This reporting is done in partnership with The Texas Newsroom—a collaboration among Texas public radio stations and NPR—and is funded in part by PBS FRONTLINE’s Local Journalism Initiative, with support from the Knight Foundation and the Corporation for Public Broadcasting.
As the COVID-19 pandemic strained health care systems around the world, rural hospitals in the U.S. were not exempt from the wrath of the virus and its widespread impacts.
In 2020, the U.S. experienced the highest number of rural hospital closures in more than a decade, with at least 19 facilities across a dozen states shutting down or converting into smaller, less comprehensive forms of health care with no inpatient unit.
But the shutdown of hospitals in these areas is not a new phenomenon. Policymakers first began noticing this trend in the 1980s, after new regulations put rural hospitals in more difficult financial situations. Closures stabilized for a period in the late 1990s, but have once again been on the rise since the recession of 2008-2009.
In the last decade, at least 135 rural hospitals across the U.S. have closed, leaving communities often already lacking in quality health care with one less resource when in need of help.
Hospital closures and emergency medical services
The closure of rural hospitals has been especially prevalent in the South, where residents are generally poorer and uninsured rates higher. Texas in particular has been hit hard by closures. Since 2005, the state has seen 24 of its rural hospitals close, the highest number in the nation.
At the same time, Texas has the highest uninsured rate among all states, with 1 in 5 residents living without insurance—more than double the national average rate of 9.9%. In terms of number of hospital beds lost, Texas again outranks all other states. Compared to the more populous state of California, Texas lost nearly 2.6 as many beds from 2005 until now.
The state of health care is even more concerning for certain counties in Texas. Rural hospital closures since 2005 have predominantly been occurring in east Texas, and have left some counties with no hospital at all to serve the community.
In total, 28% of counties in Texas have no hospital. The lack of a comprehensive medical facility in these areas, especially during a public health crisis like the COVID-19 pandemic, means that residents will often have to travel far distances to seek care. This can cause great difficulties, especially for the most vulnerable populations, such as the elderly who are not able to drive or those who need emergency care when the only ambulance in town isn’t available.
When the Van Zandt Regional Medical Center closed its doors in August 2019, it left a county of more than 55,000 people without a hospital. According to its Facebook page, the facility was forced to shut down due to Medicare cutbacks and low reimbursements from insurance companies. Half a year later when the COVID-19 pandemic shocked health care systems across the U.S., Van Zandt was one of the many counties in Texas facing the crisis without an inpatient unit to care for the critically ill.
In April 2021, Texas Tech Public Media reported that the hospital was in the process of reopening. The hospital is now registered under the Texas Health and Human Services as a specialty hospital, meaning it provides a limited range of services.
Jones County is in a similar situation after losing two hospitals within one year. Twelve months after the closure of the Stamford Memorial Hospital in July 2018, the Hamlin Memorial Hospital also shut its doors, leaving the county with no hospital to serve the community.
Some counties have it even worse—not only do they lack hospitals but also ambulances and other emergency health service (EMS) stations that can provide out-of-hospital acute care and transport to definitive care. For these regions, options are few and far between when it comes to medical emergencies.
Challenges with Medicare and Medicaid
The recent increase in rural hospital closures across the country is tied to multiple contributing factors, including the failure to recover from the recession, changing demographics in rural areas and struggles with funding, particularly in terms of Medicare and Medicaid reimbursements.
Since rural populations are more likely to rely on public insurance, the financial viability of rural hospitals is largely dependent on payments from these government programs. The problem is, Medicare and Medicaid reimburse at a lower rate than the cost of providing care, leaving rural hospitals with negative margins. Reductions and shifts in government funds have led to further cutbacks, such as the Budget Control Act of 2011 that led to a 2% reduction in all Medicare and Medicaid payments to hospitals, doctors and providers.
Yet abandoning the Medicare and Medicaid system doesn’t seem to be the solution either. In fact, data shows that states that did not expand Medicaid coverage under the Affordable Care Act have higher rates of uninsured patients, higher rates of unrecoverable debt and charity care, and more hospital closures.
Texas is one of the 12 states that have not adopted the expansion. It is also the state with the highest uninsured rates and the most hospital closures. In the Panhandle region, which includes the 26 northernmost counties in the state, more than half of the counties have uninsured rates of more than 25% and ten have no hospitals. In the Rio Grande Valley region, where uninsured rates are among the highest not only in the state but in the entire nation, residents struggle to access adequate care due to the lack of public hospitals (most in the area are private) and fear of deportation.
Population change and hospital closures
Population decline is another driver of hospital closures in rural areas. Not only does a shrinking population lead to lower patient volume—and therefore lower revenue for hospitals—but also workforce shortages. Rural hospitals already struggle with the recruitment and retention of health care professionals, so the movement of potential skilled workers out of these areas only exacerbates staffing challenges.
In Texas, 72 counties have experienced population decline since the start of the century; 44% of these counties have no open hospitals to support their residents. On the other hand, among the 140 Texas counties that have experienced population growth, less than one-fifth have no open hospitals.
When looking at where recent rural hospital closures occurred, the trend is less obvious. This may be because counties with declining populations are already more likely to have no hospitals in the area, and also because population shifts at the city and town levels could more directly impact the status of a rural hospital.
For instance, Montague County, where Bowie is located, has seen its population grow 3.7% from 2000 to 2019. But the population of Bowie has actually been on a downward trend, dropping nearly 10% from the beginning of the century to 2015, when the city’s only hospital closed for the first time.
In the case of Stamford, which is located on the border of Jones and Haskell Counties, population fell 19% in the city from 2000 to 2018, the year Stamford Memorial Hospital closed. The counties it is located in also experienced population declines, although less extreme—around 3% for Jones and 7% for Haskell.
The critical shortage of health professionals
Across the country, communities are being affected by a shortage of health professionals, including primary care physicians, registered nurses, mental health professionals and more. By 2032, the U.S. will face a shortage of up to 122,000 physicians, according to the American Hospital Association. The need for nurses is even more dire—the country will have to hire at least 200,000 nurses per year to meet increased demand and replace retirees.
The federal government’s Health Resources and Services Administration classifies areas with fewer than one primary care provider for every 3,500 residents as Health Professional Shortage Areas (HPSA). Based on these guidelines, as of July 2021, 95% of U.S. counties had communities that are considered shortage areas. When looking at instances where the entire county is a shortage area, the proportion remains a majority, at 60%. Among nonmetropolitan counties, the proportion is even higher—68% of counties are entirely HPSAs.
As is the case for its hospital closures and uninsured rates, Texas stands out when it comes to the prevalence of its HPSAs. Only five Texas counties—four of which are metropolitan—have a sufficient number of primary care physicians for their populations based on the federal guideline. A stunning 82% of Texas counties are entirely shortage areas, meaning there is fewer than one primary care physician for every 3,500 residents in the county. The situation in Texas has worsened since 2019—99 more counties identify as primary care provider shortage areas this year than did so two years ago.
Workforce shortage has been documented as a major cause of hospital closures, especially in rural areas. According to the American Hospital Association, fewer than 10% of U.S. physicians practice in rural communities even though almost one-fifth of the national population lives in those areas. In Texas, 21 out of its 24 rural hospital closures since 2005 were located in counties that are entirely shortage areas in 2021.
The COVID-19 pandemic has likely exacerbated the already desperate situation. As a result of stress, trauma and burnout, many health care workers have been struggling to continue to do their job. A recent Washington Post-Kaiser Family Foundation survey found that nearly 30% of health care workers are considering leaving their profession and 60% said the pandemic had a negative impact on their mental health. Among registered nurses, the nationwide turnover rate has already been on the rise, climbing to 18.7% in 2020—nearly 3 percentage points higher than the previous year’s rate.
Even relatively early in the pandemic, in August, 2020, the Texas Department of Health estimated a statewide shortage of 29,000 registered nurses and 64,000 physicians, leaving one in every 10 of each positions unfilled. Further, the department projected that these shortages would only worsen over the next 12 years such that the state could be facing a 16% shortage of registered nurses and a 13% shortage of physicians by the year 2032.
Funding health care through hospital districts
Hospital districts are geographic regions in which residents pay to fund a local hospital, typically through property or sales taxes. These districts can provide communities with a recurring health care funding mechanism for its poorest populations, especially for those who are underinsured or without health insurance.
Voters in the area hold the power to both create and dissolve their local hospital districts. Creating a district generally springs from a community’s desire for better access to health care, while opposition tends to stem from residents’ reluctance to raise taxes. In 2015, Bowie Memorial Hospital in Montague County closed after residents voted down an effort to create a hospital district that would have raised taxes by 17 cents per $100 of home value, or $170 per year on a $100,000 home.
But hospital districts do not always guarantee financial stability for the facilities they support. In some cases hospitals in these districts have closed—like Hamlin Memorial Hospital in the Hamlin Hospital District—but taxes continue to be collected.
The APM Research Lab identified 140 hospital districts that submitted property tax records to the Texas Comptroller of Public Accounts as of 2020. The borders of many hospital districts align with county boundaries, though this is not always the case. Some counties have multiple hospital districts—Jones County, for instance, has three—while other hospital districts may cross county lines, like Big Bend Regional Hospital District.
While Texas’ hospital districts offer a unique approach to funding health care, little research appears to exist on their efficacy. Hospital districts operate in roughly half of all states, though none have as many as Texas. Use of these districts by other states does not appear to have grown in recent years. However, 38 states and the District of Columbia have opted to increase funding for low-income health care through Medicaid expansion, an approach that Texas has not adopted.
The future of rural hospitals in Texas and across the U.S. remains uncertain. In March, President Joe Biden signed a $1.9 trillion COVID-19 package that includes $8.5 billion for rural hospitals. Reps. Tom Reed (R-NY) and Terri Sewell (D-AL) also recently introduced the Rural Hospital Support Act, which may help level the playing field for hospitals in small and isolated communities in comparison to their larger counterparts.
In the meantime, rural hospitals are doing what they can to serve their communities.
*Corrections: Earlier versions of this report stated that 84 Texas counties have no hospitals. In fact, the figure is 71. We have updated three maps and some associated text to accurately reflect the number of counties with and without hospitals in Texas according to the state’s official records.”
For more on health care issues facing rural Texas, see the Texas Newsroom’s work featured on FRONTLINE: Rural Health Care: The Other Texas Drought.