30% of All Rural Hospitals in the US Are at Risk of Closing [pdf]

https://ruralhospitals.chqpr.org/downloads/Rural_Hospitals_at_Risk_of_Closing.pdf

by belter • 3 years ago

65 126 3 years ago

ruralhospitals.chqpr.org

rqtwteye5• 3 years ago

It’s really interesting how the US has managed to get a health system that’s extremely expensive, doesn’t cover everybody, is highly bureaucratic and complex, delivers below average outcomes and has overworked hospital staff. And somehow people defend this system because it works fine for the top few percent (especially the people in Congress) and people who have Medicare or VA.

adamwong246• 3 years ago

No comment, only a thought. https://en.wikipedia.org/wiki/Saturn_Devouring_His_Son

syntheticnature• 3 years ago

From talking to veterans I know, "works for people who have VA" might be optimistic.

hotpotamus3• 3 years ago

From my experience talking to veterans, they think the VA is bad until they experience the alternative. But medicine is just incredibly individualized, so it's natural that everyones' experience will be unique.

explaininjs2• 3 years ago

Is there any country with a medical system that people don't complain about? For instance is there anyone in the world that would agree: "Gee, my healthcare is so cheap, it's surprising that it covers everything I want it to without me needing to go out of my way to justify my treatment options and I have so many medical professionals available to me at a moments notice!"

carapace• 3 years ago

Cuba.

https://en.wikipedia.org/wiki/Healthcare_in_Cuba

ethanbond3• 3 years ago

The NHS is one of the most beloved institutions on the planet AFAICT.

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.

justrealist• 3 years ago

I don't mean to start a flame war, but the most positive things I've heard are from Indian colleagues/friends who are used to paying cash for very affordable service back in India.

No insurance or national coverage, just low overhead and high skill.

alex_lav• 3 years ago

Complaining isn’t a bad thing, and shouldn’t be used as a proxy for efficacy. Citizens advocating for better care should always exist.

methehack• 3 years ago

France is #1 in care according to the world health organization for 1/2 the cost per capita. It is all private, well-regulated, and provides universal coverage (your company pays your premium; if you have no employer, the govn't does).

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-...

ajmurmann2• 3 years ago

IMO, the problem with healthcare is the same issue as with other labor-intensive things like childcare, education etc. It's Baumel's cost disease. Products hey cheaper due to automation and get cheaper relative to services. This makes these things get really expensive in relation. The most common intervention for this unfortunately is demand-side subsidies which of course make things worse. The other intervention is tighter controls which means more paperwork which also make things more expensive. Happens everywhere.

Ensorceled• 3 years ago

Is there any country with a medical system that people don't complain about?

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.

bcrosby95• 3 years ago

My employer pays $36k/year for my family's health insurance, it doesn't cover everything I want, and we still have to justify treatment options.

Doctor visits are still hundreds of dollars out of pocket.

I'll take 1 out of 3 instead of 0 out of 3.

searine2• 3 years ago

It’s really interesting how the US has managed to get a health system that’s extremely expensive, doesn’t cover everybody, is highly bureaucratic and complex, delivers below average outcomes and has overworked hospital staff.

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.

vel0city2• 3 years ago

Eh, most of the current designs in the US healthcare industry has its roots with the move to employer-sponsored healthcare in the 1940s (see: 1942 Stabilization Act and it's consequences). Private health insurance was barely a thing in the 1920's and pretty much didn't exist before then.

vkou• 3 years ago

It doesn't work very well for people going through VA.

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.

hospitalJail4• 3 years ago

And somehow people defend this system

The defenders of the system are entirely medical workers and owners.

The various medical lobbies/cartels are incredibly strong.

zamnos3• 3 years ago

Are medical workers even that loud a defender of the system? A lot of providers are burnt out and leaving the profession due to being overworked.

jjav3• 3 years ago

The defenders of the system are entirely medical workers

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.

gs172• 3 years ago

My opinion of VA healthcare dropped a lot living next to a VA hospital. There were a lot of homeless nearby who seemed to be veterans who had come for the hospital.

dragonwriter2• 3 years ago

Seems to me that the problem there is the non-healthcare part of how America provides for veterans (and citizens in general). If the same veterans with the same healthcare weren't homeless...

akuchling• 3 years ago

I don't see how this is the hospital's fault: they can't keep patients indefinitely. Today's Washington Post has an article on the increasing number of homeless seniors https://wapo.st/3q8Gzeb which includes this passage:

"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."

0000011111• 3 years ago

It is broken for sure.

oatmeal12• 3 years ago

VA works for those not on the secret waiting lists, at least.

oatmeal12• 3 years ago

It's the most obvious case of regulatory capture but also the market with the most calls for further regulation.

That further regulation could be a good thing, but it would have to be substantially different from the way things are currently regulated.

jjav3• 3 years ago

It’s really interesting how the US has managed to get a health system that’s extremely expensive, doesn’t cover everybody, is highly bureaucratic and complex, delivers below average outcomes and has overworked hospital staff.

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.

tstrimple2• 3 years ago

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.

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.

nradov5• 3 years ago

Well don't leave us hanging. If the solutions are quite simple then what are they?

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.

hn_throwaway_992• 3 years ago

I don't know how you can realistically look at this without thinking of the "I never thought leopards would eat MY face!!" meme.

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.

kevingadd• 3 years ago

Yeah, but it's not as if all the people who live in these areas voted to shut down the hospitals. There's still a sizable portion of the electorate that wants good things and they get to suffer now. Not great.

bwb• 3 years ago

It can be good as pain motivates, and hopefully they vote better or cause change vis different policies.

wwweston• 3 years ago

Rural voters as a bloc seem determined to vote in support of laissez-faire socioeconomic approaches which incentivize this result. I suppose it’s possible that they don’t intend this and merely are thoughtless about it from a policy standpoint, but if we’re being generous it also seems plausible to assume they’re not being stupid and this is either acceptable or part of the intended result.

jbm3• 3 years ago

I do not understand how Obamacare would resolve this issue. This seems to be related to the lack of income; how would Obamacare or Medicaid fix this?

ceejayoz• 3 years ago

Medicaid expansion was a key Obamacare pillar, one a number of red states opted out of.

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.

hn_throwaway_992• 3 years ago

A huge reason hospitals lose money is due to the amount of charity care they provide. There is a saying that "Reagan instituted universal healthcare in the US, he just didn't institute a way to pay for it." That is, during Reagan's time, laws were passed that required hospitals to provide emergency care regardless of an individual's ability to pay. But no laws were passed then that actually funded that mandate.

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.

sophacles• 3 years ago

The affordable care act and medicade are programs to pay hospital bills for people. Hospital income comes from someone paying hospital bills sent to people who get medical care. Since those programs pay the bills for the people who get treatment, the hospital gets its income.

Projectiboga• 3 years ago

Just over a dozen red states refused the Medicaid Expansion, which would have offered more federal health dollars to their states. Yes the Affordable Health Act was just a band-aid on our for profit health insurance system. Our country spends over 30% on health insurance administration before you count all the billing effort by the medical providers. We have out 27% without any insurance and many more with limited coverage. The money is already there this is a rare example where nationalizing would surely safe money. The thing that should be able to help even the better off is that it should eventually reduce the strain on our emergency rooms. No system would be perfect but our system is about as far as can be from supporting individual health.

rtkwe2• 3 years ago

A big drain on hospitals are treating uninsured people who they can't reliably collect payment for treatment from. Expanding insurance through public exchanges and wider employer healthcare requirements plus bringing more people on to Medicaid decreases the number of people who are uninsured. There's also the effect that if you catch issues with diseases sooner they're usually cheaper to treat for obvious reasons, same goes for chronic issues that may be poorly managed because the patient can't afford to go to a doctor regularly or keep up with their medication.

swader999• 3 years ago

Yet in Canada we have this same issue.

bombcar4• 3 years ago

Canada did not vote for Obamacare, so they get what they deserve.

(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).

rayiner3• 3 years ago

And in blue states in America that voted for Medicaid expansion we have the same issue. It’s almost as if the problem is escalating costs for skilled workers, lack of economies of scale in rural areas, and wealth/job flight to urban areas.

lifeisstillgood• 3 years ago

FYI https://knowyourmeme.com/memes/leopards-eating-peoples-faces...

notaustinpowers2• 3 years ago

I have so many rural family members that are like this. And so much of it is because they just actively and brazenly do not want to help anyone. Their individualistic ideology runs so deep that they view people homeless, struggling, or unable to afford healthcare as a moral failing.

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.

notacoward2• 3 years ago

they view people homeless, struggling, or unable to afford healthcare as a moral failing

...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.

lowercased2• 3 years ago

Pfftt.. they'll just have a church fundraiser! Then maybe a gofundme to top it off!

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...

oaktrout3• 3 years ago

The article is arguing that private payers don't reimburse rural hospitals enough, not that lack of medicaid or obamacare is an issue. Perhaps your premise is correct but it is at odds with the article, I would be interested in hearing more about why you disagree with the article.

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".

nradov5• 3 years ago

That part of the article makes no sense at all and appears to be pushing a biased political narrative. Private commercial insurers already pay more than Medicare / Medicaid for the same treatments. Patients with private insurance are effectively already subsidizing those on public plans.

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.

judge2020• 3 years ago

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

If 50% are private insurance, what are the other 50%? Wouldn't that other half influence whether the hospital has to close?

jorblumesea4• 3 years ago

Yeah and guess who keeps voting against single payer healthcare solutions or any kind of healthcare reform?

Representatives from these red rural areas. It's a different big cat that's eating your face, if that makes you feel better.

rayiner3• 3 years ago

Except rural hospitals in blue states that expanded Medicaid, etc., are also at risk of closure: https://www.beckershospitalreview.com/finance/631-rural-hosp....

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.

positron6000• 3 years ago

Based on the data here (which your source is based on) four out of the five rural hospital closures in NY are in counties that voted for Trump in 2016:

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

rhaway84773• 3 years ago

I think it’s a little more nuanced than that.

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.

peteradio2• 3 years ago

I doubt you had much empathy to begin with if you can cast it aside based on a passing reading of the title.

jeron• 3 years ago

There was a Reddit post that these rulers[0] were $80 from a medical supplier when they could be purchased for $6 on eBay, which is an easy explanation why healthcare here is ridiculously priced

[0] https://imgur.com/a/BSPRh

jbm3• 3 years ago

Um, wasn't that 100 for 80 dollars? That's how I read the imgur link.

dilyevsky• 3 years ago

In the original post[0] it was $6 for 100 pack too. And someone pointed out that msrp is $70 so it’s not that bad and ebay was probably either a scam or surplus. Most things on reddit is bs for votes or straight up astroturfing.

[0] https://old.reddit.com/r/pics/comments/1jiczi/i_work_in_a_ho...

jorblumesea4• 3 years ago

Can we please just implement some level of universal healthcare. The fact that healthcare is tied directly to payers, who fight over how to much to pay, is ridiculous. Imagine your local hospital shutting down because the hospital charged $50 for aspirin but the insurer wanted $40.

tboyd472• 3 years ago

The issue is not confusion over who pays the bill, but the overwhelming amount of corruption and cronyism in the system.

cheeseomlit2• 3 years ago

If you take an industry cornered by an entrenched cartel and then socialize it as-is you are only cementing their control over it even further, making a healthy competitive market impossible. Prices are criminally exorbitant now, what makes you think they'll go down when the government is the one paying them? If history is anything to go by the effect will be the opposite

pkaye• 3 years ago

The UK NHS is able to use its monopsony powers to keep the pay for doctors and nurses extremely low. Doctors would need a 35% pay raise to bring it back to the 2008 level of pay. Many of them are looking to leave for Australia or Canada. Even US is considered but they would have do the residency over.

https://i.redd.it/enukl0ljqk1b1.jpg

https://www.cnn.com/2023/04/14/business/junior-doctors-strik...

jorblumesea4• 3 years ago

This is a ridiculous statement, the government can negotiate prices and has little profit incentive.

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".

hospitalJail4• 3 years ago

The problem with US healthcare isnt the payer, its the supply of workers/red tape.

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.

jorblumesea4• 3 years ago

Nah, the payer system is fundamentally broken. Inability to negotiate and set proper price controls on aspirin for example ends up in a huge fight over who makes the most money out of the system.

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.

tristanb2• 3 years ago

Its also incredibly expensive (500k) to become a doctor.

bombcar4• 3 years ago

Maybe we need something like the Army, where you can join up, qualify, get trained to be a doctor for free, and all you have to do is serve out your term at army wages until you're 45, then you're retired and free to do whatever doctoring you want wherever.

It's how we get a lot of our airline pilots, after all.

lelanthran2• 3 years ago

Its also incredibly expensive (500k) to become a doctor.

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?".

mikem1702• 3 years ago

How much do we want to subsidize people who choose to live in less populated areas?

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.

zokier• 3 years ago

Perhaps the companies profiting from these activities should pay?

This is how you get company towns, and they don't have exactly stellar history.

mikem1702• 3 years ago

I wasn't thinking of normal towns with a variety of people, but instead something more like oil rigs, or Alaska oil fields, or some military bases, where pretty much only workers are present, and they rotate in and out on a schedule.

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?

tboyd472• 3 years ago

This is "too big to fail" logic applied to hospitals. How do our basic life services always become captured by huge organizations that are poorly run and require bailouts by the government?

Or is "too big to fail" just a ploy by those organizations to entrench themselves even further in our lives?

yifanl• 3 years ago

Putting on my economist's hat for a second: Services like healthcare inherently have extremely inelastic demand, and are difficult to serve to a large number of people without a large number of resources, which makes it naturally easy to build a monopoly. A monopolicist is incentivized to increase fees and/or reduce spending on the quality of service as long as the demand is inelastic... and here we are.

Admittedly, I never got past ECON 201, so I'm probably wrong on something here.

lelanthran2• 3 years ago

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.

pingpongchef• 3 years ago

Regulation increases the barrier to entry, making competition more difficult to start

DevX101• 3 years ago

One other factor triggering closures in the article: private equity companies have been on a buying spree for hospitals. The strategy is to buy the hospital, sell the land to a real estate co, and have the hospital pay exorbitant rates to lease the land. After they’ve extracted maximal value, the hospitals that can’t afford the lease are forced to close.

Hospital execs get paid large bonuses for agreeing to deals like this.

Eisenstein2• 3 years ago

Hospital execs get paid large bonuses

By whom?

zamnos3• 3 years ago

By hospitals who "can't afford" to pay their nurses more.

jeffbee• 3 years ago

I'm not 100% sure about the conclusion, in which we force private insurers to cover the cost for rural services. I suggest there is a middle ground where rural life is reformed slightly to become economically sustainable. Rural America is in many ways ridiculously expensive to serve, and not just for health care. Consolidating populations into compact towns that have several thousand people fixes a lot of those cost issues, and it also goes a long way toward preventing the need for the hospitals in the first place, which for rural ER departments comes from car crash injuries.

smileysteve2• 3 years ago

This, especially for aging populations (who may lack reliable transportation) and have higher needs

hospitalJail4• 3 years ago

The medical cartels caused this. Their greed has made it impossible to afford healthcare.

HEmanZ• 3 years ago

People here seem to go straight to politics on US healthcare, but does anyone ever stop to consider that this really is a complicated problem?

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…

bombcar4• 3 years ago

I'm not exactly sure what would drive rural hospitals to be a net drain unless they are "built too large" for the population, or are usually empty.

Most of the rural hospitals I know will send you "to the big city" anyway for specialized procedures.

tstrimple2• 3 years ago

The same reason rural areas are a net drain in other ways. They have no efficiencies of scale and since everything is spread apart, providing services becomes more expensive and difficult.

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.

hotpotamus3• 3 years ago

Serious people are aware that it's a really complicated problem - things with simple answers are not considered problems. Healthcare systems have been tinkered with in the developed world for about as long as what we'd call modern medicine has existed; in the US, the FDR administration looked into universal healthcare, but it was considered too big a reach back then, and it's been a thorny issue ever since.

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.

jmoak3• 3 years ago

The US is freakishly large. I've lived all over it and driven across it from west to east several times.

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.

duffpkg• 3 years ago

I'm sorry to say but there is a lot of nonsense in the other comments here. I wrote Hacking Healthcare for O'Reilly, created the ClearHealth/HealthCloud Open Source EMR system, and most importantly I have, amongst other things, actually managed dozens of rural hospitals and clinics.

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.

MichaelZuo• 3 years ago

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.

notacoward2• 3 years ago

The main reason seems to be that it costs more for them to deliver services than they're getting paid by insurers (especially Medicaid). I'd love to see a fuller breakdown of how those costs compare to those for urban hospitals. How much is demographics, such as serving a generally older population more prone to "deaths of despair" because rural living is hard? How much is demand, because of different eating/exercise habits or the uneven distribution of addiction to different drugs? How much is logistics, delivering care over a wider area? How much is other factors I haven't even thought of? The question of why rural hospitals don't get paid as much as it costs them to provide care doesn't have to be a political one. It just has to be asked.

30% of All Rural Hospitals in the US Are at Risk of Closing [pdf]

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