Growing up on a cattle ranch in rural Nebraska, Alexis Swendener, PhD, learned early that healthcare was rarely simple. Long drives to hospitals or specialty providers were a constant, often requiring an entire day of planning for a single appointment.
“For rural residents, it often comes down to two questions,” Swendener said. “Do the options nearby meet my needs, and can I actually get there?”
Those early experiences now guide her research on how cost and distance limit healthcare access for rural residents, particularly those with disabilities.
During her time in CTSI’s Rural Health Policy Postdoctoral Program, Swendener had the opportunity to study these challenges more closely, working with mentor Carrie Henning-Smith, PhD, MPH, MSW, to better understand how structural barriers shape real-world decisions about care.
Instead of looking at barriers one at a time, she began to see how they intersect and build on each other, shaping whether people are able to seek care at all. “The program helped me see rural health differently,” Swendener said.
How compounding obstacles create gaps in care
In a recent study published in the Journal of Rural Health, Swendener and her colleagues analyzed national survey data to better understand how rural adults with disabilities navigate the healthcare system. They found that obstacles rarely exist in isolation. Instead, they build on one another, making it increasingly difficult to get necessary care.
The findings put data behind what many rural residents already experience. Barriers do not occur one at a time. They stack, narrowing the window for when and how care is possible.
Cost remains a primary hurdle. Rural residents with disabilities are nearly three times more likely to delay essential medical care due to the expense than those without disabilities. Transportation is also a significant factor. Rural residents with disabilities are three times more likely to delay care due to transit challenges, such as travel time or lack of a ride.
“Financial pressures and access challenges often intersect for rural residents with disabilities,” Swendener said. When these factors collide, they dictate whether and when a person seeks care.
The hidden toll of daily logistics
These challenges shape daily decisions. In some communities, nearby facilities may not offer essential services or lack the specialized equipment needed to support all patients. “Smaller rural facilities may not have the accessible equipment needed to meet everyone’s needs,” Swendener explained.
For those requiring specialty care, the nearest provider may be hours away. Transportation options can also be fragile, often operating on limited schedules or relying on short-term funding. As these gaps add up, the path of least resistance is often to forgo treatment entirely.
“It becomes easy to see how someone might delay care or go without care altogether,” Swendener said.
Building a path toward more accessible communities
Through her work, Swendener has seen how clinics and state agencies are working to bridge these gaps through telehealth, mobile clinics, and local transportation initiatives.
“A lot of the work happening in rural communities is downstream,” Swendener said, referring to efforts that address immediate barriers as they exist today. “That work is important because it’s achievable and has real impact.”
However, she argues that long-term improvement also requires addressing broader "upstream" issues like rising healthcare costs and rural economic pressures. She points to the “curb-cut effect,” the idea that accessibility improvements designed for one group ultimately benefit many others.
For Swendener, the mission remains rooted in the questions of her Nebraska upbringing: can people find the care they need close to home, and can they actually get there? Today, her research is helping local communities and state agencies better understand where gaps exist, while also helping policymakers use that insight to take steps in the future to address them.
“We need work happening at multiple levels at the same time.”
Related Stories
