The Unraveling of Rural Healthcare in America

 

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Rural healthcare in the United States is at a breaking point. With nearly half of rural hospitals at financial risk, essential services disappearing, and health outcomes worsening, millions of Americans face a future of diminished access to care and rising mortality. However, solutions exist. Rural healthcare can be preserved and strengthened through policy reform, financial stabilization, and innovative service delivery models. The stakes are high, and inaction is not an option. The question is not whether rural healthcare can survive but whether the nation is willing to prioritize and invest in the health and well-being of its most vulnerable communities. The time for meaningful change is now. Let me look deeper into the duplicity and factors that must be considered. First, it is apparent that rural healthcare in the United States is facing a critical and growing crisis, with financial instability, hospital closures, and a worsening public health outlook threatening the well-being of millions. Research conducted by Topchik et al. (2025) paints a stark picture: 46% of rural hospitals operate at a financial loss, 432 are at risk of closure, and nearly 300 have ceased offering essential services such as obstetrics and chemotherapy. For rural communities comprising more than 46 million people, these challenges have created an expanding network of “care deserts,” where access to vital medical services has disappeared. Since 2010, 182 rural hospitals have closed or transitioned to models that exclude inpatient care. This trend is not merely a reflection of population shifts; it results from systemic financial pressures, policy-driven funding reductions, and an increasing burden of chronic disease within rural communities.

Rural hospitals are facing insurmountable financial pressures. The national median operating margin for rural hospitals is a mere 1.0%, but in 16 states, it is negative. More than 70% of rural hospitals operate in the red in Kansas, Washington, Oklahoma, and Wyoming. Several factors drive this financial instability. The first is reduced reimbursement rates. Government policies such as Medicare sequestration have led to a 2% cut in Medicare reimbursement, costing rural hospitals more than $509 million in 2025 alone. Additional cuts related to inadequate debt reimbursement will further reduce revenue by $159 million. Second, Medicare Advantage's impact. More than 39% of Medicare-eligible individuals in rural areas are now enrolled in Medicare Advantage plans. These plans often reimburse hospitals at lower rates than traditional Medicare, forcing facilities to operate under unsustainable financial models. Third, non-expansion of Medicaid. States that have refused to expand Medicaid under the Affordable Care Act (ACA) continue to see a more significant share of struggling hospitals. In the 10 non-expansion states (e.g., Texas, Florida, and Kansas), 53% of rural hospitals operate at a loss, compared to 43% in expansion states.

The financial decline of rural hospitals has led to a rapid elimination of essential healthcare services. The closure of rural hospitals and the reduction of services do not merely affect healthcare access; they reverberate throughout entire communities, leading to severe economic and social consequences. Here are the services that have been impacted by hospital closure:

• Obstetric (OB) Closures: Between 2011 and 2023, 293 rural hospitals stopped providing obstetric services, meaning nearly a quarter of all rural OB units have disappeared. This has left thousands of women with no local access to prenatal care or emergency obstetric services, increasing the risks of maternal and infant mortality.
• Chemotherapy Service Decline: Cancer care is also vanishing from rural America. Between 2014 and 2023, 424 rural hospitals stopped offering chemotherapy services, with some states, such as Texas and Mississippi, losing over 50% of their rural chemotherapy providers.
• Provider Shortages: More than 60% of federally designated Healthcare Professional Shortage Areas (HPSAs) are in rural locations, meaning that even when a hospital remains open, there are not enough doctors, nurses, and specialists to provide adequate care.

Increased Mortality and Poor Health Outcomes: Rural residents already face worse health outcomes than their urban counterparts. Hospital closures exacerbate this crisis by increasing the time it takes to access critical care. In emergencies such as strokes, heart attacks, or labor complications, delays in treatment can mean the difference between life and death.

• Premature Death Rates: Rural communities experience higher rates of premature death (+20 percentile points) compared to urban areas.
• Chronic Disease Burden: Rural populations have higher obesity rates (+30 percentile points), diabetes, and heart disease.
• Deaths of Despair: Suicide rates in rural America are significantly higher, with rural communities ranking at the 69th percentile for suicide-related deaths, compared to the 37th percentile in urban settings.

Economic Decline and Job Losses: When a rural hospital closes, it is not just a healthcare loss but a financial disaster.

• Each hospital closure results in an average loss of 170 jobs, directly impacting local economies.
• The ripple effect extends to local businesses, as hospitals serve as economic anchors in rural communities. When a hospital closes, professionals such as doctors, nurses, and healthcare administrators leave, reducing the town's overall purchasing power and tax revenue.

The Crisis Facing Rural Veterans: Veterans are particularly vulnerable in rural areas. Nearly 25% of all U.S. veterans live in rural communities, and many rely on rural hospitals for their care. However, with long wait times for VA services and more than 40% of rural veterans who have a service-related disability, access to care is rapidly deteriorating. Financial policy changes have also had adverse effects on rural healthcare services. Factors affecting these are:

• Medicaid Expansion: Non-expansion states must reconsider their stance on Medicaid, as states that expanded the program under the ACA have demonstrated greater financial stability among rural hospitals.
• Reimbursement Adjustments: Policymakers must revisit sequestration and bad debt reimbursement policies that disproportionately affect rural hospitals. More than $650 million in losses due to these policies in 2025 alone must be reversed.

What can be done to reverse this decline in rural healthcare?

Strengthening Healthcare Workforce Capacity:

• Loan Forgiveness and Incentives: Increasing financial incentives for medical professionals to work in rural areas could help mitigate severe provider shortages.
• Telemedicine Expansion: Programs such as the University of Rochester’s telehealth initiative, which places telehealth stations in banks, can provide rural residents remote access to specialists.

Revitalizing Rural Hospitals Through Alternative Models:

• Rural Emergency Hospital (REH) Model: The new REH designation has allowed 32 hospitals to remain operational while shifting away from inpatient care. However, legislative amendments (e.g., expanding reimbursement eligibility for Swing Beds) could further increase participation in this model.
• State-Level Support Initiatives: Some states, such as Pennsylvania and New Mexico, have introduced targeted financial assistance programs for struggling rural hospitals. Expanding these initiatives nationwide could help prevent further closures.

Addressing Population Health Challenges:

• Investing in Social Determinants of Health: Rural communities rank lower in household income (-36 percentile points) and higher in child poverty (+16 percentile points) than urban counterparts. Tackling economic and educational disparities must be part of any long-term solution.
• Strengthening Mental Health Services: Expanding rural behavioral health programs, particularly those aimed at preventing suicides and addressing substance use disorders, is critical to reversing the rural health decline.

A key finding in the 2025 Rural Health State of the State report is the expansion of "care deserts," particularly for essential services such as obstetrics (OB) and chemotherapy. While OB services primarily impact maternal health, the loss of chemotherapy services is highly relevant to older adults, who experience a higher incidence of cancer diagnoses and chronic illnesses. Older adults in rural communities face significant geographic barriers due to hospital closures and reduced services. Since 2010, 182 rural hospitals have closed or converted to models excluding inpatient care. For older adults who require frequent, specialized care for chronic conditions such as diabetes, heart disease, or cancer, these closures increase travel distances and create logistical challenges. Many older adults may be physically unable to drive long distances, making healthcare access even more difficult. I have been conducting extensive research on how hospital closures disproportionately affect older adults by reducing their access to essential medical services. This includes:

• Longer travel times for specialty care, increasing missed appointments and delays in treatment.
• Greater reliance on emergency departments due to lack of primary care access, leading to worse health outcomes.
• Higher out-of-pocket costs associated with traveling for care, particularly for those on fixed incomes.

Current research investigating older adults' barriers can be directly compared to the rural healthcare crisis described in the report. The 2025 Rural Health State of the State report highlights that Medicare Advantage enrollment in rural areas has increased to 39%, creating financial instability for rural hospitals. Unlike traditional Medicare, Medicare Advantage often reimburses hospitals at lower rates, making it less profitable for facilities to serve older adults. Additionally, Medicaid non-expansion in 10 states has resulted in more hospitals operating in financial distress. While Medicaid primarily affects low-income individuals, many older adults rely on dual eligibility (Medicare + Medicaid) for coverage. This means older adults in non-expansion states face more significant out-of-pocket costs and fewer covered services. My research can link insurance-related barriers for older adults to the worsening financial conditions in rural healthcare. Some key themes include:

• Medicare Advantage and out-of-pocket costs – How limited reimbursements affect access to specialists for older adults.
• Medicaid expansion and coverage gaps – How older adults in non-expansion states experience more significant financial burdens when seeking care.
• Hospital revenue declines and cost-shifting – How hospitals offset revenue losses by increasing patient costs, limiting services, or closing entirely, further restricting access for older adults.

The 2025 Rural Health State of the State report emphasizes that rural communities bear a disproportionate share of the chronic disease burden. Compared to urban populations, rural residents experience:

• Higher rates of adult obesity (+30 percentile points).
• Higher rates of diabetes (51st percentile in rural vs. 50th in urban settings).
• Higher rates of heart disease and stroke.
• Higher rates of cancer-related mortality (70th percentile in rural vs. 33rd in urban settings).

Given that chronic conditions primarily affect older adults, these findings align with a study’s focus on healthcare access barriers for older populations. Many older adults require frequent medical care for diabetes, cardiovascular diseases, cancer, and respiratory illnesses, yet rural hospital closures and provider shortages make routine management of these conditions increasingly difficult. In addition, research links chronic disease burden to barriers older adults face in accessing healthcare, specifically:

• Lack of specialists in rural areas – Many rural hospitals have closed oncology and cardiology departments, forcing older adults to travel for care.
• Limited access to preventative care – Older adults in rural areas may struggle to access primary care, leading to delayed diagnoses and worse health outcomes.
• Cost of chronic disease management—Due to lower incomes and insurance restrictions, medications, medical equipment, and frequent visits may become unaffordable.

The 2025 Rural Health State of the State report underscores the mental health crisis in rural America, with higher suicide rates, gun violence, and substance use disorders. Suicide rates in rural communities are nearly double those in urban areas (69th percentile vs. 37th percentile). Older adults, particularly those living alone, experiencing chronic illness, or facing economic hardship, are at an increased risk for mental health challenges. However, rural behavioral health services are scarce, ranking at only the 31st percentile compared to the 63rd percentile in urban areas. Research also highlights the link between rural mental health challenges and barriers to accessing behavioral health services for older adults. Key points of connection include:

• Social isolation and depression among older adults.
• Limited access to geriatric mental health professionals.
• Suicide risk in older men, especially those without strong family or social networks.

One of the most compelling aspects of the 2025 Rural Health State of the State report is its discussion of rural veterans disproportionately facing healthcare access challenges. Nearly 2 million of the 4.4 million rural veterans are not enrolled in the Veterans Health Administration (VHA), meaning they must rely on local rural hospitals or travel long distances for care. Key issues facing rural veterans include:

• Long wait times for VA appointments (29 days for primary care, 34 days for mental health).
• High rates of service-related disabilities (40% of rural veterans).
• Greater vulnerability to suicide (44.3 per 100,000 in rural vs. 40.0 per 100,000 in urban settings).

Correlating to current research, it can be used to hypothesize how older veterans experience additional healthcare barriers, particularly in rural communities. Key themes include:

• The impact of rural hospital closures on veteran care.
• Barriers to VA enrollment and reliance on community healthcare services.
• Mental health challenges, PTSD, and suicide risks among older veterans.

Finally, it is apparent that current research highlights that older adults’ healthcare access barriers have multiple correlations with the 2025 Rural Health State of the State report, particularly in the areas of:

1. Hospital closures and geographic barriers to care.
2. Financial constraints, Medicare/Medicaid policies, and affordability issues.
3. The disproportionate burden of chronic diseases among older adults.
4. Mental health access limitations and rising suicide rates in rural seniors.
5. The challenges facing rural veterans include service-related disabilities and VA wait times.

References

Topchik, M., Pinette, M., Brown, T., Balfour, B., & Wiesse, A. (2025). 2025 Rural health state of the state: Instability continues to threaten rural health safety net. The Chartis Center for Rural Health. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/