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‘The Loss of a Rural Hospital Is Devastating for a Local Community’

As rural-area hospitals continue to shutter their doors at a concerning rate across America, SPH professors discuss what is driving these closures and how public health can help affected communities receive the care they deserve.

More than 100 rural hospitals have closed in the United States over the last decade, leaving millions of Americans without access to emergency services, testing, inpatient care, and primary care. While these closures have been on the rise in rural America since the 2008-2009 recession, they’ve increased at an alarming pace over the last few years, including at least 18 that closed or converted to an operating model that excludes inpatient care this year alone.

In the news, story after story has captured the deadly consequences of these closures, detailing the struggles that families face when they’re forced to travel longer distances for care—or skip care altogether. 

As millions of people could soon need to decide between paying significantly higher healthcare premiums or foregoing healthcare coverage in 2026 due to federal funding cuts, addressing this growing rural crisis should be a priority on the nation’s healthcare agenda.

It’s definitely a priority among the individuals and families who live in these rural communities, or about 25 percent of the US population. Rural Healthy People 2030, the rural counterpart to the national Healthy People initiative that presents a set of ten-year objectives for improving health and wellbeing, shows that healthcare access and quality remain among the top health-related concerns for rural residents. 

“When you look at the history of rural healthcare and rural healthcare policy over the past several decades, one of the most consistent things you see is that rural Americans are struggling with healthcare access,” says Timothy Callaghan, associate professor of health law, policy & management, who served as an editor and authored a chapter on this subject in Rural Healthy People 2030. “After a hospital closes, people have to travel farther for care. They have to seek hospitals in larger cities, and in a true emergency, that can result in more negative health consequences or deaths that could have been avoided.”

Indeed, the typical rural resident travels twice as far to access medical care than urban residents, averaging around 18 miles. Currently, more than 700 rural hospitals are at risk of closing—with 300 at immediate risk of closing—meaning that this distance is likely to widen even further for affected residents. And unlike urban residents, rural residents often rely on these hospitals for both primary and emergency care, so each closing also translates to less available care for preventive and routine services.

These rural hospitals are closing because they simply don’t have enough money to cover the high cost of care delivery to their communities, but the contributing factors behind this lack of revenue are multifold: declining patient volumes, low reimbursements from both private and public insurers, staffing shortages, alternative models of care, and more. And while rural hospitals rely more on private insurers for revenue than Medicare or Medicaid, the approximate $1 trillion in Medicaid cuts under the One Big Beautiful Bill Act (OBBBA)—which is expected to eliminate insurance coverage for at least 17 million people by 2034, including 2 million in 2026—will still be a noticeable blow to hospitals’ operating costs.

“Staffing a hospital—paying for doctors and nurses’ salaries, and all of the medical equipment—is quite expensive,” Callaghan says. “If you’re a rural hospital, or a hospital anywhere, you need a consistent flow of patients to stay open.” One problem, he says, is that rural communities are shrinking. “The population of rural America is getting smaller because it’s an aging population, making it difficult to keep hospital beds full.”

Beyond each of these factors, the broader issue with hospital closures is that no one is accountable for fixing this problem, says Alan Sager, professor of health law, policy & management, who has studied local, state, and national healthcare problems and remedies for five decades. “Nobody in state government, Medicare, Medicaid, or private insurance companies has any accountability for identifying where hospitals are needed, how many beds they need, what emergency and other services they should provide, and making sure they generate enough revenue to cover the cost of efficient delivery of needed care.”

Despite this lack of action, affordable and accessible healthcare is easily achievable in both rural and urban communities because the US already spends enough money on healthcare—an estimated $5.6 trillion this year—to deliver and pay for care for everyone in the nation, Sager says. His new book The Easiest details a comprehensive plan for healthcare reform that he says can be achieved by reducing trillions of dollars in wasteful spending and paying doctors, hospitals, dentists, and other caregivers adequately to provide care. “We spend twice as much per person on healthcare as other rich democracies to treat fewer people, with worse outcomes,” he says.

In rural areas, those worse outcomes include higher rates of chronic diseases, traffic accidents, and mortality than urban residents, as well as more hazardous work conditions. Farming, logging, and mining, three of the most dangerous industries, are central to rural economies. 

“Rural life often entails working with heavy machinery on the farm, with high rates of serious accidents and injury,” says Sager. “Having the capacity to bring people quickly to an emergency room that has radiology and STAT labs—and also a surgeon on hand—can be vital.” 

So when that critical care is no longer available in a rural community, it becomes a lot harder for that community to attract skilled workers, Sager and Callaghan point out.

“The loss of a rural hospital is devastating for a local community, because not only do you lose the hospital and the ancillary services that surround that hospital, you lose a lot of other jobs, which can undermine the economic loss in that community,” Callaghan says.

“It’s hard to attract skilled managers and investors to rural areas that lack a hospital or doctor,” Sager says.

And, like many other expert assessments, neither Sager nor Callaghan believes that the $50 billion Rural Health Transformation Fund, introduced by the Republican Senate to offset the loss in funding from Medicaid cuts in the OBBBA, are a sufficient response to these cuts. The funding only covers 37 percent of the estimated cuts in Medicaid funding for rural areas, and doesn’t account for other expected revenue losses related to the Affordable Care Act marketplaces. 

Alongside this increase in rural hospital closures is another concerning development: nearly 60 percent of rural hospitals no longer deliver babies. Since 2020, at least 117 rural hospitals have eliminated or plan to eliminate their labor and delivery units, amounting to an 11 percent reduction, because they are unable to meet the high operational costs. More than 120 rural hospitals that do still deliver babies are currently operating with negative margins. And as Medicaid pays for nearly half of births in rural areas, the federal funding cuts over the next several years could further jeopardize the health of pregnant people in these areas. 

However, it’s important to view maternity ward closings in the context of the national declining birth rate, says Eugene Declercq, professor of community health sciences. In 2024, the US birth rate dropped to a record low, with fewer than 1.6 children being born per pregnant person, which has been on a sharp decline since the 2008-2009 recession. In a 2022 study published in the Journal of Community Health, he examined the number of births per maternity bed in rural hospitals during a spate of maternity ward closures from 2000-2019 and found that the ratio barely changed during this period of closures because the number of births had dropped by 16 percent. 

“The closures began at a time of rapidly declining birth rates, with 687,000 fewer US births in 2024 than in 2007—so in one sense, a reduction in maternity beds is rational,” Declercq says. 
“However, the cutbacks have not been done in any systematic way in consultation with communities. Too often, they are driven by corporate imperatives with little or no plan for how communities, especially those in rural areas, will be served after the closures.”

One solution, he says, is for community health centers to establish a more prominent role in maternity care in rural communities. Declercq has long argued that maternal care should expand beyond a hospital-based model to a community-based model that prioritized personalized, accessible care to pregnant people over longer periods of time.

“Community health centers should hire midwives and partner with freestanding birth centers to provide maternity services for the large proportion of low-risk pregnancies,” he says. “Enhanced screening could identify higher-risk cases that could then be cared for by obstetricians in regional centers. Postpartum and lifelong women’s health services could be also provided by midwives—and obstetricians, as needed—in community health centers.

“But it’s not clear that our increasingly fragmented health system is interested in such an integrated approach.”

Absent a reversal in hospital closures, Callaghan hopes to see rural healthcare embrace alternative strategies to improve patient access to primary care, such as improving broadband access to enable more opportunities for telehealth services. Health policy leaders should also focus on creating additional incentives for providers to practice in rural areas. 

“That could mean financial inducements for providers who are already in the US, or the expansion of inducements for international providers to move to rural communities in America to provide care there,” he says. “We should also make it easier for nurse practitioners and physician assistants to provide primary care in rural communities, which can alleviate some of the issues with primary care.”

Sager offers a blunt assessment: “We’ve got to think through what we need and how to pay for it with the money we’ve got. There’s not enough money left in the checking account to keep writing bigger and bigger checks for healthcare.”

And once this money is depleted, it will trigger a massive federal budget crisis in the US that will become a far worse catastrophe than the challenges the healthcare is currently navigating, he says, because it will bankrupt even more hospitals and deprive patients of insurance coverage and care. 

“For individuals who are suffering due to rural hospital closures or Medicaid ineligibility or enhanced premiums, the crisis is today,” Sager says. “But for the nation’s healthcare, the crisis is still probably 3, 5, or 10 years down the road—and that’s why I think it’s so essential to start figuring out what to do now.”