580-Article Text-3572-1-6-20190416


Online Journal of Rural Nursing and Health Care, 19(1) 
http://dx.doi.org/10.14574/ojrnhc.v19i1.580            1 

Editorial 

Where Have all the Rural Hospitals Gone? 

Pamela Stewart Fahs, PhD, RN, Editor 

Every time I hear about another rural hospital closure it brings to mind a Pete Seeger classic, 

thus I am asking where have all the rural hospitals gone?  By spring of 2019, there were 104 rural 

hospital closures since 2010 (University of North Carolina [UNC], Cecil G. Sheps Center for 

Health Services Research, n.d.). The UNC center keeps a running tab of closures reported on their 

website (https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/ 

). This number is up from 85 closures less than a year ago. An analysis of rural hospital closures 

(U.S. Government Accountability Office, 2018) showed a national marked increase in the loss of 

rural hospitals since 2013. The south had the highest number of closures and those states that did 

not expand Medicaid accounted for 63% of the rural hospital closures (Holmes, Kaufman, & Pink, 

2017). The difference in closures between those states that expanded Medicaid and non-Medicaid 

expansion states reflect only a small difference in operating margins. Rural hospitals in Medicaid 

expansion states on average had a slight (~ 1%), yet positive financial picture.  Non-Medicaid 

expansion states were more likely to report negative operating budgets for rural hospitals, with 

financial distress being one of the main reasons for closure (Kaufman, Reiter, Pink, & Holmes, 

2016).   

One bright spot is that closure does not always mean complete absence of access to care.  

Hospital closure in most reports means no longer offering acute inpatient services and rural 

hospitals are generally defined as having a Rural Urban Commuting Area (RUCA) of 4 or higher 

on the scale of 10 code levels or being a Critical Access Hospital. Hospitals that have ceased 

inpatient acute care services yet offer some type of emergency care or have converted to a clinic 



Online Journal of Rural Nursing and Health Care, 19(1) 
http://dx.doi.org/10.14574/ojrnhc.v19i1.580            2 

may be counted as closed. (Holmes et al., 2017).  What is not included in the list of closed hospitals 

are those that have significantly reduced their number of inpatient acute care beds although these 

remain classified as open, the situation does negatively affect the ability of rural patients to receive 

acute care without having to travel a further distance.  

In addition to the possible negative health care consequences from closed facilities for rural 

dwellers, rural hospitals are usually a major employer in their communities. One source (Freeman, 

Thompson, Howard, Randolph, & Holmes, 2015) noted that there were over 2000 fulltime 

equivalent (FTE) employees in rural hospitals in 2012-2013, with an average of 321 FTE 

employees. This trend of closure and downsizing can have multiple negative outcomes including 

a decrease in the number of higher paying jobs in a rural community. 

References 

Freeman, V.A., Thompson, K., Howard, H.A., Randolph, R., & Holmes G.M. (2015, March). The 

21st century rural hospital: A chart book. Retrieved from http://www.shepscenter.unc.edu/wp-

content/uploads/2015/02/21stCenturyRuralHospitalsChartBook.pdf 

Holmes, G.M., Kaufman, B.G., & Pink, G.H. (2017). Financial distress and closure of rural 

hospitals. Rural Health Research Gateway Webinar. Retrieved from 

https://www.ruralhealthresearch.org/assets/540-1584/9212017-financial-distress-closures-of-

rural-hospitals-ppt.pdf  

Kaufman, B.G., Reiter, K.L., Pink, G.H., & Holmes, G.M. (2016). Medicaid expansion affects rural 

and urban hospitals differently. Health Affairs, 35, 1665 - 1672. http://dx.doi.org/ 

10.1377/hthaff.2016.0357  



Online Journal of Rural Nursing and Health Care, 19(1) 
http://dx.doi.org/10.14574/ojrnhc.v19i1.580            3 

University of North Carolina, Cecil G. Sheps Center for Health Services Research (n.d.) 87 rural 

hospital closures: January 2010 – present. Retrieved from http://www.shepscenter.unc.edu/ 

programs-projects/rural-health/rural-hospital-closures/  

United States Government Accountability Office (2018). Report to congressional requesters: Rural 

hospital closures. Number and characteristics of affected hospitals and contributing factors. 

Author: GAO-18-634 Retrieved from https://www.gao.gov/assets/700/694125.pdf