America’s rural hospitals are closing down at an alarming rate. According to the North Carolina Rural Health Research Program, there were seventy-two rural hospital closures between 2010 and 2016, close to double the number that shut down between 2005 and 2009. Hundreds more are teetering on the brink of closure.
Consequently, rural America faces a serious health care delivery challenge, which is made all the more urgent by the fact that rural residents tend to be much sicker to begin with. They have higher rates of chronic conditions and greater psychological distress. Rural counties have higher death rates from unintentional injuries, more motor vehicle injuries, greater premature mortality (below age seventy-five), higher suicide rates among men, and higher infant mortality rates.
Health disparities between rural and urban America are very well documented, and geographic access — the ease or difficulty of traveling to a health care provider — is one of the commonly offered explanations for this disparity, especially in the case of traumatic accidents or other medical emergencies. When these rural hospitals close their doors, the distance between a person’s home and the nearest medical facility increases dramatically, and so too does the time it would take an ambulance to reach them in an emergency.
Rural hospitals have been struggling for years, largely due to changing demographics in rural areas. Right now, the most powerful predictor of closure is profitability, which is partially a function of the characteristics of the community a hospital serves. As the American populace has shifted to urban areas, the populations that remain in rural areas have gotten older, poorer, sicker, and less likely to be insured. In other words, providing their care is more costly. Rural hospitals have been dealing with the financial strain caused by these changing demographics for well over a decade.
But when the Affordable Care Act became law, the rate of rural hospital closures increased dramatically. One reason for this is that the ACA began penalizing hospitals with high readmission rates, a metric that represents the number of patients who return to the hospital after discharge. This was intended to push hospitals toward providing higher-quality care and is in line with an admirable trend in American health care toward value-based payments. But it is also an aspect of the law that disproportionately impacts hospitals that see a higher proportion of sicker patients, as rural hospitals do.