States with the most rural hospitals at risk of closing
Rural hospitals serve 60 million people, approximately one in every five Americans. These hospitals provide remote communities with critical care ranging from primary care services like health maintenance and patient education to long-term care and emergency services. Besides medical care, rural hospitals serve as major local economic drivers by providing jobs and attracting other businesses to the area. New businesses are less likely to choose a location that doesn’t have the health care infrastructure in place to care for their employees.
But as people have flocked to urban areas, rural populations have declined. This is putting some rural hospitals in vulnerable financial situations, which has led to hospital cuts and closures, with many more on the horizon. COVID-19 has put additional stress on already understaffed rural hospitals, spelling trouble for spikes in cases we are now seeing all across the United States.
To determine which states have the most at-risk rural hospitals, Stacker consulted a 2019 study from Navigant, a consulting firm acquired by the healthcare firm Guidehouse. Navigant analyzed the financial viability of about 2,000 hospitals in rural parts of the U.S., based on the hospitals' operating margins, cash on hand, and debt-to-capitalization ratios. Delaware, New Jersey, and Rhode Island did not have any qualifying rural hospitals, and so are not included in this story.
Populations served by rural hospitals are often in great need of care. In fact, rural populations have a lower average life expectancy (76.8 years) than urban populations (78.8 years), according to a 2015 brief by the National Advisory Committee on Rural Health and Human Services. Access to providers and hospitals can be a major obstacle in receiving the appropriate, affordable, and effective health care that rural communities need. Costly, unreliable, or difficult-to-access transportation can be especially challenging for patients who need treatments every week. Even if a hospital is accessible in the community, cash-strapped hospitals in many states often cut services, particularly labor and delivery units, to prevent total closures.
But even with cost-cutting measures, rural hospitals can still face closures. In Navigant’s analysis, 21%, or 430 hospitals across 43 states, are at high risk for closure without changes to improve their finances. If these hospitals were to close their doors, they would take away 21,547 staffed beds, 707,000 annual discharges, 150,000 jobs, and $21.2 billion in total patient revenue.
Keep reading to learn which states have the most at-risk hospitals.
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#44. Utah (tie)
- Rural hospitals at high risk: 0 out of 17 qualifying hospitals (0%)
In 2018, four rural Utah hospitals were nationally recognized for care quality and patient outcomes. One of the hospitals was honored for providing quality care in an affordable, safe, and effective manner. The other three hospitals received recognition for the impact of health care service or intervention on the health status of patients.
#44. Vermont (tie)
- Rural hospitals at high risk: 0 out of 13 qualifying hospitals (0%)
The Green Mountain Care Board regulates hospital budgets in Vermont, the only state to have such regulation. In order to protect rural hospitals from bankruptcy, the board wants some hospitals to create sustainability plans and check in with the board periodically, according to a 2019 report by VTDigger.
#44. Massachusetts (tie)
- Rural hospitals at high risk: 0 out of 6 qualifying hospitals (0%)
Although classified as a rural hospital, Nantucket Cottage Hospital is located on a wealthy island, which means higher wages for its staff. Since Medicare must reimburse employee wages at urban hospitals at least as much as it reimburses rural hospitals in Massachusetts, Nantucket Cottage Hospital sets a higher-than-typical floor for Medicare reimbursement across the state.
#44. Maryland (tie)
- Rural hospitals at high risk: 0 out of 5 qualifying hospitals (0%)
Maryland created a total patient revenue program to help rural hospitals manage rising costs. The state’s Health Services Cost Review Commission sets the amount of revenue the hospitals will get each year based on each hospital’s patient mix and services. The program creates a financial incentive to improve quality of care while reducing unnecessary testing and readmissions.
- Rural hospitals at high risk: 1 out of 28 qualifying hospitals (3.6%)
The Oregon Office of Rural Health noted disparities between statewide and rural health care in its August 2020 report. The 2017-2019 average preventable hospitalization rate across Oregon is 7.3 per 1,000 people per year, while in rural parts of the state the three-year average is 9.0. Statewide, it takes a patient about 13 minutes to travel to a Patient-Centered Primary Care Home (a health care clinic recognized for patient-centered care), but in rural areas, the average travel time is almost double, at 25 minutes.
- Rural hospitals at high risk: 1 out of 22 qualifying hospitals (4.5%)
When Pioneer Community Hospital closed in 2017, Patrick County was left without any hospitals. The closure meant the unemployment of over 100 people, longer trips for rescue teams to the next-nearest hospital, and difficulties in attracting new businesses to the area, according to the Associated Press. Officials have largely given up on reopening the hospital, which has a $5 million price tag, but are considering adding medical personnel to fire and rescue stations.
- Rural hospitals at high risk: 1 out of 21 qualifying hospitals (4.8%)
With an established telehealth program in place nearly two years before COVID-19 hit, St. John’s Health in Jackson was better prepared to continue caring for its rural community. The hospital was able to focus on treating patients instead of scrambling to build telehealth systems and educate patients on how to use them, as other hospitals needed to do during the early months of the pandemic.
- Rural hospitals at high risk: 1 out of 13 qualifying hospitals (7.7%)
Nevada hospitals face a physician shortage, with the state ranking 45th in the U.S. in active physicians per 100,000 people, 48th in primary care physicians, and 50th in general surgeons, according to a January 2020 report by the Nevada Health Workforce Research Center. Although the state ranks 25th in the nation in the number of undergraduate medical students per 100,000 people, Nevada’s ranking plummets to 44th in terms of residents and fellows, indicating a challenge in keeping medical students in the state.
- Rural hospitals at high risk: 4 out of 50 qualifying hospitals (8%)
In 2018, Sonoma Valley Hospital closed its obstetrics department and home care service. Cost-cutting measures like these and the building of a new diagnostic hub (so doctors won’t have to refer patients to outside providers) has the California hospital hoping it can stave off closure, according to the North Bay Business Journal.
- Rural hospitals at high risk: 12 out of 50 qualifying hospitals (9.4%)
Sixteen rural hospitals in Texas have closed for at least a period of time, if not permanently, over the four years preceding a February 2017 fact sheet prepared by the Texas Organization of Rural & Community Hospitals. The organization cites cuts and underpayments by Medicare and Medicaid costing $120 million annually as the main reason for the closures.
[Pictured: Dr. Ed Garner is the only doctor for 11,000 square miles of territory in West Texas. He practices out of Culberson Hospital, the only hospital available to serve three counties in and around Van Horn, Texas.]
- Rural hospitals at high risk: 1 out of 10 qualifying hospitals (10%)
After Kahuku Medical Center filed for bankruptcy in 2007 due to losses from not having enough patients, the rural hospital joined the state’s public hospital system as an affiliate in 2008. This allowed the hospital to receive annual state subsidies. The consistent inflow of state money makes up 12% of the hospital’s revenue and helps keep the facility afloat.
- Rural hospitals at high risk: 7 out of 65 qualifying hospitals (10.8%)
The Center for Community Solutions used Ohio as an example in its effort to understand how price models lead to higher health care spending in the U.S. when compared to other nations. The August 2020 report analyzed prices set by Ohio hospitals and recommended the creation of a more competitive marketplace, through the development of cost-effective policies and improved monitoring of price and care-quality data.
[Pictured: Dr. George Trimble, who focuses on the spread of COVID-19 in rural areas, sits for a portrait at Van Wert County Hospital in Van Wert, Ohio on November 20, 2020.]
#34. Nebraska (tie)
- Rural hospitals at high risk: 8 out of 70 qualifying hospitals (11.4%)
Maintaining federal standards for medical records has proved challenging for rural hospitals in Nebraska, according to a 2018 report by Nebraska’s Rural Health Innovation Steering Committee. All small hospitals in the state have electronic records systems, but the report states that the need for frequent upgrades are “resulting in higher costs, lower revenue, low staff morale, and no appreciable improvement in patient care.”
#34. South Dakota (tie)
- Rural hospitals at high risk: 5 out of 44 qualifying hospitals (11.4%)
Less than 1 million people populate South Dakota’s 76,000 square miles. This makes it difficult for health care providers to adequately serve patients in a financially sustainable way, according to South Dakota News Watch. Medicaid expansion could help bolster the finances of rural hospitals, but state lawmakers have refused to expand Medicaid coverage through the Affordable Care Act in order to receive federal funding.
- Rural hospitals at high risk: 5 out of 43 qualifying hospitals (11.6%)
The opioid epidemic has hit rural communities especially hard, but some hospitals have found success with the Colorado Alternatives to Opioids Project. The pilot project “promot[es] alternative pain medications and educat[es] patients about the risks of opioid use,” according to an August 2020 report by the Flex Monitoring Team. Although the pilot project sought to reduce emergency department opioid prescribing rates by 15%, one hospital system reduced the rate by 31% in 2017.
[Pictured: Brandy Turcotte, CNA, left, and Lacy Lawrence, both medical workers at Weisbrod Memorial Hospital in Kiowa County, wear personal protective equipment that they have on hand at the small rural hospital, if needed, during the coronavirus pandemic. May 14, 2020 in Eads, Colorado.]
#31. Wisconsin (tie)
- Rural hospitals at high risk: 9 out of 75 qualifying hospitals (12%)
In rural communities that lack doctors, pharmacists often fill the gaps and help patients decide whether to make the long trip to their doctors in another county. In fall 2019, the University of Wisconsin-Madison School of Pharmacy launched a two-year rural pharmacy concentration to give students experience working with rural communities and learn how community partnership can provide high-quality care.
#31. Idaho (tie)
- Rural hospitals at high risk: 3 out of 25 qualifying hospitals (12%)
After narrowly avoiding closure in 2013, Arco’s Lost Rivers Medical Center serves as a success story for rural hospitals, according to STAT. New management allowed the hospital to better serve the community by bringing in rotating specialists, updating the facilities, offering telemedicine services, and opening a surgery center.
#30. North Carolina
- Rural hospitals at high risk: 6 out of 47 qualifying hospitals (12.8%)
In North Carolina’s rural communities, 54% of children receive coverage from Medicaid and the Children’s Health Insurance Program, as compared to only 39% in metro communities, according to a 2017 report by the Georgetown University Center for Children and Families. In a July 2020 brief, the nonprofit NC Child called for Medicaid expansions to stabilize the state’s rural health system and improve children’s health outcomes.
#29. North Dakota
- Rural hospitals at high risk: 5 out of 34 qualifying hospitals (14.7%)
North Dakota implemented a two-phase plan to combat a shortage of health care providers across the state and especially in rural parts. The plan aims to increase the size of medical and health sciences classes and residency slots in the state, according to a 2019 report by the University of North Dakota School of Medicine and Health Sciences Advisory Council.
[Pictured: A day at Jamestown Regional Medical Center in rural North Dakota.]
- Rural hospitals at high risk: 6 out of 40 qualifying hospitals (15%)
The Washington State Health Care Authority (HCA) unveiled a plan in October 2020 to reform the state’s rural health care payment model. The plan aims to control costs through capitation, which creates more stable, fixed payments per patient per unit of time paid in advance. The HCA will also work toward a $5 million rural federal grant opportunity with the Centers for Medicare and Medicaid Service.
- Rural hospitals at high risk: 13 out of 75 qualifying hospitals (17.3%)
Between 2006 and 2016, outpatient visits to Illinois’ small and rural hospitals saw a 71% increase, while inpatient admissions saw a 25.5% decrease, according to a 2018 report by the Illinois Health and Hospital Association. The report states that with more outpatient services and fewer inpatient services, “many rural funding programs have become outdated and fail to provide the intended financial stability.”
- Rural hospitals at high risk: 17 out of 95 qualifying hospitals (17.9%)
The Iowa Hospital Association proposed a “three-pronged approach” to help the state’s rural hospitals in 2019. The proposal sought to create a new designation of “Rural Emergency Hospitals,” stabilize Critical Access Hospitals, and fund infrastructure changes for modernization and right-sizing to smaller or more efficient facilities.
#25. New York
- Rural hospitals at high risk: 9 out of 48 qualifying hospitals (18.8%)
Hudson Headwaters Health Network has successfully recruited providers—often a major challenge for rural hospitals—according to a May 2019 report on rural access to primary care by the Primary Care Development Corporation. The system of 17 community health centers formed partnerships with universities to bring in more medical students for rotations. Once students have exposure to rural communities, they are more likely to stay in rural practice after graduating.
- Rural hospitals at high risk: 7 out of 37 qualifying hospitals (18.9%)
Since 2012, 10 rural hospitals have closed in Tennessee, but more closures may come in the future. A May 2019 investigation by the Tennessean found that at least 15 hospitals in the state are losing money every year, toward a combined $137 million loss over three years. The report cites key financial strains on rural hospitals, such as medical advancements reducing hospital stays and the state’s high rate of uninsured residents who cannot afford to seek care.
[Pictured: View of the empty entry area at McNairy Regional Hospital in Selmer, Tennessee.]
- Rural hospitals at high risk: 10 out of 50 qualifying hospitals (20%)
In 2019, Louisiana lawmakers passed a bill to ban freestanding emergency departments in the state to protect rural hospitals from competitors. The freestanding providers provide emergency care which puts them in competition with rural hospitals, but they do not have inpatient hospital care, which rural hospitals typically provide. The bill went into effect in August 2019 after Gov. John Bel Edwards signed it into law.
- Rural hospitals at high risk: 12 out of 57 qualifying hospitals (21.1%)
When Montana lawmakers passed expansions to Medicaid, they also added requirements that those enrolled in the program (exceptions for those who are pregnant or in school) must work, volunteer, or train for jobs for a minimum of 80 hours per month, according to the Montana Free Press. A study by The Commonwealth Fund in February 2020 predicted a reduction of Medicaid enrollees due to the additional work requirements, which would reduce Medicaid revenues at hospitals in the state.
- Rural hospitals at high risk: 19 out of 89 qualifying hospitals (21.3%)
According to the Star Tribune, mergers with large health care systems, combined with federal subsidy programs, have helped Minnesota’s rural hospitals stay afloat when faced with financial issues. However, the mergers haven’t completely staved off cuts, as some consolidations in the state have led to a halt in surgeries at one facility and deliveries at another.
- Rural hospitals at high risk: 9 out of 41 qualifying hospitals (22%)
In 2019, Pennsylvania became the first state in the U.S. to create an alternative payment model called the Rural Health Model to help financially struggling rural hospitals. The new model switches the 13 participating hospitals from fee-for-service (payments based on number of admissions, which declines as rural populations decline) to global budget payments (predetermined amounts provided to serve the area).
- Rural hospitals at high risk: 14 out of 61 qualifying hospitals (23%)
The health care systems of neighboring states Missouri and Kansas are closely tied, with small hospitals referring patients to bigger hospitals, but COVID-19 is putting an increased strain on the small hospitals. The Kansas City Star reports that staff at small hospitals are having trouble locating beds in other hospitals not only for COVID-19 patients, but also for trauma and other types of patients. These hospitals may need to expand their searches to other states to find room for their patients.
- Rural hospitals at high risk: 9 out of 39 qualifying hospitals (23.1%)
A study by the Indiana Hospital Association found that rural hospitals with emergency units and fewer than 25 beds had a negative operating margin of -27.7% in April 2020. In the same month, the state’s average negative operating margin was just -8.3%, according to an August 2020 report by the South Bend Tribune.
- Rural hospitals at high risk: 16 out of 65 qualifying hospitals (24.6%)
The Kentucky General Assembly passed a bill in April 2020 to provide loans to struggling rural hospitals in the state, according to the Courier-Journal. However, moratoriums on elective surgery due to the COVID-19 pandemic could cost the state $1.3 billion, and might make it hard for hospitals to repay the loans.
- Rural hospitals at high risk: 9 out of 36 qualifying hospitals (25%)
According to the American Lung Association’s 2020 “State of Lung Cancer” report, Arizona ranked last for treatment after diagnosis. Nearly 30% of lung cancer cases in the state receive no treatment, whereas the national rate for lack of treatment for lung cancer stands at about 15%.
- Rural hospitals at high risk: 18 out of 71 qualifying hospitals (25.4%)
Some financially struggling rural hospitals close units that operate with a loss, leaving area residents to travel 30 miles or more to get the care they need. In 2017, Michigan’s West Shore Medical Center, a small community hospital, sold to Munson Healthcare, a large health care system based in a nearby county. Just two years later, Munson closed the obstetrics ward, citing a decline in projected hospital births while projecting losses to grow to $1.2 million by 2020.
#14. New Mexico
- Rural hospitals at high risk: 7 out of 27 qualifying hospitals (25.9%)
The New Mexico Hospital Association awarded its Hospital Improvement Innovation Network honor to five of the state’s rural hospitals in 2019. The award recognizes honorees for projects working to “reduce hospital readmissions, the occurrence of infections, and adverse drug events.”
#13. South Carolina
- Rural hospitals at high risk: 4 out of 15 qualifying hospitals (26.7%)
The residents of Barnwell County were left without a hospital after Southern Palmetto Hospital closed in January 2016—just three years after it was acquired by an Atlanta-based company. At least eight counties in the state are without a single general hospital, according to WMBF News.
- Rural hospitals at high risk: 29 out of 101 qualifying hospitals (28.7%)
NPR Shots reported in November 2020 that rural counties in Kansas and Missouri have some of the highest COVID-19 rates in the U.S., but only a quarter of the two states’ counties have intensive care unit beds. When rural hospitals lack certain services, it can put a strain on the nearest city hospitals taking on the critically ill patients.
- Rural hospitals at high risk: 17 out of 58 qualifying hospitals (29.3%)
The federal Coronavirus Aid, Relief, and Economic Security Act provided Oklahoma’s rural hospitals with a $5.1 million grant to help pay for personal protective equipment and bolster their workforces. Through the disbursement, 61 hospitals were expected to receive roughly $78,000 each, according to Tulsa World.
#10. New Hampshire
- Rural hospitals at high risk: 5 out of 17 qualifying hospitals (29.4%)
When COVID-19 hit in spring 2020, LRGHealthcare, the parent company of a critical access hospital and another hospital in New Hampshire, cancelled all elective procedures and thus lost a crucial source of revenue. “We are down approximately 60% from a revenue perspective,” CEO Kevin Donovan told New Hampshire Public Radio. The revenue loss, combined with the $112 million in debt the company was already carrying, moved LRGHealthcare’s financial situation from bad to worse.
- Rural hospitals at high risk: 8 out of 23 qualifying hospitals (34.8%)
Ten individuals were indicted in the U.S. District Court in Jacksonville in July 2020 for allegedly using struggling rural hospitals to conduct a $1.4 billion fraudulent lab-billing scheme, according to Kaiser Health News. Prosecutors said the defendants contracted with out-of-town and out-of-state labs to process tests for people who never entered the hospitals, then billed insurers at the higher rates for rural hospitals.
- Rural hospitals at high risk: 18 out of 49 qualifying hospitals (36.7%)
From January 2012 to September 2020, 57 rural hospitals closed in states neighboring Arkansas. The Arkansas Center for Health Improvement cites Medicaid expansion in the state as a possible reason for fending off closures. However, hospitals in Arkansas remain vulnerable, especially as younger residents migrate from rural areas and leave behind older populations with “high health-risk burdens, low median family income, limited provider capacity, and a deteriorating acute care safety net.”
#7. West Virginia
- Rural hospitals at high risk: 10 out of 27 qualifying hospitals (37%)
With rural hospitals at risk of closing in West Virginia, Gov. Jim Justice announced a plan in February 2020 to create a Rural Medicine Task Force. Justice wants the group “to develop solutions for solving the delivery of rural medicine and care in West Virginia,” he said.
#5. Maine (tie)
- Rural hospitals at high risk: 8 out of 20 qualifying hospitals (40%)
While telehealth has increased in popularity during the COVID-19 pandemic, there are barriers to access for patients in rural areas. Lack of broadband, provider resistance, provider shortages, and staff turnover are among the issues challenging telehealth usage in Maine, according to an October 2020 report by the Maine Rural Health Research Center.
#5. Alaska (tie)
- Rural hospitals at high risk: 6 out of 15 qualifying hospitals (40%)
After Alaskan lawmakers cut the state’s Medicaid budget by nearly $170 million in 2019, the Alaska State Hospital and Nursing Association sued the state and Department of Health and Social Services, citing improper use of emergency regulations. The two parties reached a settlement later that year, allowing affected Medicaid providers to request settlement payments.
- Rural hospitals at high risk: 26 out of 63 qualifying hospitals (41.3%)
While just nine of Georgia’s 159 counties have no doctor at all, looking by specialty paints a starker picture. According to the 2019 Georgia Physician Workforce Report, 77 counties were without a single psychiatrist, 74 were without a general surgeon, and 60 were without a pediatrician.
- Rural hospitals at high risk: 31 out of 64 qualifying hospitals (48.4%)
The Social Science Research Center at Mississippi State University identified nine hospitals as “most at risk” of closing in the state. If all nine of these hospitals closed, it would lead to great economic losses, including 2,600 jobs and a total economic impact of $289.2 million, according to the Center’s analysis.
- Rural hospitals at high risk: 21 out of 42 qualifying hospitals (50%)
The COVID-19 pandemic has further hampered financially struggling hospitals by slowing down or temporarily stopping elective procedures. When the state prohibited elective procedures in spring 2020, Alabama hospitals lost $739 million in the first six weeks.
- Rural hospitals at high risk: 3 out of 5 qualifying hospitals (60%)
In a survey of residents surrounding Sharon Hospital, a rural hospital in Connecticut, 60% said transportation was the greatest barrier to health care access. The 2014 survey report by the Foundation for Community Health deemed broader public transportation systems as “unrealistic” for the region the hospital serves, yet called for more funding of low-cost alternatives like Dial-A-Ride to help transport those who can’t use standard transit systems.
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