30% of All Rural Hospitals in the US Are at Risk of Closing [pdf]
ruralhospitals.chqpr.org
ruralhospitals.chqpr.org
Politics matters. Voters in rural areas (generally, of course) have consistently voted against policies that would help support health care in these rural locations, such voting in politicians who are staunchly against Obamacare, who refuse any expansion or even adequate support for Medicaid, and who enact policies that put doctors at risk of prison for doing their jobs. Just look at all the recent news coverage of all the maternity wards in Idaho that are closing because Obgyns don't want to work there anymore.
Sorry, my empathy at this point is fully tapped out for people who delight in cutting off their nose to spite their face.
https://www.kff.org/health-costs/issue-brief/rural-hospitals...
> Among rural hospitals in non-expansion states, median operating margins were 2.1 percent during the July 2021-June 2022 period and were -0.7 percent when excluding documented relief funds. In Medicaid expansion states, median operating margins dropped, but remained positive even after excluding documented relief funds.
So in rural areas where you have more people in poverty, if they had health insurance hospitals would be better able to actually collect payment for the legally required services they provide.
https://www.aha.org/fact-sheets/2020-01-06-fact-sheet-uncomp...
https://www.hhs.gov/about/news/2022/08/02/new-hhs-report-sho...
I don't know what you mean by "limited coverage". There is no such thing as unlimited coverage in any country. The Affordable Care Act does set a baseline for what all insurance plans must cover.
(Sarcasm, of course, every single problem in the USA comes neatly down on political lines and one side is perfectly good and the other objectively evil).
To them, the system is working as intended. They're cleaning out the moochers and welfare queens. But by the time they notice they need those services as they get older, it's already too late to do anything about it. Everyone they know then ostracizes them and they end up being the new moral failure of the community.
...until it's them. If you really want to rile up an old white rural dude with a Trump placard on their lawn, threaten to take away their healthcare subsidies. Or really any other kind, and for most farmers that's a long list. Then the sparks will really start to fly. They believe that government assistance is a God-given right for "salt of the earth" like themselves, but an absolute crime for those "other people" in the cities. It's not hard to see the subtext, even when they're not consciously aware of it themselves.
I had some family members similar to this, and that was their actual thinking. "God will handle it. Our church always helps its folks". 30 years later... well.. pastor's changed, the focus is always on the younger families with kids and... my relatives, now in their 70s... just don't go to their church of 30+ years because "we don't feel all that welcome any more". So... their plans for church fundraisers is essentially off the table now.
But it took them 30 years to realize this, and they'd consistently voted against their future selves all that time. And I won't even say they "realize" anything profound or deep here. They've not switched party allegiance. Trump will still save them. ugh...
Thankfully they're fine and don't rely on the church. But it, again, reiterates how much so much of it is viewed as a moral failure. And how much our nation loves punishment more than we love support.
Sorry your grandparents had to deal with that.
From the article "The biggest problem facing small rural hospitals is inadequate payments from private health plans. Most “solutions” for rural hospitals have focused on increasing Medicare or Medicaid payments or expanding Medicaid eligibility due to a mistaken belief that most rural patients are insured by Medicare and Medicaid or are uninsured. In reality, about half of the services at the average rural hospital are delivered to patients with private insurance (both employer-sponsored insurance and Medicare Advantage plans). In most cases, the amounts these private plans pay, not Medicare or Medicaid payments, determine whether a rural hospital will have to close".
Why should the burden of keeping small rural hospitals open fall entirely on private health plans? Perhaps hospitals should advocate for higher Medicare reimbursement rates.
Because that's how the majority of Americans get their healthcare? I assume that's the case, but I don't actually know - as mentioned there are multiple single-payer health plans (lol) that cover those we have deemed worthy of them. The paper linked says that rural hospitals need to bill higher because their unit costs to deliver healthcare are higher (which makes basic economic sense). Therefore it would seem like the market solution would be to charge people who live in rural areas more for healthcare/insurance.
I can never tell whether the US is a nation or an economy.
If 50% are private insurance, what are the other 50%? Wouldn't that other half influence whether the hospital has to close?
Representatives from these red rural areas. It's a different big cat that's eating your face, if that makes you feel better.
For example, 41% of rural hospitals in New York are at risk of closing, similar to the 38% in Florida, and a lot more than the 18% in Kentucky. Solid blue Washington is at 33%, worse than Iowa or Indians at 24 and 21%. Idaho, which you call out specifically, is only at 7%.
It’s quite interesting that your first reaction was to demonize rural voters for political choices, in the absence of any data supporting that assumption.
Irving, NY - Chautauqua County - Trump
Fulton, NY - Oswego County - Trump
Ticonderoga, NY - Essex County - Clinton
Amsterdam, NY - Montgomery County - Trump
Sidney, NY - Delaware County - Trump
- https://www.shepscenter.unc.edu/programs-projects/rural-heal...
- https://www.nytimes.com/elections/2016/results/president
Voting against Medicare or Obamacare aren't the only ways to vote against healthcare reform, as OP states:
> Politics matters. Voters in rural areas (generally, of course) have consistently voted against policies that would help support health care in these rural locations
Healthcare is handled at the federal and state levels, not the county level. Thus, rural areas in blue states like New York should be doing better than ones in red states like Florida. They all voted against these policies that supposedly would have helped them—but in Florida they were successful in opposing them while in New York they were overruled by urban areas and got those policies anyway.
There is no group of people in the US more subsidized by the government than the rural dweller. Both through direct and indirect subsidies.
Rural voters receive massive agricultural subsidies, they receive significant tax breaks, almost all their infrastructure, from roads, to internet, to the mail, is nearly entirely paid by the federal government with little support from local federal taxes because their tax base is so weak.
But then there’s also the indirect subsidies, such as the U.S. preventing the import of a whole lot of fruits, eve tables and meats altogether, and the ones they do, they do with high import taxes, or the US promoting the sale of rural products both domestically (USDA’s primary goal) and through international trade deals.
But rural voters actually believe, despite all the evidence to the contrary, that they are not the recipients but rather the donors of wealth to the rest of the country, particularly the urban parts. Most other Western countries’ rural areas have no such misgivings, so I suspect it’s a result of them looking at themselves as the archetype US cowboy who pulled himself up by his bootstraps, with no help, etc etc.
So you have this strange situation where the rural voter votes for the party that promises to reduce taxes thinking that they will benefit, since they believe they pay more than they receive, but in reality they are shortchanging themselves.
This worked for a while. The richest enjoyed the real tax cuts, while the rural folks got minor cuts, but nonetheless they didn’t see any downsides, because the roads, hospitals, internet had already been built. Maybe it had a few more potholes than before, and you needed to wait 2 days instead of 1, but you never connected this to the reduction of federal tax money (to be fair, the impact would have been convoluted…tax money being pulled out somewhere else, so the state having to reduce district level funds in one area to plug that hole, which was then possibly pulled out from the hospital maintenance fee by the local administrators).
However, at one point these started accumulating, and what it took was 1 major stress event to go from slowly increasing the temperature of the water the frog was in, to picking them up from the lukewarm water and dropping them in a fire.
Of course everyone would prefer if everything were better all the time, but complaints about the US system and clearly not on the same plane as those about UK’s.
It was sad when we had to use personal connections to get grandma a meal and room after 12 hours in the corridor.
No insurance or national coverage, just low overhead and high skill.
We are #37 according to the world health organization and we cost twice as much.
I'm sure people in France complain, but they have way less of a reason to.
Some reasons for the cost savings: universal, portable medical record, insurance companies have to remit with three business days, reference pricing, one system not medicare, VA, private. Private insurance companies don't make tons of money they are so well regulated...
Old source but still painfully relevant. I have seen these stats elsewhere as well: https://www.npr.org/2008/07/11/92419273/health-care-lessons-...
https://doi.org/10.1016/S0140-6736(17)33326-3
Our system has plenty of problems but let's make sure that any reforms don't ruin the best parts.
> We are #37 according to the world health organization and we cost twice as much.
Note that ranks alone are not sufficient to evaluate this comparison. If the top 40 countries for Healthcare outcomes all had near-equivalent mortality rates, e.g., it wouldn't necessarily be a problem to be #37.
That said, they don't have equivalent mortality rates, so the ranks do happen to discriminate quite a bit.
Yes, we complain about our medical system, especially as several provinces are pushing to privatize the system.
But, after the belly-aching, we all agree that at least our system in not an exploitative gong show like the US system.
Doctor visits are still hundreds of dollars out of pocket.
I'll take 1 out of 3 instead of 0 out of 3.
Well, most of Europe' social welfare systems were wiped out by the end of 1945 and were then rebooted with forethought and precedent of what not to do. The US is an archaic hodgepodge of systems over a 100 years old and were created with no precedent to model from.
People defend this system because their lives and livelihood are tied to it. It is dumb, but without a thing like a world war to wipe the slate clean it is what we have to work with.
https://en.wikipedia.org/wiki/History_of_health_care_reform_...
Or if that wiki is wrong, feel free to correct it.
In other words, I don't think it's the age that's the problem. It's that most European countries don't mind as much having their national government run things while the US tends to push more federalistic/distributed systems.
In fact, I doubt most people in 1942 would have even thought about the federal government's ability to regulate healthcare. Wickard v. Filburn was decided in November, which is the case that really opened the interstate commerce clause. Heart of Atlanta Motel v. US wouldn't happen until 1964, only then finally allowing federal laws to prevent restaurants from discriminating racially. If the federal government can't even set standards for restaurants it's rather hard to argue they have the ability to regulate hospitals and healthcare that happens inside a state. Medicare wouldn't get founded until 1965, it's not a bit coincidence this happened after SC decisions widening the interstate commerce clause.
The powers of the federal government looked extremely different in 1942 than they do today.
Source: MIL is a former nurse, former-VA claims processor. She found both the level of coverage, and the rules she had to follow to deny it, and the hoops her patients had to jump through to get treatment were utterly insane.
Everyone here likes starting wars. We're very good at starting wars. Starting wars, and support-the-troops pins are cheap. We really don't like paying for the cost of war, though. That's expensive.
The defenders of the system are entirely medical workers and owners.
The various medical lobbies/cartels are incredibly strong.
No, that's not correct. Doctors and nurses largely despise the US system. They are incredibly overworked and streched too thin to provide great care (and most of them are in it at least partially because they enjoy caring for people).
The US system only benefits the middlemen who provide no healtcare value: insurance companies and hospita/clinic adminitrators.
https://www.opensecrets.org/federal-lobbying/top-spenders?cy...
"After treatment for an acute illness, hospitals often discharge homeless patients, who wind up back in shelters or even back into their sidewalk tents and makeshift lean-tos, in what health practitioners in Phoenix ruefully call “treat-and-street.” ... A pinball effect takes hold, said health-care providers, shelter operators and advocates. Homeless people bounce from homeless shelter to hospital, then to a nursing home for a short-term recuperation stay. Once that short-term stay ends, nursing homes must decide if the person is infirm enough to qualify for long-term care. If the answer is no, they must leave the nursing home, starting the cycle over again."
That further regulation could be a good thing, but it would have to be substantially different from the way things are currently regulated.
The healthcare industry (it should not be an "industry") in the US is all about extracting maximum profit for the benefit of middlemen.
In a rational system, the only people who should be involved in health care are the patients and the providers (doctors, nurses, technicians, etc) who actually provide health care. Nobody else should be involved, let alone skimming profits from the care.
In the US both the providers and the patients are just an afterthought, the whole system is set up to extract maximum profit to the hospital and clinic administrators and, most and worst of all, to the insurance industry. The latter of course contributes nothing at all in therms of actual health care, it's pure profiteering.
The solutions are quite simple, but they don't maximize the share price and CxO bonuses at insurance companies so it's not possible to implement them in the US.
While I agree with the sentiment, hospitals require management to run well. They certainly don't need the amount of overhead they have, but it can't just be doctors, nurses and patients. Maybe in very small hospitals you could actually have doctors manage schedules and things like that, but once you reach a few dozen people you'll want to have someone coordinating availability and to deal with scheduling at the very least.
It's easy to say that only patients and providers should be involved with healthcare. But what do you propose to do with patients who need expensive treatments and can't afford to pay? Some level of cost and risk sharing is always going to be necessary, and that's where the complexities and politics come in.
First for context, the Center for Healthcare Quality and Payment Reform (CHQPR) is an advocacy organization for the types of institutions this report discusses. I think that is important context.
Second, what is rural? From a healthcare standpoint rural typically refers to area of populations centers of 50,000 people or less. Examples in California that might be familiar to people living in the San Francisco bay area would be Humbolt and Mendocino counties. This report includes some semi-rural areas, places similar to something like Yuba City, CA, a population center of about 160,000.
Thirdly, the main point is that what "rural" hospitals get paid for services from insurance companies and what it actually costs to provide those services, continues to get further and further apart. In my first hand experience, this is true. Number one amongst those is staffing, today staffing costs have risen dramatically faster in rural areas than in urban and semi-urban areas -- though they have risen their as well. The staffing levels and types of personell at what is legally called a hospital are heavily regulated and have continued to to expand. Medicare in particular is pretty "unfair" in its latest fee structures regarding these issues though HHS does provide other types of subsidy to rural areas. The meat of the report is that if that continues unabated, one hundred or more hospitals will likely "close". Closing may mean to completely cease operation or in other cases mean to continue to operate but as something which cannot legally be called a "hospital".
Finally, as a report which is not really in-depth, not really independant of the organizations it is advocating for, provides little in the way of citations and data, I am somewhat dubious of its value being posted to HN at all, other than to act as a punching bag around which everyone can throw the usual jabs at the US healthcare system as a whole.
Nowadays a large fraction of upvoted HN posts don't contain much genuinely substantive discussion at all. The farther away the post is from a purely technical topic, the higher the likelihood of this.
Instead they are often filled with what I call pseudo-substantive discussion, meaningful superficially, but that don't make much sense, or based on faulty assumptions, once anyone tries to investigate or question a bit.
This will probably come up with roads and utilities at some point, also. Did we build a lot of infrastructure in less dense areas during boom times, similar to how China was recently building, with little regard for the long term sustainability costs? One day some of those currently paved roads in the country may need to be allowed to revert to dirt. If only a few people live on a long road they obviously can't pay for it themselves.
The article does mention things like farming and mining that take place in rural areas, where workers may want nearby health care. Perhaps the companies profiting from these activities should pay these costs?
There's also the idea of subsidizing elderly people who choose to live in the middle of nowhere. I'm not sure how many people would be in favor of that. It's been over a hundred years since we lived in a small town farming economy. These places have been emptying out for a long time.
This is how you get company towns, and they don't have exactly stellar history.
Farming for example has already become quite automated, not so many actual people are needed. Same for mining.
Should everyone who chooses to move to the middle of get a paved road and emergency room subsidized by others? Or just the people who are grandfathered in? Wouldn't it make more sense for these people to move if their needs are not being met, as so many already have?
I’ll look at two political extremes:
- in a pure-market healthcare situation, these hospitals likely wouldn’t exist in the first place. Health services would be worse than they are now in rural areas, to the point that many probably wouldn’t have “real” health services at all because there’s not enough of a market to support it. You can say “well that’s my choice to live somewhere I can’t pay for healthcare” and that’s a different discussion, but free market wouldn’t get good healthcare in rural places.
- you could have a single payer system, at which point providing good healthcare to rural areas would be a “net drain” on everyone else. Basically people in dense areas would be subsidizing people in rural areas REGARDLESS of those people’s incomes or wealth (this is a similar problem to many ex-urbs in America where we basically subsidize the infrastructure of rich people who live there).
Neither of these seems to work out well, and I worry neither I politically sustainable. It doesn’t strike me as an easy problem…
Most of the rural hospitals I know will send you "to the big city" anyway for specialized procedures.
https://www.brookings.edu/research/why-rural-america-needs-c...
> "This pattern holds for state government spending, too. Studies in Minnesota, Georgia, and Wisconsin reveal that metropolitan areas contribute more to state coffers than they receive in education, infrastructure, and other public services investments. In Georgia, for instance, metropolitan Atlanta provides 61 percent of state revenue but receives just 46 percent of state investment. State spending on roads, broadband networks, schools, and other public services in small town America is funded, in part, by the economic prosperity of cities."
There's no way the majority of rural communities in this country could cover their own infrastructure costs. Those are heavily subsidized by the state. In the state I live in, Iowa, there are nearly 100k miles of rural roads to support a population of roughly 1 million rural residents. Meanwhile there are about 16k miles of road to support the other 2 million urban and suburban residents. Roughly 1/3rd of those rural roads are considered to be "farm to market" roads which facilitate delivery of farming goods to markets. The other 70k miles of roads are just to support rural residents. And while there's an argument that rural gravel roads are cheaper to build, that ignores the total cost of ownership as those roads need annual maintenance. Even things like electricity are heavily subsidized because residents pay a similar rate regardless of where they live, and rural residents require substantially more infrastructure to get the power to them in the first place. Those additional costs are borne by all residents. At least part of that "cheap rural lifestyle" is paid for by folks living in cities.
In a pure-market healthcare situation, we would treat people essentially the way we treat cars. Some would be worth much more than others and they would depreciate to approximately $0 as they age, and we would make repair calculations against that value. It would be considered morally heinous. The basic root of the problem is trying to put an economic value on human dignity and morbidity/mortality, and it will always involve tradeoffs.
Hospital execs get paid large bonuses for agreeing to deals like this.
By whom?
https://i.redd.it/enukl0ljqk1b1.jpg
https://www.cnn.com/2023/04/14/business/junior-doctors-strik...
Some level of universal healthcare works fine in 32 of 33 developed or mostly developed countries. Stop saying "but it can never be done". It is significantly cheaper in other countries that are able to negotiate drug prices.
I hate this line of logic, it's basically just ignoring that almost every other developed country in the world has figured out and has done it without the need for "healthy competitive markets".
You say the government has little profit incentive, sure, but they also have little incentive to control costs. It's "other people's money", they spend it like drunken sailors, even when they're 30 trillion in debt. Look at what happened to tuition costs after the government started handing out loans for them. I'd take these calls for universal healthcare more seriously if they talked about addressing the underlying issues in the market first, but from what I can tell it's mostly idealogues pushing their pet policy without grounding it in reality. All the bad actors in the industry aren't just going to disappear or start playing nice when they start getting funded by taxpayers (more than they already are).
Physicians are clearly the worst with their complete control through the ACGME/AMA, but pharmacists were a huge lobbyist in 2008 when it mattered. The various owners, hospitals, pharma manufacturing, pharmacies, all make sure they keep the red tape strong and the medicaid + medicare payments coming.
While there are other areas that can be improved (supply of professionals) the reality is that the payer model, at its core, is really the big issue.
All the other successful healthcare models across the world have no concept of the American Payer system.
It's how we get a lot of our airline pilots, after all.
That's a large number. I thought it was less.
In any case, in most countries, the number of doctors created is artificially limited (by the professional medical society, by lack of lecturers, artificially small classes, etc).
You want to double the number of doctors? Make each doctor serve (after internship) for at least one year as a fulltime lecturer in medicine. That'll more than quadruple the intake in the first year. The professional health organisation that registers doctors can enforce this.
In fact, they can enforce lots of things, and the question you should be asking is not "Why are the greedy corps taking all the money", but "why is the artificial limit on doctors so low?".
Or is "too big to fail" just a ploy by those organizations to entrench themselves even further in our lives?
Admittedly, I never got past ECON 201, so I'm probably wrong on something here.
I wouldn't worry about it (myself, only ECON 101); after all the people opining the loudest are the ones who have even less ECON than me, nevermind you.
I think one of the largest mistakes made with medical insurance is removing the price visibility. The hospital cannot tell you how much a procedure will cost until after it is done. They can tell you how much it will cost if you pay in cash, so they have a good ballpark figure.
So the consumer buys something without knowing how much it will cost, and is then legally on the hook for paying whatever the cost is. This is broken.
Maybe it's unavoidable in this particular field (medical care), but the one thing you can be sure of when the consumer buys something without knowing how much it costs (and only paying the cost later) is that the price of that thing is going to skyrocket.
I grew up 2 hours outside of Appalachia, and couple that with the other places I've seen I feel safe in my belief that the US has large swaths of sparsely populated regions.
Here's some fun maps if you don't believe me:
https://www.reddit.com/r/MapPorn/comments/l4zr10/red_areas_i...
If you don't like reddit, feel free to reference this night map:
https://www.census.gov/library/visualizations/2021/geo/popul...
It's no surprise that these hospitals are at risk of closing. There are few people there and fewer new people coming in, causing the cost of labor to explode. For example, there's a shortage of new blood entering the workforce compared to retiring boomers:
https://www.populationpyramid.net/united-states-of-america/2...
This leads to labor shortages especially in rural areas because the few young people are fleeing to urban environments to find work and a not-shrinking economy a la Japan & Tokyo. Here's a document referring specifically to some east coast regions, but there is likely one for your local region out there somewhere: https://www.richmondfed.org/publications/research/econ_focus...
Here's a document on Japan and Tokyo's situation:
https://www.cnn.com/2023/01/04/business/japan-pay-families-r....
It sucks that these hospitals are closing but this is what the decline of a region looks like. The labor costs are only going to get worse as time goes on because if you want nice things you have to convince people to hang out there and make it nice. The growing costs of labor will shut down hospitals and prevent the opening of new ones. It was easy to justify the construction of such things when the population of the USA almost doubled between 1970 and today. Now? Not so much:
https://fred.stlouisfed.org/series/POPTOTUSA647NWDB
Widespread immigration into these areas would help alleviate these issues, as would policy decisions that favor the industries that used to exist in them that drew people there in the first place.
[0] https://old.reddit.com/r/pics/comments/1jiczi/i_work_in_a_ho...