Rural hospitals are the cornerstones of their communities, serving as key access points of care for nearly 20% of Americans. Beyond their direct impact on health and well-being, they also offer broader community benefits. They are often the largest local employer and help attract other businesses to the area, which can improve economic stability. Having a hospital nearby is a sign of community vitality.  

But despite the value they provide in communities across the country, many rural hospitals are struggling financially and a concerning number of them have already had to shut their doors. Since 2010, 121 rural hospitals have closed, leaving rural Americans with fewer options and longer travel time to receive care. With each closure, Americans lose access to essential services, and communities lose a central component of their local economies. The consequences of closure are significant. A recent study by researchers at the University of Washington found that rural hospital closures are associated with higher mortality rates, and previous research has suggested such closures negatively affect economic measures, including per capita income and unemployment.  

The American Hospital Association has long understood the realities of providing rural health care. In February 2019, we released a report outlining the many challenges rural providers face and near-term policy recommendations to address them. Last summer, the AHA launched a task force of hospital and health system leaders to develop care delivery and financial models to address the long-term needs of rural areas. There is both a need and opportunity to improve rural health, now and in the future. The increasing stakeholder attention to rural health needs is encouraging. During the past year, the House Committee on Ways and Means, Department of Health and Human Services, and Bipartisan Policy Center have each established expert groups to find solutions and develop policies to support rural health care.  

Given the troubling trend of rural hospital closures and concerns about access to health care services, most of the activity around rural health care is focused on near-term solutions. However, while the pressing need to preserve local access to care cannot be overstated, it is equally crucial to craft longer-term solutions that provide financial and operational flexibility for rural hospitals. As part of our current advocacy and long-range policy planning efforts, the AHA is working to ensure that both immediate and future rural health care needs are prioritized.  

Rural hospitals face challenges unique to remote areas  

Although rural hospitals provide great benefits to their communities, they are not immune to the numerous challenges in providing health care, such as workforce shortages, aging infrastructure and cybersecurity threats. These obstacles — and others — are felt more acutely in rural settings due to geographic isolation, fewer patients and the large proportion of Medicare, Medicaid and uninsured populations served by rural hospitals.

In AHA’s Rural Report, we outline persistent, recent and emergent challenges facing rural hospitals that can contribute to financial and organizational hardship:  

  • Persistent challenges encompass the longstanding realities of rural health care, including low patient volume, a heavy reliance on government payers and an older population with more chronic conditions, among others.  
  • Recent challenges reflect changes in the health care field and policy environment, such as shifts from inpatient to outpatient care delivery, growing behavioral health needs, continued regulatory burden and markedly higher drug costs.  
  • Emergent challenges include those events and circumstances, such as natural disasters, violence and epidemics, which occur with little warning but require immediate attention. 

The cumulative burden of these challenges can threaten a hospital’s ability to maintain access to services. As rural hospitals are already stretched thin by caring for chronically ill patients with fewer clinicians and fewer dollars, they have to tackle changes in health care practice, payment and compliance requirements — all of this occurs at the same time as patient needs evolve. While saddled with these challenges and limited resources, rural providers simply may not have capacity to shift attention to urgent issues or remain flexible for the future. For some, this ever-more-demanding situation becomes unsustainable, leading to service reduction or complete closure. 

In our report, we describe a policy roadmap to relieve rural hospitals from many of the challenges they face today. Because each hospital has its own set of obstacles, policy solutions must be diverse. Thus, some of our recommendations — such as establishing new models of care — cut across persistent, recent and emergent issues. Other recommendations — such as targeted workforce programs — zero in on one particular challenge. Although there is no single policy change that can eliminate the challenges of providing health care in rural America, we believe that progress can be made by updating policies and investing in these communities.

How AHA’s Future of Rural Health Care Task Force is working to preserve access 

In light of the recent trend in rural hospital closures, it is time to seize the opportunity to develop thoughtful, strategic, long-term policy to protect access to high-quality care for the nearly 60 million Americans living in rural areas. To this end, the AHA has assembled a group of rural hospital executives from clinical and non-clinical backgrounds to form AHA’s Future of Rural Health Care Task Force. This group represents independent and system-owned hospitals, as well as different Medicare designations, including critical access hospitals. Their charge is to develop sustainable approaches to finance and deliver care in rural settings. Some of the early discussions have addressed the essential services that communities need available locally. While the Task Force is deep in its work, the group is exploring solutions that integrate population health and early intervention services to improve health outcomes, prevent and manage chronic conditions, and reduce low-value services.  

The Task Force members are dedicating 18 months to long-range, strategic thinking that looks beyond the issues and structures of today to envision what might be possible in the next 10 to 15 years. With all of the near-term challenges in rural health, this is no easy task. Nonetheless, they are working to develop and evaluate tangible solutions — both legislative and non-legislative — that provide the flexibility needed to meet the needs of their communities going forward. Ultimately, the Task Force will create a range of solutions that collectively build and support healthy rural communities with seamless local access to much needed health care services. 

As long as resources are finite, there will always be a delicate balance between short-term and long-term approaches to improving health and health care. However, they need not be mutually exclusive; investments to address short-term needs can be made to align with long-term goals. Strategies and policies that address the issues of today can build a solid foundation for tomorrow. Without an eye to the future, solutions aimed solely at the problems of today will not yield the sustainable system of care that rural communities need and deserve. 

The AHA knows that rural hospitals have led — and will continue to lead — their communities with resilience, innovation and collaborative partnerships. We believe that rural communities and their health care leaders understand their needs best and have the experience to develop the creative and bold solutions required for success. Our Future of Rural Health Care Task Force is committed to this effort, and we are excited to continue supporting this important work.  

AHA’s 33rd annual Rural Health Care Leadership Conference will take place Feb. 2-5, 2020, in Phoenix.

Erik Rogan is AHA senior associate director of policy. 
Joy Lewis is the AHA’s vice president of strategic policy and leads the Association’s long-range policy planning efforts.

37th Annual AHA Rural Health Care Leadership Conference. February 11–14, 2024. Orlando, Florida. Signia by Hilton Orlando Bonnet Creek. Learn More.

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