What can solve South Carolina's rural health care crisis? (2024)

RIDGEVILLE — Dr. John Creel is the only physician for miles.

Summerville Medical Center lies about 20 miles southeast, a hub of nurses and doctors bustling around a 124-bed hospital. A handful of physicians practice in nearby St. George, both privately and at affordable clinics. But Ridgeville — population 1,637 — remains Creel’s domain. When health needs arise, the Edisto Indian Free Clinic is the only local place for residents to go.

Creel, director of the Free Clinic, rents the building from the Edisto Natchez-Kusso Tribe. He is the chief. But the nonprofit clinic serves patients regardless of tribal affiliation. And true to its name, at no cost. Grants and donations subsidize services, which run the gamut from labs to minor procedures, and partnerships link patients to discounted X-rays and low-cost meds.

Set back from a two-lane road lined with mobile homes, miles from the Medical University of South Carolina's sleek bouquet of buildings, the Free Clinic is a model common to rural areas like much of Dorchester County. It’s in these sparsely settled counties where hospitals have steadily shutteredand specialists remain few and far between.

A drain of medical professionals has slashed health care access for thousands ofrural residents. And compounding the access issue is an affordability crisis. Low- and moderate-income earners tend to live outside population centers, and many — about 12.3 percent of rural inhabitants — are uninsured.

Nearly two-thirds of those people reside in a state that hasn’t expanded Medicaid coverage to adults with incomes up to 138 percent of the federal poverty level. That includes South Carolina, where the Republican-dominated Legislature’s resistance has left low-income rural residents with a dearth of affordable coverage options — and a renewed reliance on clinics like Creel’s.

In 2021, his staff saw 348 patients, with some traveling from as far as Richland County to see the physician. Creel would do well to duplicate himself in Ridgeville, which boasts a striking doctor-to-patient ratio: 0.73 physicians for 1,000 people, according to the South Carolina Center for Rural and Primary Healthcare.

Dentists in the tiny town are even rarer, at 0.42 for 1,000 people. And OB-GYNs are nearly nonexistent. The statistics comprise a dour portrait of health care in rural America, where residents are generally sicker than their urban counterpartsand overtaxed providers shoulder unwieldy patient loads.

Yet amid the fallow landscape, sustainable health care models have sprouted, from free clinics to roving vaccine vans. Could they reverse the care disparities — and keep rural South Carolinians in better health?

‘This is hard health care’

Creel’s clinic is one of 37 nonprofits that treat South Carolina residents who are uninsured or underinsured — meaning their out-of-pocket health care costs eat up 10 percent or more of their household income. Running the clinic is a grind, the physician said, though the initial whirlwind pace has slightly slowed.

In the early 2000s, after he inherited the clinic from another doctor, Creel would regularly see 30 patients over the span of a few hours. His schedule has stabilized more recently. Turning the operation into a nonprofit opened the door to grants — a huge help. And he hopes to soon bill for Medicare, which would generate more income.

He also makes use of a well-respected resource: the National Health Service Corps. The federal program, which the Free Clinic joined last year, forgives providers’ student loans so long as they practice at a NHSC-approved site, which are typically set in rural or underserved areas.

Incentivizing people to work in small towns can help staunch the rural health care shortage, said Kevin Bennett, director of the state’s Center for Rural and Primary Healthcare. But recruitment remains a challenge, he added — especially when treating more patients and performing more procedures generally means more money for physicians.

Sparsely populated areas often lack the sheer volume of patients that providers need to earn a living; that reality sometimes repels health care workers from rural places, Bennett said. But alternatives to the volume-based compensation system exist.

Take Federally Qualified Health Centers. The federal government designates some clinics FQHCs, a bureaucratic name that masks a simpler mission: to treat patients whether or not they can pay. In return, the government reimburses these centers for Medicaid patients, buttressing badly needed care in less-populated areas.

Still, sustaining an FQHC can be tough, said Aretha Polite-Powers, CEO of Fetter Health Care Network. The Lowcountry-based health center operates a string of affordable clinics where patients pay what they can, thanks to funding from the Health Resources and Services Administration.

It’s at these clinics in downtown Charleston, Hollywood and Johns Island, among other locales, where providers contend with the realities that can leave rural residents in poor health: Unreliable transportation. Inflexible work schedules. No child care coverage. And the misconception that health care — even at an FQHC — will plunge people into medical debt.

Polite-Powers said the upshot is a pool of patients who arrive at FQHCs already quite sick, beset by conditions like diabetes and hypertension that consistent care could have helped manage. Caring for these patients can be challenging, Polite-Powers said, who called FQHCs “safety net health care.”

“To do this work, you have to love it,” she said. “This is hard health care.”

Care on wheels

In addition to its clinics, Fetter Health has five mobile units — three medical and two dental — that travel to Lowcountry communities lacking abundant health care, from Adams Run to Pineville to Ravenel.

Bennett said roving clinics are a cost-effective way to treat patients in hard-to-reach areas. Telehealth is good too, he added, but it’s no substitute for meeting a doctor in an office, or in the case of mobile units, a bus, school or parking lot.

A blue bus is the roving office of a health educator and nurse who together traverse South Carolina administering vaccines. MUSC’s Community Health Van launched in 2021 with a straightforward mission: to increase the immunization rate against human papillomavirus, a sexually transmitted infection that can cause six types of cancer.

Since then, providers have doled out 1,750 shots to young people, most of whom are uninsured or on Medicaid, said Marvella Ford, associate director of population sciences and cancer disparities at MUSC’s Hollings Cancer Center. Increasing access to these inoculations is critical in South Carolina, which has historically ranked near the bottom of states in HPV vaccine rates.

Ford said immunizations have risen since 2016— when the Palmetto State had the lowest HPV vaccine completion rate among girls in the U.S. — thanks, in part, to the Community Health Van’s focus on rural areas, including Cherokee County, the I-95 corridor and the Pee Dee.

Key to the van’s effectiveness is its mobility; meeting patients where they’re at helps encourage consistent care, according to numerous rural health care providers. Creel, for his part, said he wants to launch a bus that ferries patients from their homes to his Ridgeville clinic.

It would be the latest upgrade for the Edisto Indian Free Clinic, the small brick building around which Creel has centered his long career in medicine.

At 11 years old, he told his mother he wanted to be a doctor (he doesn’t remember saying as much). Creel’s career began in earnest when he got into MUSC on his third swing. In those years, he split his time between medical school, pastoring, his young family and the Tribal Council. As a resident, while commuting home every weekend to pastor and occasionally moonlighting on Saturdays, he averaged about four or five hours of sleep a night.

Such is the high-powered pace of some physicians — especially those who are the only one in town. Creel has kept at it because he likes seeing people get better. But the hardest part of his job, and a challenge other rural nonprofit clinics face, usually comes when the grants run dry.

It’s in those situations, when a sick patient can’t afford a specialist and the Free Clinic is short on funds to subsidize the service, when the challenges of this line of work weigh on Creel.

Because for all income sources the physician has scored, his clinic in rural Ridgeville is still beholden to the forces of the health care industry. And sometimes, when it comes to covering the needs of every patient, grants and programs and partnerships still aren’t enough.