July 18, 2023

By Rachel Morrow, UNC Gillings School communications fellow

Due, in part, to worsening economic inequality, greater reliance on Medicaid and Medicare payments, and the precarious finances that result, rural communities have been disproportionately affected by hospital closures in the past 30 years. In the southern United States, the region with the greatest share of hospital closures in the past decade, approximately 10% of rural counties lost one or more hospitals to a closure between 2007 and 2018, according to a recent study led by researchers at UNC-Chapel Hill.

In nearly half of these cases, the closure left the county without a hospital. And many areas experienced worsened travel times to their nearest hospital. Rural areas within counties that had at least one closure had longer travel times to reach the nearest short-term acute hospital compared to rural areas without hospital closures.

Additionally, rural areas with a higher proportion of Black and Latinx residents had longer travel times to access acute care hospitals beyond the closest one, compared with rural areas with a higher share of white residents. In contrast, rural areas with high shares of white residents had shorter distances to access acute care hospitals beyond the nearest hospital, despite being more remote. 

The rate of rural hospital closures has grown in recent years, raising concerns about declining access to hospital-based care. Knowing the significance of these closures, the research team published their study in the Milbank Quarterly with three aims:  

  • Identify the change in rural hospital access in the U.S. South between 2007 and 2018 by looking at health system closures, mergers and conversions;
  • Measure the travel time to a health care facility after hospital closures for populations at risk for adverse outcomes, particularly in Black and Latinx rural communities; and 
  • Understand the relationship between structural factors and disparities in travel time to care. 

They conducted this research by estimating the network distance and travel times between central points for a population in a given area to the nearest and second nearest hospitals in both 2007 and 2018.

To look at demographic characteristics of places in relation to travel times to hospitals, they created mathematical models at three different levels: tract, county and state. Based on their descriptive estimates of travel distances and times in the years 2007 and 2018, the authors concluded that about half of rural-dwelling people in the U.S. South (about 6 million people) experienced worsened travel time to their nearest hospital during this period, while the remainder experienced improved travel time (32.4%) or experienced unchanged travel times (18.5%). 

Although hospital closures have impacted the U.S. as a whole, with 15% of hospitals closing since 1990, rural areas are particularly affected. Worsening economic inequality and a greater reliance on Medicaid and Medicare payers have left rural hospitals vulnerable to financial distress and closures. Additionally, hospitals in states that haven’t expanded Medicaid since the Affordable Care Act are even more vulnerable to closure. This adds an extra degree of significance to North Carolina’s upcoming Medicaid expansion.  

Dr. Arrianna Planey

Dr. Arrianna Planey

Arrianna Marie Planey, PhD, MA, assistant professor in the Department of Health Policy and Management at the UNC Gillings School of Global Public Health and Cecil G. Sheps Center for Health Services Research Fellow and the study’s first author, predicts that “Expanding Medicaid in N.C. will likely benefit N.C. hospitals, especially those that provided uncompensated care to patients who would have otherwise been eligible for Medicaid (i.e., working-age adults with incomes less than 137% of the Federal Poverty Level). The relationship between Medicaid expansion and hospital finances is a bit more complex, but on balance, more comprehensive health insurance coverage for the state’s population means better health care access and less uncompensated care provided by hospitals.”

The authors also highlight some key policy implications from their research including encouraging policymakers to invest in programs to support rural health systems, specifically in areas with long travel times or for historically underrepresented racial and ethnic groups. Additionally, they suggest that health plan adequacy standards should address travel times to nearest and second nearest hospitals, as well as incorporate equity standards for Black and Latinx rural communities. Lastly, the authors call for long-term policy solutions, such as reparations, in order to address the fundamental structural inequities in geographic allocation of jobs in rural communities of color. 

This research is essential, as rural hospital closures and the resulting increase in travel time to hospitals negatively impact health service use in rural areas, such as longer ambulance trips, more preventable hospitalizations and increased mortality due to less timely responses to emergent health conditions like heart attacks and injuries. 

Planey adds that an essential component in future research is “thinking more explicitly about time — time inequity and scarcity borne by Black and non-Black people of color and low-income people — will help us better understand patterns of health care utilization and health behaviors more broadly. This requires understanding that there are fundamental social and spatialized inequities in the organization of health care in the U.S.”

Contact the UNC Gillings School of Global Public Health communications team at sphcomm@unc.edu.

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