ST. PAUL — Rural Minnesota has so far been spared the brunt of the coronavirus pandemic, but its already struggling health care system is facing an unprecedented stress test because of it.

For some rural hospitals and clinics, the gubernatorial moratorium on elective surgeries is causing significant financial pain. Health officials question whether the bevy of federal and state relief funds coming their way will be enough to alleviate it.

Outstate hospitals were "right there on very low margins for many years" even before the pandemic struck, according to Minnesota Rural Health Association Executive Director Mark Jones. They tend to serve an older and less wealthy population that is more dependent on public programs like Medicare, reimbursement rates for which continue to fluctuate.

According to one association report, they also tend to run light on staff.

While Jones believes the $200 million emergency health care fund established by the Minnesota Legislature last month will provide some relief, he said in a Monday, April 6, interview that "the overall impact of this is going to be way greater than $200 million."

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More than 1,000 cases of COVID-19, the respiratory illness caused by the coronavirus, have so far been confirmed in Minnesota in a nationwide crisis that has shuttered businesses and confined citizens to their homes. While more than half of Minnesota coronavirus patients have recovered, 10 dozen remain hospitalized and 34 have died.

Though fewer cases have so far been confirmed in rural Minnesota than in the Twin Cities metropolitan area, hospitals and clinics serving those counties are taking the same steps as their urban counterparts to prepare for a potential surge in cases. Visitor restrictions are in place, surfaces are being rigorously disinfected and, per Gov. Tim Walz's orders, all but the most critical procedures are postponed.

For Bigfork Valley Hospital in northern Minnesota, the cost of pandemic prep and loss of revenue to the moratorium has "resulted in increased expenses and decreased revenue," said spokesperson Angela Kleffman, "which is challenging our financial operations." Donations are being sought for homemade face masks and other forms of personal protective equipment.

Despite the slowdown, the hospital foundation recently announced fundraising efforts meant to support neighboring service organizations affected by the pandemic.

Madison Hospital serves a rural county in western Minnesota. The pandemic has yet to take an economic toll severe enough for staff layoffs to be warranted there. CEO Erik Bjerke said the hospital has applied for a U.S. Small Business Administration loan in an effort to keep it that way.

"It does have a huge impact on our cash flow," he said of the pandemic.

Jones said other health care providers belonging to the Minnesota Rural Health Association are being directed to do the same. In addition to the SBA disaster loan program, businesses affected by the pandemic can apply for payroll and operating cost assistance through the recently created Paycheck Protection Program.

Approximately $350 billion have been set aside for the program, which Congress authorized last month. One catch, Jones said, is that hospitals and clinics owned by city or county governments won't be able to apply.

Health officials said that more funding will almost certainly be necessary should the pandemic persist. It has already cost at least 8,300 Minnesota health care practitioners and technicians their jobs since March 16, according to state Department of Employment and Economic Development data.

In Alexandria, the impact of the pandemic has already forced Alomere Health, a county-owned hospital, to cut employee work weeks back to four days. State officials announced Wednesday, April 8, that the hospital would be among the first to receive grant funding through the $200 million emergency fund.

It stands to receive about $300,000 in short-term aid. But aid programs might not make up for the significant amount of hospital revenue lost to canceled and postponed surgeries, said chief medical officer Dr. Deb Dittberner.

Dittberner said she did not see how "you can ever recover that 85% loss in elective procedures for a health system, or the same loss in a private clinic.”