined as areas in which most people live far from urban hubs. So while on the one hand social distancing is easier when there are fewer people per acre, those people, when in need of help, are farther from medical and social services.

As the nation braces for surges in COVID-19 cases, many health care experts are deeply concerned that high rates of contagion in senior-heavy counties could spell disaster, particularly in areas where getting help often means long drives to lightly staffed and equipped facilities.

“This is the worst possible situation,” says Alan Morgan, CEO of the National Rural Health Association, a nonprofit that provides leadership for rural health matters. “Rural America is older, sicker and poorer. Now combine that with 2,000 rural hospitals where 1,300 have 25 or fewer beds, half of which have just one ventilator on site. Our system was designed for efficiency, not surge capacity.”

Health care in rural areas was delicate before the virus arrived.

Studies show the rural elderly typically have a broader array of chronic health issues and higher mortality rates compared to their urban counterparts. And about two-thirds of rural counties have a shortage of healthcare professionals, according to data compiled by the Bureau of Health Workforce.

Other big issues that are particularly crippling during today’s virus pandemic with its social distancing mandates in most states include spotty broadband access, which is critical for telemedicine visits, and a reliance on a mostly volunteer force of emergency medical technicians and drivers.

Those factors could create a perfect storm that leaves older Americans living in relative isolation particularly vulnerable to the virus, says Luisa Franzini, chair of the University of Maryland’s Health Policy and Management Department.

“In the best of times, many of these people have issues accessing health care, whether it’s getting to facilities or just a lack of doctors in their area to begin with,” says Franzini. “Keep in mind, this isn’t just about whether people get the virus, it’s about keeping up with regular health care issues that now can be an issue.”

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5 rural counties battle coronavirus

USA TODAY reached out to health care providers in five states with a high percentage of counties that are home to large populations of seniors: Texas, Arizona, Missouri, Montana and New Mexico.

In each case, officials expressed confidence in the planning measures underway to keep doctors safe and working while acknowledging that no one truly is prepared for a worst-case scenario in which rural clinics are overwhelmed by COVID-19 cases.

Tucked away in western Arizona, La Paz County covers 4,500 square miles and has only 21,000 residents, making it the second least populous county in the desert state. In winter and spring, when snowbirds flock to the area, upward of 50% of those residents are seniors, many of whom are between 30 and 60 miles from a doctor, says Kevin Brown, CEO of La Paz Regional Hospital in the county seat of Parker.

“We’re rural, so social distancing isn’t hard for us, but, yes, everyone’s concerned about us getting overwhelmed here if things get bad,” says Brown. His Critical Access Hospital — facilities established in rural areas by a 1997 federal program — has 25 beds, three ICU units and three ventilators used to treat those suffering from COVID-19-induced lung collapse.

Brown says that although there is no shelter-in-place order yet in the county, his staff is encouraging patients to stay away except for emergencies and restricting visitations. Elective surgeries have been cancelled to preserve gowns, masks, gloves and other vital personal protection equipment, or PPE, for health care professionals.

“Given our capacity, in the end we can only do what we can do,” says Brown.

In neighboring New Mexico, where in deeply forested Catron County 41% of the 3,500 residents are over 65, Don Daniel has been preparing doctors who work for Presbyterian Medical Services, where he is vice president of business development, for the growing coronavirus threat.

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Those efforts include making sure protocols are in place to keep those who think they might have the virus from walking into health clinics, explaining how telemedicine works for those who have Internet access, and, if need be, helping to arrange transfer to hospitals that can handle COVID-19 cases.

“What we have in Catron County are two primary care outpatient clinics with no beds or ventilators,” says Daniel, noting that, at 7,000 square miles, the county is the size of Connecticut.

“It wouldn’t be unusual for patients to travel 125 miles round-trip” to go to a clinic, he says.

Things would get worse for anyone diagnosed with the virus at Presbyterian Medical Services' clinic in the town of Reserve. The best equipped hospital is a 205-mile drive away in Albuquerque.

Those sorts of distances are also familiar to those seeking medical assistance in Montana, which, at seven people per square miles, trails only Wyoming (6 people) and Alaska (1) for population density. Montana has 19 counties with between 25% and 31% seniors.

Bridget Brennan, chief medical officer for Benefis Health System in Great Falls, says that because of virus-induced flight restrictions, anyone looking to come to the Benefis 220-bed hospital in Great Falls could be traveling from up to five hours away by car.

“Montana is a big state, so this could really stress our system because most local communities just don’t have a large number of EMS staff or ambulances at their disposal,” says Brennan.

Instead, Brennan says officials are stressing to staff at Critical Access Hospitals in rural areas the importance of screening, testing and self-quarantining any cases unless conditions turn serious.

“We’re getting the message out there to seniors to be careful,” she says, noting that the state so far has fewer than 50 cases and no deaths. “But we anticipate some will have to transfer to us for care.”

Telemedicine to battle COVID-19

Telemedicine has shot up in popularity in recent weeks as doctors try and advise patients without risking exposure to the virus.

But that only works if patients are tech-savvy and have Internet, both of which can be in short supply in elderly rural communities, says Toniann Richard, CEO of Health Care Collaborative of Rural Missouri in Lexington.

“Broadband issues being what they are in more rural areas, we have even started asking our billing team to dial into our network at night to process claims, so we can free up space,” online, she says.

Richard says many of the hospital and clinics officials she works with are already facing challenges brought on by the closure of hospitals over the past few years because of financial issues. Staff often are overworked as it is, and if COVID-19 cases grow there will be a challenge with everything from staffing to PPE stock.

“And if someone needs a ventilator, oh, yeah, that makes us nervous,” says Richard. “But rural healthcare workers are creative, they’ve been making do with less, have had to deal with higher mortality rates in their patients, with difficulty recruiting doctors. So we’re all used to having to be resilient.”

In Fredericksburg, Texas, not far from the humble home and epic ranch of President Lyndon Johnson, Jayne Pope is challenging the staff at her hospital to get creative and stay safe as COVID-19 cases ramp up.

“We’re thinking outside the box to keep everyone safe,” says Pope, CEO of Hill Country Memorial, an 84-bed facility serving Gillespie, Llano and Kerr counties, where seniors make up a third of the population.

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Those measures include curbside vetting of patients with symptoms, adjusting anesthesia machines to serve as ventilators and even dragging a portable X-ray machine into the parking lot for someone whose symptoms were of concern.

“The key, especially when you’re talking about rural medicine, is to try and make sure doctors aren’t exposed,” she says. “Because if you have to quarantine them you could be left with very few people who can actually help if things get bad.”

About a 45-minute drive away, Joyce and Jim Foster of Llano are content to wait out the coronavirus in their planned community, where each home comes with five acres of rolling landscape.

She says her husband, who she met while in high school and has been married to for 71 years, isn’t the talkative type. So mostly they enjoy each other’s company in familiar silence, strolling their property or resting indoors.

“Most of the elderly people I know feel pretty good about the care we have been getting, so that’s a source of confidence,” she says. “While the virus certainly worries me, there are fewer people to run into out here in the country. Maybe that will help us.”

Contributing: Dian Zhang, USA TODAY data reporter

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