Rural hospitals throughout the United States are facing an unprecedented rate of closures, further endangering the health of rural communities. According to a recent report from the Center for Healthcare Quality and Payment Reform, 631 rural hospitals are currently at risk of closure in the immediate and near future. This equates to roughly 30 percent of all rural hospitals.
While these closures affect every region of the country, states that are likely to be hit the hardest include Connecticut, Alabama, Hawaii and Mississippi, where the percentages of rural hospitals at risk of closure are 67 percent, 60 percent, 75 percent and 54 percent, respectively.
A 2022 American Hospital Association (AHA) report indicates that the key issues threatening rural hospitals are low reimbursement rates, staffing shortages, low patient volume, continued financial challenges from the COVID-19 pandemic, and aging infrastructure. In addition, the report describes how expenses for labor, drugs, supplies and equipment have increased dramatically over the past year, putting additional pressure on rural hospital finances.
This is not a new phenomenon. The AHA report states that 136 rural hospitals closed from 2010 to 2021, with a record 19 closures in 2020 alone, the most of any year in the past decade.
Before the pandemic, hundreds of rural hospitals were barely able to keep their doors open. The COVID-19 pandemic greatly exacerbated financial pressures, due especially to cancellation of scheduled procedures and care, creating an estimated loss of 70 percent of income for rural hospitals.
The financial burden on rural hospitals is only growing. Mark Holmes, director of the Cecil G. Sheps Center for Health Services Research that oversees the North Carolina Rural Health Research Center, stated that many rural health professionals “are gravely concerned about what the rest of this year and … 2023 are going to look like.”
The effects of hospital closures on rural communities are numerous and far-reaching. With the closure of a hospital, patients can be forced to travel hours for emergency or regular medical care, which can result in significantly delayed treatment. These delays compound existing health disparities faced by workers in rural areas who are more likely—due to poverty, poor access to primary care, or less access to health insurance—to suffer from chronic disease.
Health care workers struggle with the conditions created by hospital closures and hospitals on the brink of financial collapse. World Socialist Web Site reporters reached out to health care workers on social media about their working conditions in rural areas and the stresses of increased hospital closures on the medical system.
An ER physician, who chose to remain anonymous, told WSWS reporters on Reddit that he had recently resigned from his rural job due to untenable conditions. “I couldn’t feel good about providing shitty care in a collapsing health care system and I quit. I don’t know if I made the right choice, but I hit my breaking point.
“The staffing was gutted during COVID, now volumes are back up but they left the skeleton crew to manage this. At a single doc location, I was consistently overwhelmed with volume and acuity.”
He continued, “To make matters worse, this critical access hospital cut both ICU beds and floor beds in half, meaning there was almost never any room in the inn. In normal times, this would just mean I’d need to transfer more people, no problem. But today, there are no other hospitals to take these patients, so they just languished with me.”
He described the emotional difficulty of repeatedly watching patients deteriorate for lack of better resources. “I could no longer stomach watching a [necrotizing fasciitis, a rare bacterial infection] patient deteriorate until they were on [vaso]pressors before I could get a tertiary center to bite. Same thing for GI bleeds, hand trauma, psych, etc. There was also no viable outpatient pathway to direct my patients on government insurance to. It was all so sad and stressful.”
An EMS worker from rural Colorado described the particular challenges of EMS workers in areas with poor access to care, as well as the domino effect the long transfers can have on the entire health care system.
“Our closest regional ERs are 40–60 miles one way over mountain passes. It pulls an ambulance out of district for the 3–6 hour round trip depending on weather or traffic going to and from. Our closest STEMI/Stroke/Level I traumas are 60–85 miles from our district if we can’t get a flight.”
This worker also described how additional lack of resources in his area due to closures have created a situation in which EMS has become the only available health care option for some workers.
“It leaves us picking up the slack for chronically ill individuals in the district that become frequent users of our service for lift assists, ER visits when they become sick/deal with infections because their illness isn’t effectively managed and similar issues.”
An OB/GYN physician, who also chose to remain anonymous, told reporters about the impact of the COVID-19 pandemic on the already struggling rural health system in her area.
“COVID hit us hard, but about 6 months later than everyone else. We lost a ton of surgeries in 2020, which hurt the bottom line. We’re still in the black, but barely.”
She continued, expressing concern that her hospital may close its Labor and Delivery unit, as nearby hospitals have done. “Several other hospitals in the area are probably cutting their L&D units—some due to lack of doctors, some due to lack of deliveries. We’re still OK there, but I’m working hard to ensure that by building up a midwifery service so that fewer docs can cover. This will not help maternal morbidity/mortality if all of the rural county hospitals close their L&D units.”
It is the working class that suffers the brunt of the crisis in rural health care. The closure of a county’s hospital creates worsening unemployment, with hundreds of workers abruptly laid off. With the loss of nearby medical care, many workers across all industries forgo care altogether, with no time off or money for gas to make the multiple-hour-long trek to the closest open hospital.
Rural communities are already plagued with other medical shortages. The 2022 AHA report indicated that 70 percent of primary care shortages are in rural areas. In addition, 65 percent of rural counties in the US don’t have a psychiatrist, 47 percent don’t have a psychologist and 81 percent don’t have a psychiatric nurse practitioner. The March of Dimes also recently released a report showing that one-third of US counties are “maternity care deserts,” a tragedy that significantly increases infant and maternal mortality rates in rural and urban areas alike.
Rural hospital closures are wholly the result of the capitalist market, which treats health care provision as a for-profit business rather than a social right. Many facilities, in rural and non-rural areas, have been bought, merged or had cuts to services deemed not lucrative enough. Fueling the profit drive has been the deterioration of Medicaid reimbursement rates accompanying the imposition of the Obama-era Affordable Care Act, which shifted millions of poor Medicaid recipients into the private health insurance industry market.
Emergency rooms and hospitals in rural and urban areas alike are in a deep crisis, reeling from decades of cutbacks and austerity, compounded by the spread of COVID-19 variants, RSV, the flu and unprecedented staffing shortages. At a time when rural health systems are needed more than ever, the increase in hospital closures only underscores the need for a socialist reorganization of health care.
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