According to the Center for Health Services Research at UNC Chapel Hill, over one hundred rural hospitals have closed across the United States since 2010. In a recent report by iVantage Health Analytics, almost 600 rural hospitals are at risk of closing.
In these studies, both closures and at-risk hospitals are in the 14 states that have not passed Medicaid expansion. States like North Carolina that have not chosen to have expanded health care access for low-income families, have deprived millions of rural area residents and its hospitals.
Without that money, many rural hospitals in Texas and other non-expansion states have closed obstetrics units and other expensive services, forcing patients to travel long distances to seek treatment at the next-closest hospital, which is sometimes hours away.
By shedding those services, the hospitals diminish their reason for existing, said Maggie Elehwany, head of government affairs and policy for the National Rural Health Association.
To date, 36 states plus Washington, D.C., have expanded Medicaid. By 2017, expansion under the ACA had covered 17 million new enrollees. Roughly another 4 million people would qualify in the remaining states, according to a 2018 Kaiser report.
Instead, many of those low-income residents remain uninsured or under insured in plans with high deductibles and co payments.
But that doesn’t mean people don’t receive health care. Without health insurance, low-income people are less likely to get preventive care, which often results in worsening health conditions that frequently bring them to hospitals where they are guaranteed treatment. Under federal law, hospitals must stabilize and treat anyone showing up at the emergency room, regardless of their ability to pay.
Rural hospitals, like their urban counterparts, are forced to absorb those costs. But unlike bigger hospitals, their patient volumes and operating margins are so low that “uncompensated care” burdens can be crippling.
A 2018 study in the journal Health Affairs found that the rate of closures of rural hospitals increased significantly in non-expansion states after 2014, when states began implementing the expansion. At the same time, closure rates decreased in expansion states.
Rural Americans tend to be older, in poorer health and less insured than those living elsewhere, the latter resulting in a greater share of uncompensated care for rural hospitals. Because of declining populations in rural areas, hospitals there often have empty beds, which means less revenue.
“It’s been a long, slow bleed,” said Fred Blavin, a health policy expert at the Urban Institute.
The loss of rural hospitals not only means patients having to travel longer distances to the next medical providers, but the closures also can often have a crippling effect on the local economy.
Last month, state lawmakers failed to adopt Medicaid expansion during their “mini” session, further continuing their stalemate. Until their next session in April, GOP leaders will continue to halt the expansion that would ultimately bring down healthcare costs for everyone, even those with private health insurance.
If passed, Medicaid expansion would bring healthcare to over 600,000 NC residents and create 37,000 jobs for the state. North Carolina remains one of only 13 states not moving to expand health coverage for low-income residents.