Seven months into the COVID-19 pandemic, Oregon’s rural health care system is limping.

When Oregon Gov. Kate Brown required medical providers to cancel non-emergency procedures in March, health care clinics statewide — especially in rural areas — saw their revenues plunge. Even though non-emergency procedures were allowed to resume May 1, patients have been slow to return.

Experts say Oregon’s rural hospitals and primary care clinics are still sorely underfunded, clinicians are overstretched and rural patients’ physical and mental health is declining.

“Thanks to federal dollars, everybody’s still here. But some providers are just hanging on,” said Robert Duehmig, interim director of Oregon Health and Science University’s Oregon Office of Rural Health.

A study released this month by the Larry A. Green Center, a research organization working with the Primary Care Collaborative, found that nationwide nearly half of primary care clinicians said things look “somewhat rosier” than last spring, but their clinical workforces are still “fragile.”

Half of the clinicians surveyed said the overall physical health of their patients has declined, 41% said their patients with chronic conditions are “noticeably worse,” and 86% reported they’ve seen a decline in patients’ mental health.

The pandemic has been hard on providers, too.

Many rural Oregon providers and administrators who were furloughed or laid off last spring were brought back, said Duehmig, but others have not returned.

Nationwide, more than a quarter of primary medical practices have permanently reduced staff, and about the same number say a third of their practice’s work goes unpaid.

“There’s been a lot of stress on our rural providers. Those remaining have been asked to work more hours, work under very, very different and difficult circumstances,” said Duehmig.

Ann Greiner, president and CEO of the Primary Care Collaborative, said most rural clinicians were already overstretched pre-pandemic. Rural areas have fewer specialists, so a rural family medicine physician might deliver babies, provide care from birth to death and even perform surgeries.

The crisis has also impacted the “next generation” of medical providers. Educational institutions have struggled to find hospitals or clinics willing to let medical students do clinical rotations because of virus concerns. And recent graduates of medical programs have had trouble finding jobs.

Healthcare experts say many challenges are structural.

Health insurance is often tied to employment, said Duehmig. With high unemployment during COVID-19, he said he expects more patients on Medicaid, which reimburses providers at a fraction of what private insurers cover.

Telehealth — video or phone medical appointments — continues to expand, but providers face challenges with low-speed internet in rural areas and uncertain reimbursement rates.

Many rural practices are independent.

“It means they may not have access to capital to help them ride out a financial storm. They also lack clout in getting (personal protective equipment) and tech, and they’re much more vulnerable to foreclosure and layoff,” said Greiner.

Oregon’s rural hospitals got some money from Congress this year, but Greiner said rural primary clinics still need targeted federal aid.

“We still have work to do,” said Duehmig.