Beyond Rural versus Urban

As a 55-year-old Black kidney transplant recipient living in Chicago, I read the recent study by Al Ammary et al. with more than passing interest—It felt personal. Their findings reveal what many of us already know from lived experience: Access to transplant care is not simply about being rural or urban, but about being seen, supported, and heard, no matter where we live. A strength of this study lies in its scope and timing. Drawing on data from nearly 300,000 recipients, the authors present a clear picture: Most (85%) patients receiving kidney transplant live in nonrural areas.1 This challenges the common assumption that only rural communities benefit from telemedicine. For those of us in dense urban environments like Chicago, distance is not always measured in miles—it is in bus transfers, missed work, caregiver coordination, and the hidden costs of navigating complex health systems. The study also highlights important disparities: Black, Hispanic, and Asian transplant recipients are disproportionately located in nonrural ZIP codes and are more likely to live in lower-income areas. These intersecting challenges—race, place, and income—are too often overlooked in health policy decisions. The potential rollback of telemedicine flexibilities would hit these communities hardest. From a patient perspective, the weakness in the study is not in its analysis—but in the limitations of data alone. Numbers can tell us where people live, but they cannot fully capture what it feels like to delay an appointment because you cannot afford the ride, or to juggle follow-ups between two jobs and caregiving responsibilities. The study does not include direct patient voices, but it opens the door for us to speak up and fill in those gaps. Telemedicine is especially important for patients like me who have rare kidney diseases. I have APOL-1–mediated kidney disease and while I can find a nephrologist as I live in a major urban area, it might not be easy for me to find a nephrologist with experience with my rare kidney diseases. Being able to find and communicate with an expert who might not within an easy distance for me to travel to can be a godsend. For those dealing with post-transplant fatigue, financial strain, or limited mobility, that flexibility is not just a convenience—it is a necessity. I volunteer with other kidney patients in the Chicago area, and what I have seen is consistent with the authors' conclusions: Urban patients often face access challenges as daunting as those in rural regions. Public transit is unreliable, transplant centers are few, and safety concerns make travel difficult—especially for immunocompromised patients. Ending telehealth coverage for nonrural areas ignores these realities. What should this mean for patient care? First, policymakers must recognize that geography alone does not define vulnerability. Nonrural patients deserve the same telemedicine access as their rural counterparts. Second, transplant teams should proactively offer telemedicine options—not just when in-person visits are impossible, but as a default choice when clinically appropriate. Third, access must be equitable: We need tech support, translated instructions, and culturally sensitive care to make telehealth usable for everyone, not just the tech-savvy. As for future research, I hope more studies will center the patient experience. Quantitative data are important, but qualitative research—interviews, focus groups, and stories—can help us understand how telemedicine affects trust, satisfaction, adherence, and quality of life. We also need research on how telemedicine affects long-term outcomes, especially in underrepresented communities. The authors note that Centers for Medicare & Medicaid Services' new Increasing Organ Transplant Access model may expand access, but policy changes take time. Meanwhile, real patients live in the uncertainty of shifting rules. As someone who has already walked the long road from dialysis to transplant, I cannot afford to wait. None of us can. In closing, I commend the authors for bringing attention to this issue. But now it is time to go further—beyond ZIP codes, beyond assumptions—and recognize telemedicine as a critical piece of equitable transplant care, not a temporary fix. For patients like me, it is not about convenience. It is about survival.