Rural hospitals: Give up inpatient care for federal stipend?

The U.S. is a very large country. There are vast expanses of countryside – farm, prairie, mountain, coast – with low population density and small towns. The people depend on rural hospitals because they may be many hours away from large city hospitals.

Rural hospitals are part of the Macro economy. When rural hospitals close, it is medically and economically devastating for communities. They have supported one in every 12 rural jobs and contributed to about $220 billion in economic activity per year, according to the American Hospital Association. A community’s population typically shrinks soon thereafter.

Over 600 rural hospitals — 30 percent of the total — are at risk of shuttering. In 10 states, at least 40 percent of rural hospitals are in danger of closing.

A Rural Hospital’s Excruciating Choice: $3.2 Million a Year or Inpatient Care?

A new federal program offers hefty payments to small hospitals at risk of closing. But it comes with a bewildering requirement.
By Emily Baumgaertner, The New York Times, Dec. 9, 2022

For 46 million Americans, rural hospitals are a lifeline, yet an increasing number of them are closing. The federal government is trying to resuscitate them with a new program that offers a huge infusion of cash to ease their financial strain. But it comes with a bewildering condition: They must end all inpatient care.

The program, which invites more than 1,700 small institutions to become federally designated “rural emergency hospitals,” would inject monthly payments amounting to more than $3 million a year into each of their budgets, a game-changing total for many that would not only keep them open but allow them to expand services and staff. In return, they must commit to discharging or transferring their patients to bigger hospitals within 24 hours.

The government’s reasoning is simple: Many rural hospitals can no longer afford to offer inpatient care. A rural closure is often preceded by a decline in volume, according to a congressional report, and empty beds can drain the hospital’s ability to provide outpatient services that the community needs…But bigger hospitals — bogged down with Covid surges, pediatric R.S.V. patients and their own financial woes — are increasingly unwilling to accept transferred patients, particularly from small field hospitals unaffiliated with their own systems…[end quote]

This is an issue on the remote north Olympic Peninsula where I live in a small town about 45 minutes away from a rural hospital that has inpatient beds. People I know have had less than stellar experiences at this hospital so I traveled to Seattle (2.5 hours each way) for my cancer care. (Thanks to DH who drove many times.) But I would not want to see the local rural hospital give up inpatient care for the many patients who can’t travel.

When a rural hospital is losing money, especially from inpatient care, what is the answer?



Socialised healthcare is a nice solution. Governments can run healthcare at a loss in rural areas to ensure that large areas of the country remain viable/attractive to live in. A subsidy from cities to the countryside, certainly. It works in many European countries, at least. Standardising staff wages nationally (which is often seen with socialised care) + living cost adjustment, has the effect of allowing people who enjoy the country to work there, and people who enjoy cities to work there, rather than see the biggest and best hospitals push salaries up to levels that small hospitals can never keep up with. Winner takes all dynamics are not good in geographically distributed healthcare systems.


It is uneconomic for the power company to run copper lines all the way out to farmland with its low population densities, but we did it with the rural electrification act during FDR’s term. It was just as uneconomic for telephone companies to run wires to unpopulated areas to connect the last few people without service, but the Rural Telecommunications Act of 1934 empowered the FCC to require larger companies to serve everyone.

There are small airports which are not economic, and which would close down if it was not for the Essential Air Service, which subsidies outlying airports and allows people in less populated areas to have some air transportation available.

It is more expensive to provide highways and other infrastructure services over a small population than a large one on a per capita basis, yet we do it because we believe that everyone should be included.

And the thanks we get are that rural inhabitants are far more likely to complain about government, government spending, and things which benefit others, all the while championing the virtues of self-reliance even as they depend on so many others for their lifestyles.

Rural hospitals? Let them close. Make their telephone service and electricity bills reflect the true cost of service. Close the airports which can’t support themselves. Don’t offer government aid when a tornado sweeps through, don’t have FEMA set up trailers for them after a flood, Give them only the schools and resources they pay for out of pocket.

Then hand them all a copy of “Atlas Shrugged” and say “have a nice life”. I’m tired of the caterwauling.


The rural areas produce the food that the metropolitan areas consume. If you make the rural areas unpleasant to live in, who will produce the food supply?


Sorry for changing the subject from hospitals to food supply but the U.S.D.A. data shows that small family farms are 90% of all farms and use half of farm land but produce only one fifth of farm products. While large family farms and corporate (“nonfamily”) farms occupy about 1/20 of the number of farms and about 1/3 of farmland but produce 58% of farm product value.

@Goofyhoofy described how America has generously provided many valuable services to rural areas that they could not possibly have paid for themselves. Then he shifted into political gear (a reflex for that gentleman) and explained how all services should be withdrawn from them because he doesn’t like their lack of gratitude.

Back to the original topic, couldn’t hospitals be considered at least as vital a service as roads and airports?


Actually, I can see the efficiency in small hospitals being ER only, stabilize the patient, then transport to a large hospital for warehousing.

When I first retired, I considered moving to less congested areas. I started comparing ACA plans by city. Grand Rapids was almost as cheap as metro Detroit, but coverage in Kalamazoo or Allegan was significantly more expensive. Allegan is dinky, but Kalamazoo County is home to some 260,000 people, with two hospitals. You would not think Kalamazoo was “rural”, but evidence says, using either of them costs a lot more than hospitals in metro Detroit.

So, that was one more reason to stay here. As luck would have it, my doc is employed by Beaumont Hospital, so I have been registered on their patient web site for years. When the covid vax became available, Beaumont announced that they would be selecting eligible people from among those registered on their web site to be invited in for a jab. So many people tried to register, they crashed the site. Being already registered, I sat back. A few days later, I received an e-mail that, if I wanted to be eligible for the jab, confirm my contact info on the web site, which I did, A few weeks later, I received an e-mail invite to make an appointment. No huge line. No travel to the far side of the moon for a jab (my neighbors drove to somewhere in Ohio). “Big hospital” took good care of me.



Lots of things “could be”–but should be is a different analysis.

If “pay for what you use” is a supposedly valid claim, then a LOT of stuff would NOT exist much further than a moderate distance from any reasonably-sized city or town. Lots of stuff people expect to have would be available the same way the Pony Express functioned–at a range of about one oasis every set distance, defined as hours of travel that is a reasonable driving distance until a traveler might want/need a stop. That is why there are so many essentially “ghost towns” in the US–they were bypassed by more modern transportation because they were no longer needed as a stopping point in travel.

Most small farmers’ existences are VERY dependent on larger cities (not vice versa) because the smaller farms tend to specialize in products aimed at a niche market (organic, kosher, etc)–which really only exists in a large/major distribution system. People who seek those products can be found in a sufficient quantity in large markets to justify the farms’ multiple market niches/specializations.


Right on target, Goofyhoofy. I agree 100%. Wish i had more recs.

Part of the problem with supporting rural hospitals is declining population. Lower birth rate and mechanized farming have greatly reduced population. In rural Missouri typical population density was 30/sq mi in 1900 in the day of the horse. In 2010 some counties were down to 8/sq mi. And as baby boomers die we seem headed for 2/sq mi.

Part of the problem is physicians who specialize and prefer to serve in cities. Public health service could offer scholarships in return for agreement to serve in rural areas for x years.

Worst case is public health medical schools to train more doctors.

Lack of insurance for the poor is also a problem. We need some form of universal health care. It will better fund rural hospitals.


This is already happening. Some rural areas will fund med school for a doctor who will commit a certain number of years to serving that area.


Ever watch “Northern Exposure”? That was exactly the scenario, Jewish guy from NYC has his med school funded by the state of Alaska, in return for him being the GP in a small town.


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Right on target, Goofyhoofy and Paul.

Having lived for decades on the lightly populated (2020 census ~24,000) south Oregon Coast, we saw first hand the difficulties of doctor recruitment/retention: (1) when a Physician has a spouse who expects to have professional employment and; (2) when a couple also expect to have modern educational opportunities available for their children.

It is complicated…

Curry County, Oregon’s South Coast

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A childhood friend of mine wound up doing something that, only I’m pretty certain it was a federal thing. He practiced in rural Utah and Colorado. He split his time between different small towns out in the boonies.


We are going through this already in Missouri. Audrain County recently lost their hospital in the county seat, Mexico, MO. Now patients must drive 60 miles or so to Columbia or Hannibal.

If you are expecting a baby, can you wait that long? Or do you give birth at home? Or move to one of those cities close to your due date?

I can’t believe this is adequate health care for new mothers or their babies.

And yes, in an emergency they can call an air ambulance. Fees can be high. And insurance coverage iffy. For a baby delivery, doubtful.

Used to watch it regularly.

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They are.

The issue is not removing the hospitals. The issue is funding them.

Bringing down the cost and improving the care is to transport in patients to larger complexes for treatment.

Treatments these days means machinery. That is expensive for only a few rural patients. Also we are discussing in essences a myriad of medical problems. Plus it means specialists who are not necessarily in rural places. Plus it means techs who are not necessarily in rural areas.

In patient treatments no longer mean in bed on the ward with little done for you.

It also means rehabilitation and physical therapy which may not be available in rural areas.

In other words in patient treatment in rural areas may be dismal. Malpractice not to send people to urban or suburban centers for care.

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It doesn’t matter who owns the land. It takes people to manage and run them. These people need the rural hospitals/services.

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3.2 million dollars doesn’t seem like that much money to me for a hospital. But then again the long term care of patients is what really hurts profits. Patients who come into the hospital for a few days usually don’t eat up a hospitals resources like a sick patient who is in the hospital for a month. Also, the way insurance is set up, the longer a patient is in the hospital, the lower the hospital profits on the payments…doc

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Actually, it matters a lot. Corporations are able to hire people to work on the land the business owns. So providing health care to employees is a cost the corporation carries–or else they do not have good employees. The good employees get hired away and go elsewhere because health care is something of significant value to them.

Small farms can not afford to hire many workers because they only profit by having the small farm owner do a major share of the work and then get paid via farm profits–if any.

Well, no.

I agree entirely for the patients who need high-level care: urgent cardiac catheterization/angioplasty; high-risk OB; chemotherapy; emergent neurosurgery.

But a lot of community hospitalizations fall short of this.

Grandpa’s COPD flares. Two days of IV antibiotics, respiratory treatments, general tuneup and home.

Great-grandma is acutely confused. Ooops, she has a UTI. IV antibiotics, careful hydration and nursing, home (or previous care facility) by Monday afternoon.

Hunter Bob is brought in because he got lost/ran out of gas and is modestly hypothermic. Or, maybe he veered into a ditch, rolled his truck, hit his head. Overnight and home.

Dad has chest pain after shoveling snow. EKG and labs in ER are equivocal. Overnight monitoring and re-check labs; probably home in the morning with a cardiologist evaluation next week.

Teenage Tom does something stupid involving alcohol/drugs/his truck and fortunately needs only overnight observation and not ICU care while he comes down.

Sarah didn’t take her seizure meds, again, and spent too long outdoors until she was picked up. IV fluids for the kidneys, get seizure meds back on board, home in 48 hours

Aunt Edith got her chemo in the big city Wednesday, and is due back next Wednesday. It’s no Friday night and it’s snowing hard. She has a low-grade temp and feels rotten. She might well need a 100-mile transport back to the major medical center…or, she might not. Or, the roads might not be open, and the helicopter grounded.

You get the idea.

A country as rich as ours should be able to provide adequate rural health care for its people.

And, as far as the “I’m sick of their whining”…well, me too. (See my previous rants re: overheard conversations at the Redneck Cafe) (Kidding! Those were before the Great Purge)

But seriously: as a smarter, better man than I once said, “We are not enemies, but friends. We must not be enemies. Though passion may have strained, it must not break our bonds of affection.”

who is not a fan of his species’ susceptibility to propaganda. Even the ones of average intelligence


The comment is about the need for rural services. It doesn’t matter who you are working for, yourself on a family farm or a corporate farm. The need for rural services is there.