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March 18, 2020  | Updated: May 13, 2020

Category: Rural Health


  • 97% of country’s land mass is rural, home to 20% of the population
  • Rural hospitals facing closures
  • Travel time to hospitals major concern

A variety of issues contribute to health care complications in rural America, including a shortage of health care workers, continuing closures of hospitals, a high rate of elderly, poor, and underinsured residents, as well as a high frequency of chronic illness. In the first edition of our three-part series on the dilemmas faced by rural health care administrators, we examine the difficulty of accessing health care facilities and the rate of hospital closures.

One of the primary goals of health care facilities should be making care easily accessible for its patients. Cost factors aside, this can be a barrier for those that live in rural areas for a variety of reasons.

The U.S. Census Bureau classifies “rural” based on population thresholds, density, distance, and land use. Urban areas make up only 3 percent of the entire land area of the United States but are home to more than 80 percent of the population.

On the other hand, 97 percent of the country’s land mass is rural, but 20 percent of the population lives there—which equates to approximately 65 million people spread out across 3.6 million square miles3.

This sparse population density creates a variety of problems in health care, predominantly care access for patients. Hospital administrators need to carefully evalua how to improve care access for patients.

Delay in Medical Care:

Residents in rural areas who live on farms, reservations, and frontiers are usually required to travel long distances to reach a health care provider. An extended travel time can have various negative consequences for patients beyond a delay in medical treatment. It could entail taking time off from work for an initial appointment or follow-up. Since many people do not have the privilege of paid time off or paid sick leave at their disposal, it could cause patients to delay or avoid care. Greater distances also result in longer wait times for emergency medical services (EMS), which can endanger patients requiring EMS treatment7.

Hospital Closures:

Another issue that affects patient access for residents of rural areas is hospital closures. According to a report1, 168 rural hospitals have closed since January of 2005: more than 120 of those closures occurred since 2010.

Researchers utilized the definition of a “closed hospital” as provided by the Office of Inspector General: “A facility that stopped providing general, short-term, acute inpatient care [….] We did not consider a hospital closed if it: Merged with, or was sold to, another hospital but the physical plant continued to provide inpatient acute care, Converted to critical access status, or both closed and reopened during the same calendar year and at the same physical location.”

The report from the Office of Inspector General found various factors that contributed to rural hospital closures. The study found the primary reasons to be business-related decisions, such as relocations, consolidations, or mergers. Other factors for a business-related closure would be due to a low number of patients, rising costs or lagging revenues.

Only a small number of rural hospitals reported Medicare and/or Medicaid reimbursements as the primary reasons for closure.

Hospital Networks:

One study4 examined whether or not hospital patients who bypass their local rural hospital to receive care in another hospital will base their decision on if the hospital is in a less competitive or a more competitive market. If the patient is price-sensitive and competitors have decreased hospital prices, the patient might choose a hospital in a more competitive market. If patients are concerned with issues that do not involve prices, such as facility amenities, the patient might choose a hospital in a less-competitive market.

Due to the fact that most hospital care is paid for by third party payors, an insured patient is likely to be motivated to bypass their local rural hospital to select another facility which is located in a less-competitive market. Patients were found to base their decisions on higher perceived levels of service, clinical outcomes, amenities, and service quality. The hospital network and the number of services provided by the hospital were other positive predictors of bypassing, while a public hospital affiliation and distance to the patient’s residence were negative predictors. Researchers found that rural patients were more inclined to visit hospitals that participated in a network with other hospitals. Overall, networked hospitals were preferred over non-networked hospitals by nearly 50 percent4.

However, not all rural hospitals are quick to join a sizeable hospital network. Another study2 found that the rate at which rural hospitals have been linked to large, multihospital systems has slowed. Aside from possible financial losses, there are concerns by rural hospital administrators that an affiliation with a large hospital system could result in a lack of awareness to local needs and hospital autonomy. Alternatively, an increasing number of rural hospital leaders have looked at establishing less structured and joint arrangements by participating in voluntary hospital networks.

Even a smaller, rural hospital network isn’t always easy to sustain. There are some network-sponsored programs that are relatively straightforward and in expensive, such as educational programs or physician recruitment. Yet other network activities need extensive cooperation and a high level of trust among participating hospitals. This could result in the aforementioned change in the mission of a health care facility, such as joint quality-assurance or credentialing programs².


There is no easy, end-all solution to the issue surrounding patient access in rural health care. One possible solution that has been examined is telehealth and telemedicine. There are various benefits to integrating technology and health care within facilities, yet it is not always feasible. In Part 2 of our Rural Health Care Hurdles series, we will look at the intricacies involving telehealth in rural areas.



  1. 168 Rural Hospital Closures: January 2005 – Present (126 since 2010). (n.d.). Retrieved from:
  2. Moscovice, I., Christianson, J., Johnson, J., Kralewski, J., & Manning, W. (1995). Rural hospital networks: implications for rural health reform. Health care financing review17(1), 53–67.
  3. Nasser, H. E. (2019, May 23). What is Rural America? Retrieved from
  4. Rehnquist, J. (2003, May). Office of Inspector General: Trends in Rural Hospital Retrieved from            00610.pdf
  5. Roh, C.-Y., Lee, K.-H., & Fottler, M. D. (2008). Determinants of Hospital Choice of Rural Hospital Patients: The Impact of Networks, Service Scopes, and Market    Journal of Medical Systems32(4), 343–353. doi: 10.1007/s10916-   008-9139-7
  6. Rosenburg, J. (2019, February 5). Understanding the Health Challenges Facing Rural Retrieved from
  7. Warshaw, R. (2017, October 31). Health Disparities Affect Millions in Rural U.S. Retrieved from:       disparities-affect-millions-rural-us-communities
  8. Weisgrau S. (1995). Issues in rural health: access, hospitals, and reform. Health care financing review17(1), 1–14.

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