Imagine you are in Washington, D.C., and have a sudden onset of severe chest pain radiating to your left arm, diaphoresis, dyspnea, and nausea—you are having an acute myocardial infarction. You call 911, but the nearest hospital to you is in Baltimore, more than 40 miles away. The only emergency medical services (EMS) unit available is transporting a victim from a motor vehicle collision to the trauma center an hour away. EMS will not be able to respond for at least an hour, if not longer. Welcome to the dilemma faced by many rural Americans when their local hospitals have closed.
Explore This IssueACEP Now: Vol 34 – No 01– January 2015
Ezekiel Emanuel, one of the architects of the Affordable Care Act, predicts that one in five hospitals will close by 2020. In his book Reinventing American Health Care, he wrote, “Long live fewer hospitals. Welcome to the new age of digital medicine.”1 He also predicted that the first to close would be smaller hospitals, which I interpret as being mainly rural hospitals. It may be the cynic in me, but predictions often come true when they are self-fulfilling prophesies of a well-designed plan.
Trend in Rural Hospital Closures
Whether this is the inevitable fate of rural hospitals or part of a deliberate plan to cut federal spending, the rural hospital closure trend has started. In 2013, 14 rural hospitals closed nationwide, leaving whole communities without sufficient access to emergency care. In Georgia, where I live, four of the state’s 65 rural hospitals have closed over the past two years, with at least 15 more at risk, according to HomeTown Health, an association representing rural Georgia hospitals. The main reasons are financial, due to stressed budgets, shrinking revenue, growing expenditures, and gossamer-thin reimbursements.
When a rural hospital closes, it worsens access. Almost one in five Americans lives in a rural area. For the most part, these people are older, less educated, have more chronic illness, and are uninsured or underinsured. They have less access to specialist care and often must travel long distances to receive it. Sometimes travel out of town is difficult, unaffordable, unavailable, or impossible for them.
These barriers are not just inconveniences; they impact lives. For example, a study from California showed that when distance to the hospital increased, so did death from injury and time-sensitive conditions such as acute myocardial infarction.2 Another study from Canada documented increased adverse perinatal outcomes when local hospitals close and travel distances increase.3