By on 4.30.24 in Health & Environment, NC in Focus

Since 2010, there have been 149 closures of rural hospitals across the US. These closures have taken place in 34 of the 50 states. Eight of these closures took place in North Carolina.  

What is a rural hospital? 

The NC Rural Health Research Program at the Shep Center for Health Services Research at UNC Chapel Hill defines a rural hospital as a hospital that meets the following criteria: 

  • A Critical Access Hospital, or 
  • A Rural Emergency Hospital, or 
  • Any short-term general acute, non-federal hospital that is located in: 
    • any non-metro county, 
    • metro census tracts with RUCA codes 4-10, or 
    • large area Metro census tracts of at least 400 sq. miles in area with population density of 35 or less per sq. mile with RUCA codes 2-3 
    • Beginning with Fiscal Year 2022 Rural Health Grants, we consider all outlying metro counties without an Urbanized Area to be rural.  

What is a closed rural hospital? 

The NC Rural Health Research Program offers a detailed description of what they include in the definition of the term “closed rural hospital.” In short, they describe the closure as A facility that stopped providing general, short-term, acute inpatient care [….]”  The complete definition is available on their website. 

Why do rural hospitals close? 

Underlying causes of rural hospital closures vary, but notable community-level factors include worsening economic inequality and financial dependence on Medicare and Medicaid payments.  

The demographics of where hospitals close

Arianna Marie Planey is a Faculty Fellow at the Carolina Population Center and an Assistant Professor in the Department of Health Policy and Management. In a recent study, Planey and other members of the NC Rural Health Research Program found that rural US counties where hospitals closed had higher shares of Black and Hispanic residents, over the time period 2010-2020. These counties also had lower per-capita income and higher unemployment rates compared to the median rural county.  

Five of the eight NC counties that have had rural hospital closures since 2010 have higher shares of Black residents than the rural county average of 20%. Franklin and Yadkin counties have higher shares of Hispanic residents than the rural county average of 7%. Half of the counties in North Carolina that experienced rural hospital closures since 2010 have lower median household incomes than the rural county median in North Carolina of $54,435.

Other work by Planey et al. finds that between 2007-2018, residents in 49% of rural census tracts experienced worsened spatial access to their nearest hospital. This means that populations in these census tracts had longer travel times to the nearest acute care hospital than populations in counties that did not experience a closure. It also means that rural places with longer distances at baseline (2007) experienced increases in travel times to access their nearest hospital. 

Persistence of primary care shortages areas

In addition to rural hospital closures, several communities in NC have been designated as primary care shortage areas. Washington, Tyrell and Northampton Counties have been experiencing a primary care desert for the last 40 years according to an analysis conducted by KFF Health News using US Health Resources and Services Administration (HRSA) Data.

A primary care desert is defined as an area of the nation that has fewer than 1 physician for every 3,500 residents. Planey et al. find closure counties were more likely to be primary care health professional shortage areas (HPSAs). Other research has shown that rural hospital closures exacerbate health care provider shortages in the short run (up to 6 years). 

Northampton, Washington and Tyrell counties are all classified as rural counties and have among the highest concentrations of Black residents in the state. Black residents make up 54% of Northampton County, 48% of residents in Washington County and 33% of residents in Tyrell County.  

The persistence of primary care deserts in Northampton, Washington and Tyrell counties can be attributed to a combination of various factors. Many of the counties that have experienced closures or primary care deserts have populations that are aging faster than the state and are projected to decline At the same time, fewer residents of these counties are obtaining medical training. In order to make healthcare more accessible in rural counties, federal programs have been designed to incentivize health care professionals to practice in these areas.  

A recent analysis in KFF Health News by Rae Ellen Bichell found that many federal designations aimed to boost primary care capacity have not yet helped make care more accessible.

Federal funding currently supports 18,000 primary care doctors, nurse practitioners, and physician assistants to provide care in rural and urban communities. This incentivizes health professionals to practice in communities that need providers. Most physicians who benefit from federal funding stay beyond their obligation of several years, but not necessarily forever. Others leave and don’t return.

Looking forward

In addition, Medicaid has recently expanded in North Carolina to adults ages 19-64 to coverage for singles earning about $1,730 a month and families earning $2,970 a month. This may increase access for individuals in counties with health professional shortages. 

With the Medicaid expansion and incentives for healthcare providers, it's possible that trends will change. We will continue to monitor these datasets and will share updates as they emerge.

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