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

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.

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.

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.

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.