Heidi Schultz grew up traveling from one end of South Dakota to the other, tagging along as her sister saw doctors and specialists in the “big cities” to treat her diabetes.

Schultz thought she knew rural America well when she took a position as a rural health care program officer for the Helmsley Charitable Trust in Wyoming and Montana.

But even she has been surprised by how she can drive hours on country highways seeing few cars and just “a handful of gravel driveways going somewhere you can’t see.”

“It’s almost scary,” Schultz says. “You’re thinking, ‘If something happened to me here on this road now, how long would it take for someone to get to me? An ambulance? And where would they take me for care?’ “

Now part of her job is to help organizations apply for grants to provide care in rural areas. She understands that people living in these places must come up with creative solutions to deal with their health care needs — whether it’s getting help in an emergency, receiving treatment for ongoing illnesses or softening the natural consequences of old age.

It’s a quickly changing landscape as more rural hospitals close, and some health policy analysts say it’s time communities made some hard decisions — starting with completely changing the health care structure in small towns.

For example, says a recent report by the Bipartisan Policy Center, instead of making sure each rural resident can easily get to a full-service hospital, some communities should consider what kind of primary care and more specialized care they could offer at a facility instead — short of having a full-service hospital.

Hospitals tend to be cornerstone institutions in rural communities. They provide jobs and contribute to a town’s economy. For many citizens in small-town America, losing the local hospital would threaten the livelihood of the town and its people, says Patrick Roche, chief operating officer at Faith Regional Health Services based in Norfolk, Neb.

“There are two things they don’t want to lose. The first one is their school, the second one is their hospital,” says Roche.

But there are big challenges to keeping these hospitals open. They cost money and it’s difficult to find a qualified workforce.

There are other concerns, including limited funding, regulatory restrictions, problems with transportation, broadband internet accessibility and the unique characteristics of the population, according to Dr. Anand Parekh, chief medical advisor with the Bipartisan Policy Center and one of the report’s authors.

“Rural America,” Parekh says, “is a little bit older, a little bit sicker, a little bit poorer.”

In 2016, the Census Bureau reported that 19.3 percent of the U.S. population lived in rural areas, which cover 97 percent of the country. Up to this point, the medical needs of that group have been addressed by a system that has medical facilities, many of which do receive some federal support, including about 1,300 small hospitals known as critical access hospitals.

A hospital is designated as critical access by the Centers for Medicare and Medicaid Services if has 25 beds or fewer, is more than 35 miles from another hospital and provides 24-hour emergency services.

The National Rural Health Association says 673 rural hospitals are at risk to close, and 210 of those are at “extreme risk”— 60 rural hospitals closed between 2010 and February 2016.

One of the main reasons for the significant rural hospital closures is that the average number of in-patients is low, says Schultz.

“Running a full hospital is very expensive — the overhead, 24/7 staffing, the facilities,” she says. “Think of a 25-bed hospital, and you’re only using four of your beds and how expensive that is.”

Residents of Tilden, Neb. — a town of less than 1,000 — know what happens when the town hospital can’t make ends meet. They lost their critical access hospital in 2014 and had to find a different solution for their medical care.

Roche explains that Faith Regional Health Services in Norfolk, just 22 miles away from Tilden, worked out an agreement to lease the hospital and clinic from the little town; Faith Regional then provided the medical operations—staffing, providers and equipment.

“The operations are, in effect, owned by Faith Regional and are operated just like any other clinic that is owned and operated by our system,” Roche says. But the facility in Tilden is no longer a full hospital.

“There’s been a fear in the air and you read a lot, and you hear a lot about hospitals closing,” says Schultz, who travels often to rural communities. “And that’s rightfully so. But if you look at the communities that are losing their hospitals, you need to look at, ‘What do they still have?’ “

The Bipartisan Policy Center and Helmsley Charitable Trust partnered to propose a possible solution for communities struggling to keep facilities afloat and provide quality care miles away from city and suburban hospitals and clinics.

Their January 2018 report, which surveyed health care professionals in seven states in the upper Midwest, says that the whole rural health care system needs to be addressed. Each community should determine the best health care structure, the report suggests, not the other way around. And that difficult analysis may lead to closing a small town hospital.

Darrold Bertsch, chief executive officer of Sakakawea Medical Center in Hazen, N.D., says he agrees with the idea of catering health care facilities to the population — whether it’s with an outpatient clinic, urgent care center, a hospital or something else.

“If communities had a little bit more flexibility,” he says, “then they could adapt a health care delivery system in their area that is more relevant to the needs that they have, rather than trying to make a hospital fit in a community where it might not be able to be supported anymore.”

The critical access hospital in Cody, Wyo., has stayed open — partially because of this idea of flexibility, says Jeanine Brus, who works as the laboratory director for the hospital.

Cody sits outside the eastern edge of Yellowstone National Park and is a town of about 10,000 people. Cody Regional Health, which includes the hospital and other health care facilities, such as a surgical center, a cancer center and a dialysis center, serves the town and the farms and ranches in a 200-mile radius, as well as tourists from the park.

Brus says that the key to adapting has been collaboration between the different facilities. And that’s been good for the health care workers, as well as the community, she says.

Bertsch from the North Dakota hospital says federal regulations and the way hospitals are reimbursed mean there’s no one-size-fits-all fix for every community.

Still, Parekh underscores his hope for the possibilities that can come when communities are open to new kinds of solutions.

“You know, you don’t have to close your hospital,” he says. “You can transform the hospital to meet your community needs, improve health and still continue to improve your local economy. Rural America can thrive as health care transforms.”

This story is part of NPR’s reporting partnership with Kaiser Health News.

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Health plans that don’t meet the standards of the Affordable Care Act; work requirements for Medicaid coverage; changes to Medicare’s approved drug lists: As the ground continues to shift on health care coverage, I’m answering readers’ queries this week about these three different types of plans:

I lost my job last year and my employer coverage ended in January. I bought a new plan through the marketplace that went into effect last month. I just received policy information, and it states that because the plan does not cover major medical services, I may have to pay additional taxes to the government. I was told that the plan didn’t cover major medical, but wasn’t told about any taxes. Will I be fined next year?

It sounds like you bought a plan that doesn’t comply with the Affordable Care Act’s requirements, and if that’s the case you may indeed have to pay a penalty for not having comprehensive coverage when you file your taxes next year.

The tax reform law repealed the individual penalty for not having health insurance, but that provision doesn’t take effect until 2019. So for 2018 you may be charged the greater of $695 or 2.5 percent of your household income.

The federal- and state-run marketplaces established by the ACA sell only comprehensive plans that cover 10 essential health benefits, including “major medical” services like hospitalization and prescription drugs.

But some insurance broker websites call themselves marketplaces too, says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. And that can be confusing. These companies may sell other insurance products — like short-term or accident coverage — alongside comprehensive plans that comply with the law.

Ever since the health law was passed, “There have been opportunistic companies trying to take advantage of consumer confusion to make money,” Corlette says.

If you aren’t happy with your plan, you may still be able to switch. Losing your employer coverage qualifies you for a 60-day special enrollment period to pick a new plan. Since it appears you’re still in that window, you may be able to choose a comprehensive plan.

To ensure you’re using your state’s official marketplace, go to healthcare.gov and click on “see if I can change.” That will take you to your state marketplace, even if you live in one of the dozen or so states that run their own exchanges.

I’m in a state that is looking into work requirements for Medicaid. At sign-up time, can I simply tell the exchange that I intend to be ineligible for Medicaid by refusing to work and get the premium tax credit to buy a private plan on the insurance marketplace?

Federal health law regulations don’t clearly address the situation you describe, but the short answer is probably not, according to policy analysts.

In general, people who are eligible for employer coverage or Medicaid — the federal-state health program for people with little income — can’t qualify for federal tax credits that help pay for premiums on plans sold on the health insurance exchanges.

This year, Kentucky and Indiana became the first states to receive federal approval to require some Medicaid recipients to put in 80 hours each month at a paid job, school or volunteer work (among other activities), to receive benefits. Nearly a dozen other states have made similar requests.

If you refuse to work, does that make you ineligible for Medicaid? The rules aren’t clear, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

States might argue that someone in your situation is eligible for Medicaid — you just have to fulfill the work requirements, says Timothy Jost, a professor emeritus of law at Washington and Lee University in Virginia, who is an expert on the health law.

There are other actions people could take — or fail to take — where this issue might come up. “You could argue that someone is not eligible because they haven’t completed the Medicaid application or provided the required documentation,” Jost says. “There are any number of requirements, but I can’t imagine someone saying they didn’t do those things and so they’re not eligible for Medicaid.”

Whatever the rules, it’s unlikely that many people will be in a position to consider taking this stance. To qualify for premium tax credits, your income must be between 100 and 400 percent of the federal poverty level (about $12,000 to $48,500 for an individual in 2018). But you’d also have to be eligible for Medicaid, generally with an income limit of 138 percent of poverty (about $16,750) in states that expanded coverage to adults. In addition, the Medicaid work requirements in your state would have to apply to you.

I picked a Medicare Part D drug plan that covered all the drugs I take. But as soon as I got my first Novolin R prescription filled, they notified me that they don’t cover it anymore. Can they just switch it like that?

Medicare drug plans can change their list of covered drugs, called formularies. If they’re doing so at the start of the new calendar year, as appears to have happened in your case, the plan may notify you of the change when you fill the prescription for the first time in the new year. At that time, the plan would typically give you a 30-day transition refill so you can switch to another drug that’s on the formulary or start the appeals process to continue taking your current insulin drug, Novolin R.

If you and your doctor think it’s important that you have Novolin R and not another drug that is similar, you can ask your plan to make an exception to allow you to continue to take the drug.

To go that route, you would need to get your doctor to “make the case for why that formulary drug is not the right drug” for you, says Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.

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