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When rural hospitals close, minorities pay the biggest price

June 10, 2020
By Annalisa Merelli

Rural hospitals in the US have been struggling for years, and coronavirus has accelerated their demise.

About 25% of rural hospitals were already in dire financial situations before coronavirus, according to the 2020 Rural Hospital Sustainability Index, published April 8 by Guidehouse, a consulting firm. These hospitals, according to the report, employ 51,800 people, and provide over 222,350 annual treatments that generates $8.3 billion in revenue from patients. About 81% of these hospitals facing closure are considered essential to their communities.

While Covid-19 is only now spreading to rural communities, the preventative measures hospitals took to avoid putting patients at risk—such as pausing outpatient services and elective procedures—have cut important revenue streams for rural hospitals, making their financial situation even more precarious.

Hospitals are key to the health of rural communities, of course, and the majority of them serve as the only healthcare provider for the local population. But the damage goes beyond the loss of health services—and it can affect minorities disproportionately.

In many rural counties, the hospital is a—if not the—main employer and economic actor, said Janice Probst, a public health professor at the University of South Carolina. Alongside the loss of healthcare services, when hospitals close there are job losses for the hospital’s employees and physicians, pharmacists, workers providing services to the hospital and its staff (such as cafeteria workers), and even down the line for business in the vicinity of the hospitals that lose the clientele brought in by hospital services.

“When you close a rural hospital, you lose about 1.6% of the total county’s economy,” Probst said.

Although Probst’s research on the rural health crisis of the 1980s showed that local economies eventually recovered from the loss, a large percentage of the people laid off by the hospitals end up having to leave or change profession.

Further, when a hospital closes, the county loses attractiveness for other potential employers. “When you haven’t got a hospital you can’t attract industry,” Probst said, “because their insurance is going to look at things like ‘how far is it to get medical care in the case of an injury?'”

This affects rural communities across the country, but researchers from the University of North Carolina at Chapel Hill who track rural hospital closures around the country found critical-access hospitals are at higher risk of closure in communities that have a higher percentage of non-white people, and especially Black people.

Specifically, rural hospitals that are more financially secure serve communities that are overwhelmingly white, with populations that are only 0.9% Black, and 8.1% overall non-white. Hospitals are at risk of closure, however, serve 2.5% Black and 18.1% non-white populations.

These are the states where over 50% of rural hospital are at high-risk of closure (according to Guidehouse data):


























Many of these states are in the south, where rural communities are more likely to be non-white than in the midwest, for example. These are also areas where hospitals—particularly emergency services—are more essential, as people who don’t have insurance coverage are more likely to seek emergency care than preventive and ongoing services. Many of these states with rural minority populations have not passed the Medicaid expansion contained within the Affordable Care Act, which increases the financial threshold to qualify for Medicaid, leaving more people uninsured and hospitals are more likely to struggle, Probst said.

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