This is true and the healthcare access problem is more than just cost. If you're an hour and a half away from any specialists, then the ER you went to likely doesn't have access to set up those referrals. I have worked in both metropolitan and rural medical systems, and the biggest problems in rural healthcare are almost always access-based. If a hospital/ER is not in the same medical group as a specialist, they can't put in emergency referrals to that specialist, and I have worked in rural hospitals that don't even always have imaging services available. There's an MRI on a trailer that gets brought around to the various hospitals in the group meaning that each hospital has one day a week or one day every other week where an MRI is available. The other option a small, rural ER has is to call EMS to transfer you to another hospital with more resources, but if your insurance doesn't like the reason they give, you end up on the hook for that 90 minute ambulance ride. Small community hospitals are really between a rock and a hard place when it comes to connecting patients with resources while trying to avoid unnecessary expenses.

The best advice I have for anyone in a rural area with poor healthcare access is to establish care with a family physician for primary care because, most of the time, the primary care physician is the one that actually gets to the bottom of things or coordinates the referrals for specialists. If you have a standing relationship with a physician, it's a lot easier to make an appointment and they have a baseline to work from as opposed to starting from scratch like an ER physician has to.