Hospital closures have been concentrated in rural communities and are associated with longer distances to care, fewer local hospital services, and worsening financial performance before closure. The Government Accountability Office (GAO) recorded 101 rural hospitals closing between January 2013 and February 2020, while KFF counted 62 rural general acute-care closures and 10 openings from 2017 through 2024. These figures use different definitions and periods, so they should not be combined as a single series.
Contents
- Recent closure counts and trends
- Where closures occurred
- How far patients traveled after closure
- Providers and services in closure counties
- Health status and Medicare use
- Financial and operational warning signs
Recent closure counts and trends
The GAO defines a rural hospital closure in this analysis as cessation of inpatient services. Under that definition, it recorded 15 closures in each of 2013, 2014, and 2015. The count then fell to 11 in 2016 and 9 in 2017, before rising to 14 in 2018 and 19 in 2019. The 101 closures identified from January 2013 through February 2020 exclude six hospitals that later reopened. They occurred across 28 of the 50 states. These are findings from GAO-21-93, Rural Hospital Closures: Affected Residents Had Reduced Access to Health Care Services.
KFF uses a different series covering rural general acute-care hospitals. It counted 62 closures and 10 openings from 2017 through 2024, producing a net reduction of 52 hospitals. The UNC Sheps Center count cited by KFF reached 193 rural hospital closures from 2005 through 2024. KFF also reported that 69% of rural closures from 2014 through 2024 occurred in states that had not expanded Medicaid when the closure occurred. The KFF series and the GAO series therefore describe related but nonidentical measures of hospital change. See KFF, “10 Things to Know About Rural Hospitals”.
Where closures occurred
Closures were not distributed in proportion to the rural hospital population. Southern states contained 38% of rural hospitals in 2013 but accounted for 77% of rural closures from 2013 through 2017. Texas contained 7% of rural hospitals but accounted for 22% of closures during that period. These comparisons come from GAO-18-634, Rural Hospital Closures: Number and Characteristics of Affected Hospitals and Contributing Factors.
Several institutional categories were also overrepresented among closures. Medicare Dependent Hospitals made up 9% of rural hospitals in 2013 but 25% of closures from 2013 through 2017. Low Volume Hospitals represented 22% of rural hospitals and 42% of closures. By contrast, Rural Referral Centers represented 10% of rural hospitals but only 2% of closures.
| Hospital characteristic | Share of rural hospitals in 2013 | Share of closures, 2013–2017 |
|---|---|---|
| Southern states | 38% | 77% |
| Texas | 7% | 22% |
| Medicare Dependent Hospitals | 9% | 25% |
| Low Volume Hospitals | 22% | 42% |
| Rural Referral Centers | 10% | 2% |
| For-profit hospitals | 11% | 36% |
| Hospitals with 26–49 inpatient beds | 11% | 23% |
For-profit hospitals accounted for 11% of rural hospitals in 2013 but 36% of closures in 2013–2017. Rural hospitals with 26 to 49 inpatient beds accounted for 11% of rural hospitals and 23% of closures. These proportions describe composition, not a probability that an individual hospital in a category will close.
How far patients traveled after closure
GAO compared median straight-line distances in service areas before and after closure, using 2012 and 2018 measurements. Across 64 closed rural hospital service areas, the median distance to general inpatient care rose from 3.4 to 23.9 miles, an increase of 20.5 miles. Across 62 service areas, the median distance to an emergency department rose from 3.3 to 24.2 miles, up 20.9 miles. Outpatient-care distance rose from 3.2 to 24.1 miles across 58 service areas, also a 20.9-mile increase.
The median distance to an operating room increased from 3.1 to 23.2 miles across 46 service areas, while the distance to computed tomography increased from 3.4 to 24.3 miles across 45. Magnetic-resonance-imaging distance rose from 3.8 to 23.8 miles across 31 service areas. Obstetric distance rose from 3.5 to 22.8 miles across 13 service areas.
Some specialized services showed even larger changes. Across 11 service areas, the median distance to alcohol- or drug-abuse treatment increased from 5.5 to 44.6 miles, a 39.1-mile increase. Geriatric psychiatry rose from 3.4 to 39.9 miles across 11 areas, up 36.5 miles. Coronary-care-unit distance rose from 4.5 to 35.1 miles across 11 areas, an increase of 30.5 miles.
Among smaller samples, neonatal-nursery distance rose from 2.5 to 32.9 miles across seven service areas, and acute renal dialysis rose from 2.9 to 28.2 miles across seven. The median distance to a designated trauma center rose from 4.5 to 24.8 miles across seven areas. Optometry distance rose from 2.5 to 48.1 miles across five areas, while audiology rose from 3.8 to 44.6 miles across five. Across four areas, child or adolescent psychiatry rose from 4.0 to 46.2 miles, and urgent-care distance rose from 3.1 to 42.2 miles.
These are straight-line median distances, not driving times. The number of service areas varies substantially by service, from 64 for general inpatient care to four for child or adolescent psychiatry and urgent care. The results should therefore be read as service-specific access comparisons rather than a single average travel burden.
Providers and services in closure counties
Provider availability was lower in counties with rural hospital closures and changed differently from counties without closures. In 2012, closure counties had a median of 71.2 physicians per 100,000 residents, compared with 87.5 in counties without closures. By 2017, the medians were 59.7 and 86.3, respectively. From 2012 to 2017, all-physician availability fell 16.2% in closure counties, versus 1.3% in counties without closures.
In closure counties, general-surgeon availability fell from a median 4.8 per 100,000 residents in 2012 to 3.1 in 2017. Primary-care physicians fell from 42.7 to 36.0 per 100,000. Advanced-practice registered nurses moved in the opposite direction, rising from 68.7 to 110.8 per 100,000.
The share of closure counties with particular hospital services also declined. Hospital-based outpatient-care centers were present in 57.1% of closure counties in 2012 and 34.9% in 2017. Hospital emergency departments were present in 79.4% in 2012 and 39.7% in 2017. Hospital obstetric care was present in 44.4% in 2012 and 27.0% in 2017. These county-level percentages do not show whether another facility opened outside the county.
Health status and Medicare use
GAO’s 2017 comparison of Medicare fee-for-service beneficiaries found higher median prevalence of several chronic conditions in rural hospital closure service areas than in non-closure service areas. Hypertension prevalence was 62.0% in closure areas versus 56.3% in non-closure areas. Diabetes prevalence was 29.3% versus 26.3%; chronic kidney disease was 24.4% versus 21.8%; and chronic obstructive pulmonary disease was 14.1% versus 12.5%.
Utilization patterns also differed. In 2012, the median inpatient-stay rate was 306 per 1,000 Medicare fee-for-service beneficiaries in closure service areas, compared with 274 per 1,000 in non-closure areas. By 2017, the rate had fallen 9.5% in closure areas and 8.0% in non-closure areas.
The median outpatient-visit rate was 4,264 per 1,000 beneficiaries in closure areas in 2012, versus 4,760 in non-closure areas. By 2017, it had fallen 5.1% in closure areas, while rising 8.9% in non-closure areas. The median emergency-room visit rate was 774 per 1,000 in closure areas in 2012, versus 644 in non-closure areas; it fell 4.2% in closure areas and rose 3.7% in non-closure areas by 2017.
These comparisons describe populations and service areas, not a causal estimate that closure alone produced the differences. The measurements also apply specifically to Medicare fee-for-service beneficiaries.
Financial and operational warning signs
Financial measures deteriorated more sharply among hospitals that later closed. For rural hospitals closing from 2014 through 2017, the median total facility margin fell from -3.3% in 2012 to -13.8% in the year before closure. For open rural hospitals, the median total facility margin fell from 3.0% in 2012 to 1.9% in 2017.
The share of rural hospitals classified at high or mid-high risk of financial distress rose from 24% in 2015 to 26.2% in 2019. Rural hospital closures during 2013–2017 eliminated 2,066 inpatient beds and 6,347 full-time-equivalent positions.
The hospitals that closed were not necessarily the smallest by inpatient-bed count. For rural hospitals closing from 2014 through 2017, the median number of inpatient beds was 30 in the year before closure, compared with 25 in open rural hospitals in 2017. Staffing was lower, however: the median number of full-time employees was 96 in the year before closure, compared with 179 in open rural hospitals in 2017.
Medicare was also a major revenue source. In 2016, it accounted for approximately 46% of rural hospitals’ gross patient revenue, compared with approximately 43% for urban hospitals. This revenue comparison, like the closure counts and financial margins, is a historical measure for the stated year and should not be treated as a current estimate.