STATENVILLE, Ga. — Georgia’s Echols County, which borders Florida, could be called a health care desert.

It has no hospital, no local ambulances. A medical provider comes to treat patients at a migrant farmworker clinic but, other than a small public health department with two full-time employees, that’s about the extent of the medical care in the rural county of 4,000 people.

In an emergency, a patient must wait for an ambulance from Valdosta and be driven to a hospital there, or rely on a medical helicopter. Ambulances coming from Valdosta can take up to 20 minutes to arrive, said Bobby Walker, county commission chairman. “That’s a pretty good wait for an ambulance,” he added.

Walker tried to establish an ambulance service based in Statenville, the one-stoplight county seat in Echols, but the cost of providing one was projected at $280,000 a year. Without industry to prop up the tax base, the county couldn’t come up with that kind of money.

In many ways, Echols reflects the health care challenges faced in rural areas nationwide, such as limited insurance coverage among residents, gaps in medical services and shortages of providers.

Dr. Jacqueline Fincher, an internal medicine physician who practices in rural Thomson, in eastern Georgia, said such communities have a higher share of people 65 and older, who need extensive medical services, and a much higher incidence of poverty, including extreme poverty, than the rest of the country.

About 1 in 4 Echols residents has no health insurance, for example, and almost one-third of the children live in poverty, according to the County Health Rankings and Roadmaps program from the University of Wisconsin’s Population Health Institute.

Like Echols, several Georgia counties have no physician at all.

It’s difficult to recruit doctors to a rural area if they haven’t lived in such an environment before, said Dr. Tom Fausett, a family physician who grew up and still lives in Adel, a southern Georgia town.

About 20% of the nation lives in rural America, but only about 10% of U.S. physicians practice in such areas, according to the National Conference of State Legislatures.

And 77% of the country’s rural counties are designated as health professional shortage areas. About 4,000 additional primary care practitioners are needed to meet current rural health care needs, the Health Resources and Services Administration has estimated.

“Many physicians haven’t experienced life in a rural area,” said Dr. Samuel Church, a family medicine physician who helps train medical students and residents in the northern Georgia mountain town of Hiawassee. “Some of them thought we were Alaska or something. I assure them that Amazon delivers here.”

Rural hospitals also have trouble recruiting nurses and other medical personnel to fill job vacancies. “We’re all competing for the same nurses,” said Jay Carmichael, chief operating officer of Southwell Medical, which operates the hospital in Adel.

Even in rural areas that have physicians and hospitals, connecting a patient to a specialist can be difficult.

“When you have a trauma or cardiac patient, you don’t have a trauma or cardiac team to take care of that patient,” said Rose Keller, chief nursing officer at Appling Healthcare in Baxley, in southeastern Georgia.

Access to mental health care is also a major problem, said Dr. Zita Magloire, a family physician in Cairo, a city in southern Georgia with about 10,000 residents. “It’s almost nonexistent here.”

Dr. Zita Magloire, a family physician in Cairo, Georgia, says access to mental health treatment for patients is a major problem in rural areas. “It’s almost nonexistent here,” she says.(Andy Miller/KHN)

A map created at Georgia Tech shows wide swaths of rural counties without access to autism services, for example.

One factor behind this lack of health care providers is what rural hospital officials call the “payer mix.”

Many patients can’t pay their medical bills. The CEO of Emanuel Medical Center in Swainsboro, Damien Scott, said 37% of the hospital’s emergency room patients have no insurance.

And a large share of rural hospitals’ patients are enrolled in Medicaid or Medicare. Medicaid typically pays less than the cost of providing care, and although Medicare reimbursements are somewhat higher, they’re lower than those from private insurance.

“The problem with rural hospitals is the reimbursement mechanisms,” said Kirk Olsen, managing partner of ERH Healthcare, a company that manages four hospitals in rural Georgia.

Georgia is one of 12 states that have not expanded their Medicaid programs under the Affordable Care Act. Doing so would make additional low-income people eligible for the public insurance program. Would that help? “Absolutely,” said Olsen, echoing the comments of almost everyone interviewed during a monthslong investigation by Georgia Health News.

“If Medicaid was expanded, hospitals may become more viable,” said Dr. Joe Stubbs, an internist in Albany, Georgia. “So many people go into a hospital who can’t pay.”

Echols County isn’t the only place where ambulance service is spotty.

Ambulance crews in some rural areas have stopped operating, leaving the remaining providers to cover greater distances with limited resources, said Brock Slabach, chief operations officer of the National Rural Health Association. It’s difficult for a local government to afford the cost of the service when patient volumes in sparsely populated rural areas are very low, he said.

“If people aren’t careful, they’re going to wake up and there’s not going to be rural health care,” said Richard Stokes, chief financial officer of Taylor Regional Hospital in Hawkinsville, Georgia. “That’s my big worry.”