Where Have All the Rural Hospitals Gone?

Since 2010, nearly 100 rural hospitals across the United States have closed, and the closure rate has been accelerating in recent years. The National Rural Health Association (NRHA) warns that at least 673 are vulnerable to closure in the future.

What happens when the only hospital for miles around closes down?

People lose access to care, and the community suffers. In fact, the NRHA estimates that 11.7 million patients could lose access to care if the federal government doesn’t take action to halt the tide.

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The losses

It’s not easy to tell people they now have to drive to the next county, or a few counties away, when they need to go to a hospital.

“A lot of people don’t have the means to drive that far,” said Sultan Babar, MD, CAQSM, FAAFP, a family and sports medicine physician who practices in a small township in New Jersey. Babar has seen what happens to small communities that have gone through a hospital closure, or had their community hospital stripped of most of its services.

Patients may not have a car or access to a car. Even if they do, many people in rural areas may not be able to take the time off work to drive those extra miles to a hospital that’s further away, Babar noted.  Plus, those who may need emergency care are more vulnerable to complications and adverse outcomes when treatment is delayed.

It’s not just patients who suffer when rural hospitals close, either.

The NHRA estimates that 99,000 healthcare jobs and 137,000 community jobs would be lost as a result of rural hospital closures, if all those currently in danger were to shut their doors. The GDP could experience a loss as large as $227 billion over 10 years, too.

Staff Care recently honored one rural physician in California who has worked for 30-plus years to serve patients at the clinic in his small community, and help keep the rural hospital open in his neighboring town. For his dedicated service, Daniel Dahle, MD, was named the 2019 Country Doctor of the Year.

Challenges facing rural hospitals 

Unfortunately, many rural hospitals have been unable to survive some of the challenges facing them. The biggest obstacle? Money.

A report issued in August 2018 by the U.S. Government Accountability Office (GAO) noted that financial issues were the biggest reason for most of the closures that occurred between 2013 and 2017.  A report released in early 2019 by the American Hospital Association (AHA) reached the same conclusion.

“Due to low population density in rural areas, hospitals lack scale to cover the high fixed operating costs,” noted the authors of AHA’s Rural Report 2019.

Rural hospitals in states that expanded Medicaid under the Patient Protection and Affordable Care Act were not hit quite as hard as those in states that didn’t expand Medicaid, the GAO report noted. Reduction in Medicare reimbursement also played a role in the financial pressures that led to some of the closures.

What about possible solutions? 

The GAO report found that nearly half (47 percent) of the 64 rural hospitals that closed between 2013 and 2017 ceased providing any type of services. The others “converted to other facility types, providing more limited or difference services, such as urgent care, emergency care, outpatient care or primary care,” the authors wrote.

Indeed, rather than close down altogether, some hospital owners are trying to preserve some measure of care in rural communities.

For example, Kaiser Health News reported in January on a hospital in the rural Texas community of Crockett that reopened a year after closure—but with a smaller, streamlined set of services, which included an emergency department and a handful of inpatient beds. The revamped rural hospital no longer offers any obstetrics services, so pregnant mothers still have to drive out of town to a hospital with a labor and delivery unit.

A 2016 policy brief on maternity care from the NRHA documented a decline in obstetrics services in rural areas between 2004 and 2014. “As of 2014, only 45% of rural counties had OB services, down from 54% in 2004, showing a rapid decline,” the authors wrote. They pointed to the financial challenges that hindered many rural hospitals from keeping their OB units open, highlighting “the low Medicaid reimbursement rate and the high cost of malpractice insurance.”

Some hospitals in jeopardy, however, may find that focusing on maternity care could keep the doors. CBS News recently reported on a hospital in Lakin, Kansas, that decided to focus on obstetric care to preserve an element of care in their small community. The Kearny County Hospital employs family medicine physicians who can deliver babies, while also providing other types of care. The area’s young mothers who have received good care continue to bring in the baby and the rest of the family for treatment, strengthening the hospital’s base.

The hospital also received a grant from the Children’s Medical Network of Kansas and continued pursuing other grants and partnerships to keep the doors open—and to even grow.

While some rural medical centers have found assistance through federal designation as Critical Access Hospitals (CAHs) and other programs, many leaders insist that more needs to be done. Babar said he can see the value in federal subsidies to preserve the rural hospitals that are vulnerable to closure.

“Smaller hospitals should be subsidized to remain independent, so they can continue to serve the communities and continue to act in their best interest,” he said. “We subsidize travel to small airports through a U.S. government program called Essential Air Service. I think something similar for healthcare would benefit rural hospitals.”

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STAFF CARE places physicians and advanced practitioners in locum tenens jobs across the U.S., in both rural and urban settings. 

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