This qualitative study offers multi-ecological understandings of the experiences of rural Eastern San Diego County residents with healthcare access and public health systems. Similar to previous findings, participants expressed concern regarding factors such as limited access to healthcare services, socioeconomic constraints, geographical isolation, transportation limitations, and poor public health infrastructure, all of which impact their health outcomes.7, 8, 13,34,35,36,37,38 While urban communities may experience similar healthcare barriers, these limitations are amplified in rural communities due to their unique challenges of demographic and financial diversity, leading to greater health inequities.
Given the severe economic challenges, participants consistently reported their inability to address their medical needs. Many participants approached self-treatment as the only feasible option given their isolation from health facilities and the limited transportation available. A sense of hopelessness manifested among participants when discussing their reasons for dismissing crucial care, as they felt their lives were at risk. Our findings reflect the common gaps in rural healthcare services nationally. According to a Rural Healthy People 2030 survey, increasing access to healthcare services, economic stability, and transportation were among the top priorities for addressing rural health issues.39 Our results support previous findings where the barriers our participants encountered delayed routine healthcare.7, 34, 35 A potential solution to address challenges related to primary care needs among rural communities includes mobile health clinic (MHC) services to prevent further delays in care.35,40,41,42 Participants highlighted the need for compassionate, high-quality care that addresses rural health disparities and social needs. They envisioned the MHC not only as a localized provider of medical services, but also as a hub for connecting individuals to social service programs, improving health literacy, and rebuilding community trust in healthcare systems. To expand their reach, MHCs can be integrated within federally qualified health centers, such as our partner, San Ysidro Health. MHCs provide a unique opportunity for localized healthcare access, improved patient–provider relationships, and reduced healthcare costs among medically underserved communities.
While many participants were acutely aware of their personal limitations in seeking medical attention, they also placed shared responsibility on healthcare systems to address their medical needs. Participants gave details of the endless hurdles they encountered to obtain reliable health insurance and health services (e.g., information being unclear), expressing frustration and uncertainty about where their coverage status remained. Compared with their urban counterparts, rural areas are highly dependent on public health insurance programs (e.g., Medicaid and Medicare) for health coverage.43, 44 Previous study findings have also shown that rural residents are less likely to receive preventive health services than their urban counterparts.45, 46 The lack of preventive health screenings is potentially connected to the extensive administrative burdens rural participants face with public health insurance. Administrative burdens are considered the “costs,” or challenges experienced by medically disadvantaged individuals in accessing health-protective services, encompassing learning, compliance, and psychological factors.47 Participants reported difficulty navigating comprehensive healthcare coverage options, benefits, and services, which impacted their ability to enroll and understand their eligibility status. Future initiatives could prioritize addressing administrative burdens in rural communities to help reduce health coverage-related barriers.
Participants also reported a delay in care related to the high premiums and out-of-pocket costs associated with health insurance and primary care services.7, 45, 46, 48 Participants asserted that public insurance programs do not accurately account for the complex navigation hurdles and unique financial hardships that rural communities face. Therefore, participants associated their dismissal of health-related expenses with the multifaced barriers they faced. This pattern is seen nationally, with health coverage uncertainty surging due to recent policy changes. On July 4th, 2025, the H.R.1, or the One Big Beautiful Bill Act, was signed into law, making significant spending cuts to Medicaid and Medicare.49 To counteract the impact of H.R.1 on rural communities, the Centers for Medicare and Medicaid Services launched a temporary solution, the Rural Health Transformation (RHT) Program.49 The $50 billion program provides States the opportunity to invest in rural health. Despite the law’s intention to reconcile the effects of H.R.1, RHT provides funds for only five years and does not address the potential financial strain that Medicare and Medicaid spending cuts may cause in rural areas. More information is required to understand the impact of RHT on rural communities. Public and state health programs must reevaluate the unique structural and financial challenges rural communities face to address access to care and community health outcomes.
Aging rural participants discussed community and healthcare system-level barriers they face, expressing a desire for health programs to provide quality and comprehensive aging health care services. Similar to other findings[13, 39, 50], reliable transportation was reported as a necessity for accessing healthcare services among our older participants. In an already vulnerable stage of their lives, older participants expressed feeling disregarded when transportation was either denied or postponed. They voiced their fear of untimely death due to the barriers that limited their access to aging life care. The transportation services that aging residents periodically received, as noted by our participants, were severely uncomfortable and not designed to meet the needs of disabled individuals. Certain individuals shared that they are subscribed to receive services from PACE or the Veterans Transportation Service (VTS). Transportation services are prescribed as a plan of care for PACE participants51 and qualifying Veterans.52 It has been noted that rural PACE staff and VTS stakeholders acknowledged challenges such as staff shortages and the higher cost associated with traveling greater distances as barriers to healthcare access among rural beneficiaries.53, 54There are significant fiscal challenges in providing transportation services to deliver care to rural communities. Additionally, participants believed they did not receive the required level of care from their insurance provider due to their geographical isolation. The denial of care increased frustration among participants, and they felt this gap contributed to the decline in their health. While modern-day solutions include telehealth services to overcome access barriers[55, 56], telemedicine continues to produce inequities for older rural residents, given their limited technology literacy and unreliable services. Aging participants’ poor experience with health programs stresses the need for creative strategies by federal and state health systems. These efforts should prioritize transportation needs and tailor services to advance healthcare access for aging communities in rural areas.
Participants believed that minimal local government intervention resulted in poor public health and safety infrastructure, contributing to their poor living conditions. Participants showcased their fear regarding the physical state of their environment. They felt that the poor quality of water running through their community required them to seek additional medical attention. However, with the physical and financial barriers they experienced, they felt defeated. The sentiments expressed by our participants reflect the national findings, indicating that water quality in rural areas is worse than that in urban areas.57 Twenty water systems in San Diego County failed repeated water quality tests in 2024, six of which were located in our target population area.58 According to the California Water Boards, failing systems are considered noncompliant or consistently failing to meet drinking water standards.59 The contaminants that exceeded the allowable limits among our target population areas included nitrate, arsenic, iron, magnesium, and combined uranium.58 Arsenic is identified as a priority pollutant by the U.S. Environmental Protection Agency60 because of its association with acute and chronic adverse effects.57, 61 As reported by the participants, physical ailments associated with contaminated water caused individuals to question local government intervention. Community members felt as if the local government was not doing enough to address this issue, weakening their support for the government officials. According to the NIMHD Framework, the synergistic impact of community-level barriers and physical/built environment-level barriers may contribute to a participant’s susceptibility to poorer health outcomes.32 Strategic investment in public health and safety by the local government could mitigate these effects. One example is the Safe and Affordable Funding for Equity and Resilience Program (SAFER) to address the lack of safe drinking water in communities.62.
Limitations
The narratives of healthcare access and public health infrastructure are limited to six rural communities in Eastern San Diego County. This limits perspectives on healthcare access and public health infrastructure in these rural communities. However, patterns seen nationally were noted. Additionally, participation in individual interviews was accessible only to those who initially received a health screening by the mobile health clinic team. Despite the researchers’ effort to localize the mobile health clinic, limitations in participation for individual interviews reflect the transportation barriers rural community members face in obtaining care. Furthermore, participation was selected by individuals who were available during working hours and specific interview dates. Bias towards the utilization of the mobile health clinics as a potential solution to address rural healthcare access arose, as it was the method of healthcare delivery in this research project. Brief interviews and novice interviewers could have affected the richness of the data, encouraging further probing by interviewers. Additionally, our study was conducted in Kumeyaay land. Despite recruiting within tribal lands, we did not focus on indigenous rural health because of the presence of the Indian Health Service serving the indigenous communities. Lastly, most of the study participants identified as White, aging females. Limited participant variation may have narrowed data depth in terms of healthcare needs and experiences. We encourage future studies to recruit participants of diverse ages, races, and ethnic backgrounds in medically underserved rural communities.
