Photos: How older adults navigate their health care needs in rural America

By Tim Evans,

Juliana Kim

Published September 5, 2024 at 5:00 AM EDT

A rainstorm passes over Interstate 94 in Morton County, N.D., on May 25. Inclement weather and long travel distances to medical providers present serious access barriers for seniors here, many of whom are not able to drive or are uncomfortable driving in low-visibility conditions.

Senior health care access across much of rural America is in a state of crisis.

Decades of agricultural industrialization and consolidation have eroded rural employment opportunities, leading to a steady exodus of younger residents to suburbs and cities in search of work.

As small towns have depopulated, aged, and lost their economic base, their medical infrastructure has contracted in kind.

Hospitals, clinics, dentists, nursing homes, pharmacies — they have all felt the pain of increasing financial pressures. Most facilities depend on Medicare’s razor-thin reimbursement rates and alarming numbers of them have been forced to shutter operations in recent years.

Randy Anderson has his eyes examined by Dr. Andrew Rodenburg during an optometry appointment on May 22. Anderson has to drive over an hour to Bismarck, N.D., to seek specialty care a few times a week on average, despite living two blocks from his small town’s hospital and clinic.

Providers that stay open deal with many staffing challenges, with both money and skilled workers in short supply. Residents who remain find themselves stuck in a growing number of medical deserts. While these dynamics affect all rural residents, seniors — with their more frequent and varied care needs — are hit particularly hard.

NPR reporter Juliana Kim and I traveled across the Great Plains of North and South Dakota in May to photograph and document this predicament.

Along the way, we heard from a cross-section of Americans, including residents of shrinking farming towns, medical providers, assisted living facility staff, caregivers and Indigenous citizens.

Demolished walls surround a bathtub at a recently shuttered nursing home in Armour, S.D., on May 29. The facility, which operated as the only nursing home in town for many years, closed after sustained staffing and financial pressures.

Dr. William L. Bender screens a patient with flu-like symptoms at the Heart of America Medical Center in Rugby, N.D., on May 14. Increasing numbers of rural hospitals such as Heart of America have become dependent on temporary contract providers such as Bender to fill their ranks as they struggle to recruit long-term practitioners. While these providers can offer a high level of care, they are more expensive to employ and do not provide stable staffing.

The Rev. Gary Benz offers Holy Communion to Viola Weinhardt, 94, at her home in Glen Ullin, N.D., on May 24. Benz offers Communion and the chance to connect with homebound, often socially isolated seniors who are dealing with health issues.

Tanya Urquieta, who was working as a project coordinator for the Older Adult Resource Network, would help connect seniors in the medically underserved areas in South Dakota's Douglas and Charles Mix counties to vital services aimed at improving their health and maintaining independence.

A plane flies over the Beacom/Reischl Transitional Care Unit and Oakwood Assisted Living facility in Sioux Falls on May 18. Senior care facilities are in short supply across much of rural America, especially in depopulating areas of the Great Plains, where a majority of facilities are concentrated in larger cities.

Adolfo Pino, 73, prepares a batch of local newspapers for delivery during a work shift at Rocket Printing in Armour on May 29. Pino, a Cuban immigrant, is a participant in the Older Adult Resource Network, which connects people aged 65 and older in South Dakota’s Douglas and Charles Mix counties to resources to maintain their quality of life. Pino and his wife Neri Jorge Cruz have benefited in various ways from the program, including Spanish translation for medical appointments as well as financial assistance to help cover otherwise prohibitive health care bills.

From having to drive hours for emergency or specialist care to dealing with a patchwork system of health insurance, older rural people confront a range of access struggles, with many left to ration or forgo care altogether.

We also learned about various attempts by committed providers, nonprofit organizations, state employees and community members to help close some of the many coverage gaps.

A nurse checks a patient’s pulse following a cardiac stress test during a special monthly visit by a cardiology team to Douglas County Memorial Hospital in Armour on May 30. — Registered nurse Ashley Vanden Hoek checks a patient’s pulse following a cardiac stress test during a special monthly visit by a cardiology team to Douglas County Memorial Hospital in Armour on May 30.

Wade Kottre, an EMT on the Glen Ullin Ambulance Service, stands for a portrait on a county road in Glen Ullin on May 25. The ambulance service is staffed entirely by volunteers and provides an essential service for Glen Ullin and the surrounding area. While many of the volunteers are seniors themselves and have worked on EMT crews for decades, some younger volunteers have joined the team in recent years.

Dr. Richard Clark, a cardiologist from the Sanford Cardiovascular Institute, and a team of nurses spend a day each week traveling from their Sioux Falls offices to one of four rural hospitals that do not have cardiologists on staff. He checks a patient’s heartbeat during a monthly visit to Douglas County Memorial Hospital in Armour.

Randy Anderson flips through a calendar filled with medical appointments at his home in Turtle Lake, N.D., on May 22. Randy and his wife Marlys, who both deal with various health concerns, find their regular trips to Bismarck for care to be a considerable burden. “It’s like a full-time job almost,” Anderson said.

Tim Evans is a freelance photographer based in Minneapolis. Follow Tim on Instagram @timevansphoto.

This story was supported by the Pulitzer Center on Crisis Reporting.