There are two kinds of Americans: those who live 12 minutes from an emergency department and those who live 72. The distinction has become one of the most consequential divides in contemporary life. Whether you survive a heart attack, deliver a healthy baby or die from something entirely treatable increasingly depends not on the severity of your illness, but on the distance to the nearest hospital. You might have the most skilled surgeon in the state ready to operate, the most experienced trauma team standing by—but if you can’t reach them in time, their expertise becomes irrelevant.
Over the past 20 years, 110 rural hospitals have closed across the United States. The doors have been locked, the parking lots abandoned, the once-bright emergency signs gone dark.
The closures rarely generate headlines beyond the local weekly paper, but their cumulative effect has been to redraw the American map along lines of medical access—creating vast territories where the most basic assumption of modern life, that help will come quickly when you dial 911, no longer holds.
For some rural hospitals, the choice hasn’t been to stay open or shut down—it’s been to shrink. Since 2023, more than 40 facilities have taken the Rural Emergency Hospital route, eliminating inpatient beds for enhanced federal payments and higher Medicare reimbursement. They keep 24/7 emergency care but offer no admissions, no surgical suite, no labor and delivery ward. It is survival by subtraction.
Another 85 have ended inpatient care since 2005—outside the Rural Emergency Hospital trade-off—some converting to primary care, skilled nursing or outpatient hubs.
Taken together, the picture is stark: rural America is trading hospitals for workarounds, swapping beds for stopgaps and hoping the ambulance makes it in time. With more than 430 rural hospitals at risk of closing due to severe financial problems, the question becomes how far rural healthcare will stretch before it snaps.
A town without a hospital
I grew up in Carmi, Illinois, a town of about 5,000 people in the state’s southeastern corner, where the rolling farmland gives way to the floodplains of the Wabash River. It’s the county seat of White County, which is shrinking, greying and politically steadfast. Nearly 80% of voters chose Donald Trump in the 2024 election. Poverty touches about one in six residents. Medicaid covers a significant share of care, and for roughly 10% of adults under 65, health insurance is still out of reach. The metrics shift year to year, but the trend line remains steady.
We had a hospital in Carmi—White County Medical Center—a modest building that served the kind of mundane, essential function that small-town institutions do: broken bones, chest pains and car accidents—the ordinary crises that punctuate daily life. It was a critical access hospital, meaning it was a small, rural facility with no more than 25 inpatient beds, designed to provide round-the-clock emergency care and basic services to communities far from other hospitals. It abruptly closed in 2005, a victim of the economic conditions that were already beginning to strangle rural healthcare. I was in high school then, old enough to notice but too young to understand what we were losing.
The loss revealed itself slowly, in the way that profound changes often do. People began driving 30 or 45 minutes for routine care or simply going without it. Across rural America, residents carry a heavier burden of chronic disease such as obesity, heart disease and diabetes, and face higher premature mortality than their urban peers. Those burdens are compounded when hospitals close: access falls, travel times rise and mortality for time-sensitive conditions increases.
I watched friends and family move away, temporarily or permanently, because they needed to be near specialized doctors, near neonatal intensive care units, near the infrastructure of survival that urban dwellers take for granted. There is a particular cruelty in this form of geographic sorting: to be exiled by the basic requirements of staying alive.
In a story that echoes the experience of many small towns that have lost their hospitals—cutbacks, promises of reopening, revised timelines, private owners who arrive with grand plans and leave quietly—a local reporter captured the Carmi saga in an article titled “The Rise and Fall of Phoenix: A Fleecing of Carmi.” Phoenix refers to the organization that once pledged to bring the hospital back to life. The story ends with a stark line: “Carmi as a community has lost.”
The arithmetic of crisis
The American rural hospital exists in a state of permanent contradiction. It is asked to function like a modern medical facility while operating on the economics of a corner store. It must provide 24-hour emergency care, maintain expensive equipment and employ specialized staff, all while serving a population that is simultaneously shrinking, aging and increasingly unable to pay.
The median operating margin for rural hospitals is 1%. In 16 states, the median operating margin for rural hospitals is negative, including Connecticut, Kansas, Oklahoma, Washington and Wyoming, where between 70% and 100% of rural facilities are operating in the red.
Oklahoma offers a window into the arithmetic. Seventy percent of the state’s rural hospitals run at a loss, and those with critical access designation teeter on the edge with a median operating margin of -16%.
“The only way we have a bottom line at the end of the year are these special payments that come in,” Rich Rasmussen, president of the Oklahoma Hospital Association, told me. “Eliminate or reduce them, and you cannot sustain.”
Those “special payments” are supplemental Medicaid dollars—known as directed-payment programs—that states use to offset chronic under reimbursement from federal insurance. They prop up hospitals that would otherwise collapse. If Congress cuts or caps them, Rasmussen said, “we’ll lose a third of our facilities.”
The collapse has been methodical, driven by a convergence of policies that might as well have been designed to eliminate rural healthcare. Medicare reimbursement rates—set far from the realities of keeping a critical access hospital solvent—remain stubbornly low. Ten states, most in the South, have also declined to expand Medicaid under the Affordable Care Act, leaving rural facilities to absorb more uncompensated care.
Because rural hospitals serve a higher share of patients covered by Medicare and Medicaid, they have less commercial revenue to offset those low public rates. It’s no surprise, then, that states that have not adopted Medicaid expansion, or that only did so recently after years of debate, have been hit hardest by rural hospital closures.
Oklahoma expanded Medicaid in 2020, the 37th state to do so. But expansion was not a cure for years of negative margins and an uninsured rate still hovering in the double digits. Even with more people covered, hospitals in Oklahoma and across the country still face a Medicaid shortfall: the difference between what Medicaid pays and the cost of providing care.
The Medicaid shortfall reached $27.5 billion in 2023, according to an analysis by the American Hospital Association. In rural hospitals, which see a disproportionate share of Medicaid patients, that gap becomes a structural deficit.
A reprieve
Rural hospitals across the nation have been on shaky financial footing for years. After three years of accelerating closures, 2019 marked a grim record, with 19 facilities shutting down or giving up inpatient care, the service that defines a hospital.
Then came a jolt no one asked for: a pandemic that, paradoxically, steadied the ledgers. Federal relief funds sent rural hospital closures plummeting to just two in 2021—the lowest number since at least 2005. Rural hospitals experienced a 1,600% increase in total margins from 2019 to 2021, as COVID relief money flooded into facilities that had been operating on the edge of insolvency.
The temporary federal funding made many rural hospitals appear more financially stable than they really were, masking structural problems that predated the pandemic and would outlast it.
By 2022, as relief dollars dried up and hospitals ran headlong into labor shortages and inflation, margins sank and closures resumed. Peiyin Hung, Ph.D., co-director of the University of South Carolina Rural Health Research Center, noted that while closures slowed during the pandemic, “that wasn’t stability—it was a pause.” COVID relief and one-time funding, she said, masked deeper problems. “The financial stress never went away.”
The human cost
Most rural hospitals in the U.S. no longer offer labor and delivery services. When a hospital closes, they vanish along with everything else, and even in facilities that stay open, obstetrics is often among the first cuts to stave off losses. Since the end of 2020, more than 116 rural hospitals have stopped delivering babies or announced they will stop by the end of this year, according to a report by the Center for Healthcare Quality and Payment Reform.
“Rural maternity care is in a state of crisis, and more women and babies in rural communities will die unnecessarily until the crisis is resolved,” the Center wrote in its report, noting that the U.S. already has far worse maternal and infant mortality rates than other high-income countries.
As rural hospitals vanish—or shed services to stay open—the risks rise. When a hospital or OB unit closes in a rural area, the travel time to the nearest birthing facility often increases substantially. That creates delays in care and increases the risk of out-of-hospital births and emergency deliveries. Research shows that rural women face a higher adjusted risk of severe maternal complications—including sepsis, pulmonary edema and acute renal failure—and a higher risk of maternal mortality, even after accounting for sociodemographic and clinical factors.
Maternity care deserts now stretch across much of rural America, raising the risk in any crisis and thinning out prenatal and newborn care. In cities, the average trip to a birthing hospital is just over 15 minutes. In rural areas, it grows to about 26 minutes. In maternity care deserts, it is longer still, with people traveling roughly 38 minutes on average—and many going far beyond that.
In Oklahoma, where more than half of the counties are maternity care deserts, the lack of services is forcing some to cross state lines to have a baby.
“There’s nobody delivering babies in southeast Oklahoma,” Rasmussen said, “and only one provider in the northwest. If you live in Boise City, you drive to Texas to deliver your baby. If you live in Buffalo, you drive to Kansas.”
The realities for pregnant women in rural Oklahoma are echoed across the country. In the small rural Illinois community where I grew up, many women have long made the 50-mile-or-so trip to Evansville, Indiana, to deliver their babies and to receive prenatal and postnatal care.
That distance comes at a high cost. Between 2019 and 2021, the rural maternal mortality rate was nearly double that of urban areas.
Maternity care is often the first to vanish, but it’s rarely the last. The same forces that erase delivery rooms soon reach cardiac units and cancer care. Nearly two-thirds of counties have no oncologist based in them, and about 12% also lack an oncologist in any neighboring county, according to a study published in JAMA Open Network. That kind of scarcity makes it harder to receive guideline-concordant treatment and forces patients who are able to travel to log long trips for chemotherapy and radiation, driving up out-of-pocket costs and fracturing continuity of care.
Distance is punishing for chronic disease, but it becomes lethal when the crisis is measured in minutes rather than months. In much of rural America, those minutes are increasingly spent on highways rather than in treatment rooms.
One working paper from the National Bureau of Economic Research found that rural hospital closures increased mortality for emergencies such as heart attacks and strokes by about 10%. Ten percent is not a small number when multiplied across thousands of communities and millions of people. It represents neighbors, grandparents, the woman who runs the local diner, the man who coaches Little League—people who might have lived if they had been born somewhere else.
The spiral of rural economics
When Rasmussen warns that hospital closures eliminate “75 to 100 of the highest-paying jobs in the county,” he is describing only the most visible wound. The research on what follows paints a picture of economic disintegration that extends far beyond the unemployment line.
Studies show that when a rural county loses its only hospital, per capita income drops by $703—a 4% decline—and the unemployment rate increases by 1.6 percentage points. Healthcare employment falls by about 14% in counties experiencing a closure. But the fallout reaches far beyond the hospital. Local businesses lose nearly 2% of their jobs, which ends up accounting for about 40% of all job losses after a closure.
Other research looks at the same event through a demographic lens rather than an economic one, and the picture is just as grim. When a community loses its only hospital, population size decreases by an average of 1.1% and the labor force shrinks by 1.4%. These percentages represent families packing U-Hauls, houses going on the market, children moving to schools in other districts.
And in many of these places, the slide had already begun: per capita income, overall employment and joblessness were moving in the wrong direction even before the hospital shut down, suggesting closures are landing hardest in communities already on the brink.
The mechanism is straightforward but ruthless. Hospital workers who lose their jobs either leave town or remain but commute elsewhere for work. The loss of jobs and residents shrinks the tax base, reducing resources for schools and other public services. Local businesses lose customers.
And then comes the impossible math of economic development. Some businesses require, as a condition of locating in an area, that their employees have access to a hospital emergency department in close proximity. Try recruiting a technology company, a manufacturing plant or any employer with professional staff when you cannot promise that an ambulance will arrive within an hour. Try convincing young families to relocate when the nearest labor and delivery unit is an hour away.
When a hospital closes, it becomes harder for rural communities to attract employers or convince new industries to move in. The closure compounds the very economic strains that contributed to it in the first place—a death spiral where each loss accelerates the next.
In interviews conducted after rural hospital closures, some community leaders said the bigger shock wasn’t to healthcare access but to the local economy. One expert put the dilemma bluntly: “How can we make sure rural communities can be left financially viable without a hospital?”
The answer, increasingly, is that they cannot. “When a hospital fails,” Rasmussen told me, places risk becoming “paper towns” —still on the map, hollow in reality.
His warning is not hyperbole—it is a description of a process already underway across hundreds of rural counties. When the hospital closes, everything else can begin its slow drift toward irrelevance. The school loses enrollment and funding. The grocery store closes. The gas station follows. Property values decline. Young people leave and do not return. The elderly remain, stranded in places that can no longer care for them, watching their communities die in slow motion.
The expanding void
The closures aren’t slowing. In 2025 so far, 18 rural hospitals have closed or shifted to models that no longer offer inpatient care.
In Texas, Mid Coast Medical Center in Trinity closed in late April, just 14 months after it had reopened. “It has a huge impact on the community. We will lose lives,” Marjory Pulvino, president of the hospital district’s board, told CBS News. The facility had been serving 400 patients a month.
In north Alabama, Moulton’s Lawrence Medical Center ended its emergency and inpatient services in May, leaving the county without an emergency department. Northern Light Inland Hospital in Waterville, Maine, closed May 27, with administrators citing low reimbursement rates, workforce challenges and high operational costs.
On Sept. 30, Glenn Medical Center in Willows, California, closed after 75 years. It couldn’t keep its doors open after the federal government determined it no longer met the distance requirement of a critical access hospital. Glenn Medical Center is just over 32 miles from the nearest hospital, short of the 35 required for CAH status. CMS said Glenn Medical Center, which had had CAH status since 2001, should never have received the designation.
Oklahoma lost two rural hospitals this year: Valley Community Hospital in Pauls Valley went dark in January, and Stilwell Memorial Hospital closed in June. Losing a hospital wasn’t new to people in Pauls Valley because their facility had previously closed in 2018 and reopened in 2021.
Each of these closures carries its own backstory of declining volumes, financial pressure and failed rescue plans. Together, they are part of the same arithmetic: Hospitals that once stitched communities together are being erased.
The geography of rural hospital closures is uneven, but some states stand out for both the number of closures and the fragile financial condition of the hospitals that remain. Texas sits at the top of the list, with 47 rural hospitals considered vulnerable to closure, followed closely by Kansas with 46, Mississippi with 28, Oklahoma with 23 and Georgia with 22. Looked at another way, by the share of a state’s rural hospitals at risk, Arkansas rises to the top, with half of its rural hospitals considered vulnerable, followed by Mississippi at 49%, Kansas at 47% and Tennessee at 44%.
The cumulative effect is striking. Entire regions of the country now face the prospect of life without an emergency department, without labor and delivery services, without the basic infrastructure of survival. Each hospital that closes redraws the American map of care, leaving behind longer drives, higher risks and communities stripped of one of their last public anchors.
The policy paradox
This summer, President Donald Trump signed into law the One Big Beautiful Bill Act, a sweeping measure that, among other changes, imposes new work requirements on Medicaid recipients and raises copays for low-income patients. The Congressional Budget Office estimates that the law’s provisions will leave more than 10 million additional people uninsured by 2034.
The reality is more complex. Rural hospitals depend heavily on Medicaid reimbursements to remain solvent, and the new restrictions threaten to accelerate closures in precisely the communities that can least afford to lose medical care. According to health policy analysts at Families USA, a consumer health advocacy group, independent rural hospitals could lose more than half their net income by 2026 under the new rules—an average loss of about $630,000 per facility. In rural America, $630,000 is the difference between a community that can sustain itself and one that must accept the slow hemorrhaging of its population.
The American Medical Association, the American Hospital Association and many other healthcare and provider groups came out against the One Big Beautiful Bill Act.
“This bill moves us in the wrong direction,” Bobby Mukkamala, M.D., president of the American Medical Association, said in a statement. “It will make it harder to access care and make patients sicker. It will make it more likely that acute, treatable illnesses will turn into life-threatening or costly chronic conditions.”
Members of Congress, both Republicans and Democrats, raised concerns about the impact of the cuts on rural hospitals during debate over the legislation. Prior to passage, $50 billion in funding over five years was added for a new Rural Health Transformation Program.
On Sept. 15, CMS released details on how states could apply for this funding—the largest rural health investment in American history, according to HHS Secretary Robert F. Kennedy Jr. The program invited all 50 states to design transformation plans addressing their specific rural health challenges. Every state submitted an application by the Nov. 5 deadline, with awards to be announced by year’s end.
Half of the $50 billion will be distributed equally among all approved states—meaning Connecticut, with three rural hospitals, could receive the same baseline amount as Kansas, with 90. The other half will be allocated by CMS based on factors including rural population size, the number of rural health facilities, uncompensated care burden and the quality of proposed state initiatives. Notably, the Notice of Funding Opportunity specifies that states adopting “Make America Healthy Again” policies will receive favorable consideration in this discretionary allocation.
States can use the funds to expand the rural health workforce, promote care interventions, pay for health services and provide technical assistance with system transformation. The money flows in annual installments of $10 billion from fiscal years 2026 through 2030, with states required to spend funds within one fiscal year or risk redistribution. After 2030, the program ends unless Congress acts again.
Even on generous assumptions, the $50 billion is a partial patch. Analysis suggests it would blunt about 37% of the rural Medicaid cuts over 10 years—only about 5% of the overall federal Medicaid reductions. And that tally leaves out other revenue losses: trimmed ACA Marketplace subsidies and the coverage erosion expected as enhanced premium tax credits lapse.
Hung was cautiously upbeat about the Rural Health Transformation Program—“promising,” she said—but only if states tune it to local realities: needs assessments, triage and regionalization strategies, and equity goals for communities with and without broadband or system partners. “It may slow closures temporarily; sustainability remains a question.”
Rasmussen was blunter: “Those dollars can’t be used for capital improvements, and they don’t pay hospitals more.” In a state where critical access hospitals run at -16% on operations, he argued, grants that can’t fund roofs, chillers or rate adequacy won’t change the slope.
Both flagged workforce as the swing factor; without workable debt-forgiveness pathways and recruitment tools, the program risks propping up buildings while the clinicians disappear.
For now, it’s a tourniquet in a country that keeps inventing new ways to reopen the wound.
The political irony is inescapable. The states that have shed the most rural hospitals, or have the largest share now on the brink, are largely Republican strongholds that have handed President Trump repeated victories. They were drawn to his promises of renewal, his rhetoric about a forgotten America, his pledge to restore what globalization and government indifference had taken away. But the policies he’s championed are steadily eroding the infrastructure that makes rural life possible.
A patchwork of loss
This is not merely a crisis of the rural South or the declining Midwest. Rural hospitals are under strain in every region of the country, from California’s Central Valley to the plains of Kansas to the mountains of upstate New York, as facilities cut services, fight to stay open, or rely on emergency lifelines to survive.
“Over the next decade,” Rasmussen warned, “we’re entering a real period of reckoning in rural America in terms of their access to healthcare.”
Taken together, these closures show that what once looked like a slow bleed has become a flood. The word “rural” has become a euphemism for “expendable,” a designation that suggests these communities and their residents are somehow less essential to the American project.
When an emergency room shuts down, the consequences ripple outward in ways that statistics cannot capture. Ambulances are diverted to hospitals an hour away. Babies are born in the back seats of cars racing down empty highways. Preventable deaths are reclassified as “complications,” their true cause—the systematic abandonment of rural America—hidden behind medical euphemisms.
The silence that follows
We have grown accustomed to discussing American healthcare in the language of innovation and market disruption: breakthrough therapies, precision medicine, the promise of artificial intelligence. But most healthcare happens quietly, in examination rooms and hospital corridors, in the ordinary encounters between patients and providers that make up the daily work of keeping people alive and well.
When that infrastructure disappears, what remains is not just the absence of medical care, but the absence of hope—the knowledge that your community has been judged unworthy of investment, that your life is worth less because of where you happened to be born. Healthcare becomes not a right or even a service, but a form of geographic privilege, distributed according to ZIP code and population density.
“At the end, it’s fundamentally about values,” Hung said. “Which communities are deemed worthy of keeping a hospital?” The consequences of those value judgments, she noted, will echo for generations—we’ll be tracking the effects on mothers and babies born during this period decades from now.
My hometown has been without a hospital for 20 years now. I haven’t lived there in almost as long, but the people there have adapted, as small towns learn to do. For people in Carmi, a drive of 30 minutes or more has become the norm to have access to an inpatient facility. As a person’s need for more specialized treatment increases, so does the journey. It has become routine for those in Carmi to make their way to Evansville, Indiana, for inpatient procedures and childbirths. For more complex conditions, many drive two or three hours to Indianapolis or St. Louis to get the care they need. Those unable to do so simply go without.
I do not want other communities to navigate this loss. I do not want proximity to medical care to remain a matter of luck or circumstance. The crisis in rural healthcare has been building for decades, accelerated by policy choices made across administrations and both parties—chronic underpayment through Medicare that hasn’t kept pace with rising costs, Medicaid expansion decisions left to individual states, and a persistent failure to square a market-based healthcare system with the needs of sparsely populated regions.
We all deserve a hospital close enough to save us—not because it is economically efficient or politically expedient, but because the alternative is unconscionable. In a country that can afford trillion-dollar expenditures across the political spectrum, the notion that we cannot afford to keep rural hospitals open is not a matter of fiscal constraint. It is a matter of moral choice.