In the last 10 years, more than 100 rural hospitals in the U.S. have closed and another 600-plus rural facilities remain at risk of closing.
Of course not all existing hospitals should stay open. They might be too big or too obsolete for today’s needs and technology. In some cases there are good reasons to close. For others there are opportunities for modernization.
But overall, rural populations are suffering substantial institutional losses.
On closer scrutiny, what seems a sudden acceleration in rural hospital and clinic closures over the past few years is actually concentrated in a select group of 14 states. They are all holdouts that have declined to fund the expansion of Medicaid that was made possible by the Affordable Care Act, which took effect in January 2014.
As a result, rural hospitals in the states that have refused to participate—hospitals already operating their public healthcare systems with the slimmest of margins and resources—are now collapsing and closing at an quickening rate.
A study in Health Affairs last year confirmed that closures of rural hospitals increased significantly in states that haven’t expanded Medicaid, but noted that the closure rate in states that expanded the program decreased almost immediately after adoption.
The income cutoff in the 14 states that have not expanded Medicaid is set at a barely surviving level—the median eligibility limit is $8,532 for a family of three in 2019.
Worse, a gap is created in these states alone for some 2 million uninsured residents—hard-working people with low-wage jobs whose incomes are above Medicaid eligibility limits but who fall below the lower limit to receive premium tax credits to help them buy insurance through the ACA marketplace.
The best outcomes for patients ultimately depend upon whether or not they are insured. The challenges we face in delivering care to a rural population, insured or not, are steep. I’m a board-certified obstetrician and gynecologist and have spent most of my career serving this population.
I have seen women show up for their first prenatal visit when they are already well into their second trimester. This can prove dangerous for the mother and baby. Early prenatal care is critical in identifying, treating and managing health conditions, thereby reducing the risk of complications during pregnancy and delivery and improving maternal and birth outcomes.
The nonpartisan Medicaid and CHIP Payment and Access Commission has confirmed what should be obvious: Women without health insurance are far less likely to receive adequate prenatal care than women with coverage.
I also know from my own clinical experience that rural Americans are more likely than those in other parts of the country to have multiple chronic health conditions; they are at greater risk for obesity and have higher rates of mental illness and substance abuse disorders. And they’re less likely to be insured.
In the upper Midwest, where Sanford Health is based, farmers have to plant their crops as early as possible in the spring because they know it’s a short season before the arrival of snow and bitter cold. Many of the physicians I work with grew up on farms and in small towns that lie within the borders of the states declining the Medicaid expansion. Planning ahead is in our bones, and that sense of urgency and focus should be a priority everywhere.
Medicaid is jointly funded by the states and federal government. States with an established commitment to providing care for the poor stepped up immediately and signed on to the 2014 expansion, which initially was covered 100% by the federal government.
The feds now pay 93% of the total costs of the Medicaid expansion for enrollees in the new eligibility category. The states that continue to decline that option would be only required to moderately increase their spending to qualify for the expanded federal share.
Now, not later, is the time for these holdout states to replant and replenish their healthcare resources so desperately needed in rural America.