Rising rates of rural hospital closures impact the health of many Americans. According to the U.S. Census, 20 percent of the United States population, or 67 million people, reside in rural areas. Because 80 percent of rural America is already medically underserved and rural hospital closures make it more difficult for rural residents to access care, Congress should fund and direct federal agencies, such as the Agency for Healthcare Research and Quality (AHRQ), to expand research on this pressing issue.
Since January 2005, 193 rural hospitals have closed or converted to delivering non-inpatient health services, most of which occurred in the South and non-Medicaid expansion states. Although rural hospital closures are not a recent phenomenon, they have been increasing since the 2008 recession. This increase has prompted renewed demand for mitigation and adaptation strategies. Federal relief funds delivered during the COVID-19 public health emergency helped stem closures. As these funds end, the rate of closures may increase again – as of 2023 30 percent of rural hospitals are at risk of closure.
Many closures are related to a complex set of both market and hospital factors. These include depopulation and small patient volume, challenges in workforce recruitment and retention, low profitability due to payer mix, and the socio-demographic landscape of rural America. For example, financially distressed rural hospitals are more likely to close when their communities have high rates of unemployment or uninsured residents under the age of 65.
These closures increase challenges in accessing care and may widen existing health disparities for rural Americans, such as higher incidence of chronic conditions and lower life expectancy.
Indeed, hospital closures can reduce access to emergency care. This may be problematic for rural residents who have higher age-adjusted death rates from unintentional injuries, stroke, heart disease, respiratory disease, and cancer. Rural hospitals are also a source of primary and ongoing care for residents, and loss of access may compound disparities. Particularly as closures not only have immediate effects on access but can result in declines in the future. One study found as high as a 9.2% annual decrease in physicians in the county after a closure.
Rural hospital closures also result in residents having to travel substantially further to access care. The median distance to access general inpatient services increased by 20 miles after a closure and some specialty care much more. For instance, the median distance to drug and alcohol treatment services increased by 39 miles, outpatient psychiatry by over 45 miles, and pediatric intensive care by over 75 miles. The increased distance to these services is particularly alarming due to the ongoing opioid epidemic and the high rate of suicide in rural America. And while these increases may be difficult for everyone in the community, they may be especially hard for older adults and those with low incomes, who might delay or forgo care if they have to travel far.
Still, there is limited empirical evidence on how rural hospital closures impact health disparities. There is some indication that closures lead to increased mortality rates, other estimates find no difference. There are also mixed findings related to the effects on maternal and infant health based on rurality. Lack of significant changes in mortality or other outcomes immediately following a closure does not necessarily indicate that health disparities will not be affected over time. Instead, closures leading to higher out-of-pocket costs for patients may deepen health disparities influenced by socioeconomic factors, even if these are not immediately detectable. Better understanding of how closures impact a range of disparities over time, across regions, levels of rurality, and sub-populations can help with designing effective solutions.
With rural hospital closures on the rise, it is crucial for federal policymakers to fund and direct agencies, such as the Agency for Healthcare Research and Quality (AHRQ), to conduct research on the implications for rural health. Several key areas of inquiry include:
Community health implications of rural hospital closures. The relationship between hospital closure and immediate and long-term community health outcomes is unclear. This is further complicated by the fact that rural health varies substantially across regions and subpopulations. Funding for research on this topic can ensure that alternative models of care adequately address the needs of rural communities and can serve as a benchmark for ongoing evaluation. Additionally, it can inform best practices for supporting patients during the transition. Research in this area should take a holistic approach considering health outcomes, time, costs, and stress involved in seeking alternative care.
Evaluating alternative models of care. There are several policy options for alternative models of preserving access to emergency care in the face of rural hospital closures, such as the newly implemented Rural Emergency Hospital designation. There is an ongoing need for robust funding for AHRQ to expand, evaluate, and design updated models of care, and to gather and incorporate patient perspectives. Sustained funding for research in this area can help improve rural health moving forward.
As rural communities face the uncertainty and stress that comes with fewer hospitals and providers, the need for generating evidence-based solutions to support patients is only growing.