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In rural Oregon, a healthcare crisis is festering. Gov. Kate Brown labeled healthcare providers “essential” during COVID-19, but the pangs of lockdown have thrashed providers.

March and April, many rural hospitals and clinics sat nearly empty with outpatient procedures and elective surgeries postponed. Delayed care may have health impacts for patients, and the revenue drop battered already-fragile rural health systems.

May 1, Gov. Brown permitted medical providers to resume 50% of normal patient levels. But 50% means less than breaking even, said Eric Wiser, medical doctor and deputy director of Oregon Area Health Education Center.

“At a rural clinic, a couple procedures less is all you need to run into the red,” said Wiser.

Oregon’s rural practices look red — very red.

March through May, according to Larry A. Green Center survey data, of more than 100 Oregon primary care practices, 33 of which are rural, three in four experienced severe financial strain, 39% furloughed or laid off workers, one in four had clinicians skip salaries and 16% temporarily closed.

Hospitals, too, took a hit. About three in five rural hospitals lost up to 70% revenue, according to the Oregon Association of Hospitals and Health Systems.

Federally-funded community health centers, called CHCs, are also hurting. CHCs serve populations with limited health care access. Statewide since March, CHCs have lost about $40 million, said Joan Watson-Patko, executive director of Oregon Primary Care Association.

Some larger urban providers have relied on reserves.

Recent financial tallies show Oregon Health and Science University, PeaceHealth and Providence Health have about $1.1 billion, $2.1 billion and $6 billion in reserves respectively.

“Smaller hospitals have fewer resources to fall back on,” said Kevin Mealy, spokesman for Oregon Nurses Association.

In a late May survey, the majority of respondents at Oregon primary care practices said they don’t know how much cash they have or think their reserves will last only one to three months.

Less money also means fewer jobs.

Statewide, CHCs have lost 20% of jobs, said primary care expert Watson-Patko.

Hospitals also trimmed workers. Curry Health Network in Gold Beach furloughed, laid off or cut hours for 192 employees. Columbia Memorial Hospital in Astoria furloughed 90, North Bend Medical Center in Coos Bay 130, Mid-Columbia Medical Center in the Dalles 225.

Mealy, spokesman for Oregon Nurses Association, said ONA advocated for nurses to receive cross-training while departments were shuttered, making furloughs and layoffs a last resort.

Providers continued serving patients during lockdown, but most appointments were “telehealth” videos or calls. Experts say insurance reimbursements for telehealth are unsustainable and rural areas already have more patients on government insurance that pays providers less.

While revenue dwindled, expenses jumped.

The cost of personal protective equipment, or PPE, increased tenfold because of worldwide demand, disrupted supply lines and opportunists, said Harris. A $0.40 mask became $4.00.

“PPE, hands down, continues to be the greatest need,” said Johnson of La Clinica.

Patients are trickling back, but providers say impacts will endure.

People delaying care, experts say, may face health consequences later. Parents have canceled children’s immunizations. Patients have postponed preventative care. And statewide, emergency rooms saw a 30% reduction in patients, said Harris of the hospital association.

“Doctors are asking: Where are the heart attacks? Where are the strokes?” she said.

Many providers fear another long-term effect: a potential exodus of providers who were laid off from rural to urban areas. The biggest challenge in rural healthcare, experts say, is provider recruitment, and the pandemic could leave rural areas with fewer clinicians.

Suffering hospitals have also had ripple effects on businesses they fuel: architects, manufacturers, suppliers.

“I’m starting to recognize our focus on surviving is impacting all other businesses we touch,” said Jenn Welander, CFO of St. Charles Health System in Bend. “It’s like a crack in the ground that will keep growing. Some businesses we worked with may never open again.”

But not everything has been negative.

Providers say they are learning to be financially resilient, establish diverse PPE supply chains, are excited about the rise of telehealth and have seen “incredible wins” in coordinated care between urban and rural providers.

“There’s a long road ahead,” said Welander of St. Charles. “An event of this magnitude is not lived down within weeks or even within months. This is going to be a multi-year event.”