Share (%) of Rural Hospital Closures by Census Region for each Decade between 1990 and 2020: Rural Hospital Closures Became Concentrated in the South (Source:

Over the past four decades, rural hospitals that have closed were more likely to come from counties that were neighboring metropolitan counties, had higher shares of Black and Hispanic residents, and were located in the South, a new study has found.

The report from the North Carolina Rural Health Research Program looked at the closure of 334 hospital closures in rural communities between 1990 and 2020 to analyze for the first time the characteristics of the rural communities where hospitals have closed, and to see if the communities that saw their hospitals close in the 1990s differ from those where rural hospitals have closed today.

Looking at the socio-economic, demographic, and health system characteristics for rural counties, the study found that between 2010 and 2020, rural counties where hospitals closed were located next to metropolitan areas, and were more likely to be in the South compared to prior decades. Those counties were also more likely to have higher-than median levels of income inequality, lower per capita income, and higher unemployment rates.

Nationally, the states that saw the most closures were Texas with 39, Minnesota with 22, Tennessee with 20, and California with 18.

The study also found that counties where closures had happened had increasing shares of Black and Hispanic residents. For counties with closures between 2010 and 2020, the median share of Black residents was higher compared to prior decades. But, the study showed, those counties also had growing Black populations.

“This pattern is partly explained by (1) the disproportionate clustering of rural hospital closures in the U.S. South region after 2010 where most states have not expanded Medicaid post-(Affordable Care Act) and (2) the growing concentration of closures in rural counties that neighbor metro counties,” the study found. “Simply, the U.S. South, where most rural hospital closures in the past 31 years occurred, is also home to over half of Black people in the U.S.”

However, as Arrianna Marie Planey, with the North Carolina Rural Health Research and Policy Analysis Center noted, the increase in Black populations is not a cause for the increase in rural hospital closures. 

“We do not imply causality, but we are highlighting the racially and ethnically disparate impact of rural hospital closures, which have increasingly occurred in rural counties neighboring urban areas,” she said in an email interview. 

“Basically, since 1990, rural hospital closures have increasingly affected rural people of color. Addressing rural hospital closures would also mean addressing racial and ethnic disparities in access to healthcare in rural areas.”

The study also found that counties with closures had a higher unemployment rate – 10.2% between 2010 and 2020; a lower median income – $44,360; and a higher poverty rate – 16.9%. And counties with closures were more likely to be in a healthcare provider shortage area.

The study highlighted the increased need for rural hospitals to stay open, Planey said. 

“In terms of policy, this speaks to the importance of policies that address the higher burdens of uncompensated care borne by rural hospitals,” she said. 

“We know that these hospitals are more likely to experience financial distress, and we know that they serve patients who are older, have more comorbid, chronic conditions and are more likely to have public insurance [Medicaid and Medicare].”

What the study also shows, said Brock Slabach, COO of the National Rural Health Association, is that rural hospital closures have a bigger impact on their communities.

“When you look at the health equity issues around rural hospital closures that report does an excellent job, I think, of documenting what we knew to be true and that is that hospital closures are existing within our communities that need them the most,” he said.

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