Reimagining and reinvesting in rural hospital markets

摘要

A key issue facing the United States is how to structure rural health care delivery. In research and policy discussions of this challenge, a core focus has been the appropriate role for rural hospitals. In rural areas, hospitals face structural barriers to delivering care: low patient volumes limit revenues and drive up the cost of care delivery, leading to closure and undermining surviving hospitals' capacity to provide high-quality care.1 Yet, losing access to hospital care can be detrimental to the health of local residents.2-4 Rural hospitals also provide important services in times of crisis, most recently during the COVID-19 pandemic, when there is an influx of patient needs.5-7 These issues raise two core questions about rural health care. First, what hospital infrastructure is needed in rural areas? While decreased access to care can lead to treatment delay, not all rural hospitals can safely provide the full suite of health care services. Some rural residents may benefit from a health care system that facilitates referral to care outside the community, limiting local care delivery. Second, how should rural hospital care be financed? Low patient volumes make rural hospital services inherently expensive, given the high fixed costs of care provision. Considering when increased financing is warranted and what form additional financing should take is also an essential component of policy discussion. In this commentary, we discuss major issues facing rural hospitals and outline possible roles for public policy in restructuring rural hospital care. While hospital services are an important component of rural health care, there are many determinants of rural health. As rural hospitals are considered in research and policy debates, attention should expand beyond hospital services to imagine how the broader health care and public health infrastructure can support rural health. A core challenge in rural communities is declining access to hospital care. Eight percent of rural hospitals have closed over the last decade, and closure rates have increased in recent years.8 Even hospitals that remain open are downsizing and closing individual service lines. Only 40% of rural counties had obstetric services in 2018, for example, down from 55% in 2004 and 75% in the 1980s.9, 10 Among rural communities, reductions in access have not been not equally distributed.11 Since 2010, rural counties with hospital closures have had above-median shares of racialized residents, including Black and Hispanic people.12 Similarly, obstetric unit closures have disproportionately affected rural communities with a higher proportion of Black residents, those in more remote areas, and in states with less generous state Medicaid programs.13, 14 Promoting access to care in areas with low population density is inherently challenging. Even with recent closure trends, rural hospitals have more unoccupied beds than urban hospitals, suggesting little strain on aggregate availability.15 However, travel distances to access hospital care in rural areas can be substantial. Thus, a challenge in rural areas is that hospital beds may be oversupplied at the market level but undersupplied in local communities that face heavy travel burdens. Importantly, access to hospital beds does not necessarily guarantee access to adequate care. Work by Hegland et al. in this issue shows that rural hospital markets have more bed capacity per capita and lower occupancy rates than urban areas but less access to other hospital resources such as capital funding and staffing.16 Hospital closures are concerning, in part, because of the potential effects on patient health. On the one hand, hospital closure decreases access to care and increases travel times, raising concerns about adverse health outcomes for patients with time-sensitive conditions. This may be exacerbated for Black or Latinx residents, who face additional barriers to access, such as longer travel distances and the higher likelih