by James A. Bacon

It turns out there’s not just a hospital shortage and a physician shortage in rural Virginia — there’s a nursing shortage. A couple of articles over the weekend highlighted growing problems with health care access in rural and small-town western Virginia communities.

Community leaders in Patrick County have given up on bringing back a local hospital from the dead, reports the Associated Press. Efforts to resuscitate the old Pioneer Community Hospital were hampered by complex licensing issues and the high cost of retrofitting the 1960s-era hospital building, which has deteriorated since it closed two years ago and suffers from extensive deferred maintenance issues.

Local officials now are looking for other ways to deliver health care services to the mountainous county where the population is declining and aging, the AP says. In the meantime, still-functioning hospitals are shutting down floors and units due to an inability to staff them with nurses.

A Roanoke Times article highlights the problem at the Holston Valley Hospital in Kingsport, Tenn., which serves parts of far Southwest Virginia. The nursing shortage, though national in scope, is especially acute in western Virginia. The job growth rate for nurses is the fastest of almost any occupation in the U.S., and nursing schools are hard-pressed to keep up. There are two big problems: a shortage of faculty and a shortage of clinical spots to train them.

As nursing schools struggle, hospitals are resorting to a variety of strategies to address the shortages, from increasing pay and recruiting nurses from other countries (particularly the Philippines) to experimenting with “shared governance” systems that give nurses a bigger voice in management.

Bacon’s bottom line: There are no simple fixes to Virginia’s rural health care crisis. One of the promises of Medicaid expansion is that it would put more money into the pockets of small community hospitals like those in Patrick County and Lee County that have shut down. Maybe the influx of funds will help keep other community hospitals afloat — we’ll see how that works out. But if an inability to hire doctors and nurses forces community hospitals to close floors and departments, extra Medicaid money may not make a difference.

Absent a magical infusion of billions of dollars into Virginia’s rural health system, we may have to come to terms with the reality that it is economically impossible to maintain the same level of hospital service as in the past. But that’s not to say that rural residents need to travel 30 to 60 miles for all their treatment. Perhaps the focus should shift to providing primary care, urgent care (as opposed to emergency room care), and outpatient ambulatory surgery in lower-cost settings than hospitals. Such a vision is far from perfect, but it’s better than no local health care at all.

What is preventing such a transition? Does the Certificate of Public Need review process and other licensing barriers make it more difficult for health-care entrepreneurs from devising lower-cost settings and providing a less-than-perfect-but-better-than-nothing level of health care? It’s a question worth asking.