In the 1940s and 1950s, the Hill-Burton Act promoted building relatively large institutions in rural communities to meet the local health care needs.⁷ At the time, the majority of the population lived in rural America, and hospital stays were much longer. However, over time, the rural census decreased as the population shifted into more urban areas. Furthermore, with medication and technological advancements, those lengths of stay have significantly decreased with more efficient outpatient and inpatient management. As a result, rural hospitals have decreased revenue, which is the most common reason for closure.⁸ 

Additionally, decreased economic infrastructure compromises the ability of small towns to keep hospitals open because communities are unable to subsidize them. Interventions have been implemented to prevent closures, such as the Medicare Rural Hospital Flexibility Program in 1997, which preserved hospital infrastructure, creating and subsidizing critical access hospitals.¹ However, even with significant federal and local subsidies, critical access hospitals are struggling financially. 

When addressing financial challenges, unintended consequences of implementing the Emergency Medical Treatment and Labor Act of 1986⁹ must be addressed. The act guarantees basic screening, treatment, and stabilization in any emergent setting no matter the patient's ability to pay, and it resulted in a significant increase in emergency department (ED) use often by patients who are uninsured and underinsured.¹⁰ These ED visits are thus not compensated as charity care.¹⁰ 

Emergency department use also increased because of a decrease in primary care infrastructure. With less access to primary health care professionals, rural patients are left with the ED as the only intervention available to manage disease and chronic illness.¹⁰ Treating patients in the ED is far more expensive than treating patients in an outpatient setting, which can result in debt or charity care. The operating margins of most rural hospitals are typically less than 2%, and these additional costs often put the hospitals below financial sustainability.¹¹ 

The Patient Protection and Affordable Care Act was intended to increase insurance access by subsidizing lower-income families. Middle-income families had to purchase costly insurance plans as a mandate, and a significant number of people subsequently purchased insurance with high deductibles.^12,13 Circumstantially, if a patient's situation is dire enough, he or she will be transferred from a rural hospital to a tertiary care facility. The larger institution submits the bills after the patient meets his or her deductible at the rural facility, which means the larger hospital gets paid by insurance and the smaller hospital has to collect from the patient.¹² Forty-six percent of rural hospitals operate below sustainable margins for this and other similar reasons.^11,13 Proposed recovery mechanisms do not adequately remedy the increased hospital financial burden created by patients who default on hospital bills. 

Most rural communities have significant shortages of health care professionals and are unable to adequately staff hospitals and clinics because of a ratio mismatch: approximately 20% of people in the Unites States live in rural areas, yet only 10% of physicians practice in those same areas.^13,14 In 2015, a hospital chief executive officer I interviewed in rural Oregon stated that the hospital was at 23% of the necessary manpower, and most of their practicing physicians were older than 60 years. In a follow-up conversation in May 2018, he stated that his workforce diminished further, making the situation more dire. 

In another case, a community hospital in rural Nevada was able to recruit and hire a physician; however, the physician stayed for less than a year because he experienced burnout due to having no backup and was required to be on call 24 hours per day/7 days per week. After his departure, the hospital eventually closed because of the workforce shortage. 

During the Rural Training Track Collaborative meeting in Spokane, Washington, in April 2018, a chief financial officer of a critical access hospital in Idaho stated that the hospital's mean census was only 3 even during the cold and flu season. There was no regional primary care infrastructure to staff the community clinic or the hospital. The hospital was still operating because of community needs and subsidies; however, the operating margin was typically less than 1%. Health care professional shortage was the key concern when attempting to sustain operations, and the hospital had to transfer patients to other hospitals for even routine inpatient illness management. 

The Save the Rural Hospitals Act/HR 2957⁴ addresses 8 issues, mostly focused on financial challenges. The Table breaks down each point in the bill and addresses the targets and challenges. The main issues addressed in HR 2957 are capturing bad debt and maintaining expensive infrastructure. The bill does not address the cost to maintain economic viability and, ultimately, transfers the cost of operations to the patients. It does not address the direct cost of care to patients, which is problematic because medical debt is the number 1 source of personal bankruptcy filings in the United States.¹⁵ In 2019, an estimated 66.5% of bankruptcies in the United States cited unmanageable debt due to medical expenses.¹⁵ 

House Resolution 2957 is not sustainable; it only partially addresses the economic challenges of rural institutions. It does not address the changing climate of rural health care delivery and how interventions are managed at larger tertiary institutions where higher levels of intervention are available and more appropriate. Therefore, my recommendation is to not support this bill as the means to resolve the challenges faced by the rural community hospitals. 

The following list provides short-term and long-term solutions to the physician shortage in rural communities: (1) Adjust the Health Professional Shortage Areas (HPSA) guidelines to improve workforce recruitment and retention in rural areas; (2) Increase physician retention by increasing rural health care pipeline programs; (3) Support the community outpatient hospital model; and (4) Change the current payment rules and regulations of Centers for Medicare and Medicaid Services. 

Currently, the HPSA program uses a designation based on the following scoring system ranging from 0 to 25 to determine a community's eligibility for provider incentives such as student loan repayment¹⁶: 

Health Professional Shortage Areas incentives are a tool used to recruit physicians, who are often saddled with significant medical school debt, to settle in a rural community. With this scoring system, many rural communities without a hospital do not score high enough to recruit or retain a physician and are unable to staff the facility to maintain services. If “Travel Time to Nearest Source of Care Outside of the Region” were more heavily weighted, remote communities would be able to offer health care professional HPSA incentives, and which would be a potential short-term solution to the workforce shortage. 

Often, once physicians pay off their medical school debt using HPSA incentives, they tend to return to urban areas; however, the same studies show that if a person from a rural community enters a health profession, that person is significantly more likely to return to that rural community to practice.¹⁷ 

Rural health care pipeline programs can provide exposure to medical professions, and participating students are more likely to choose a health care career and return to rural areas.¹⁷ Incentive programs should start early in primary education. Many small communities lack the infrastructure to provide the education needed to get students into health care professions, and developing programs that target those deficits will be the best long-term solution to recruit health care professionals to rural areas.¹⁷ 

Another long-term solution is to promote a paradigm shift to the community outpatient hospital model, which has significantly lower overhead expenses. Patients no longer stay in the hospital for extended periods.¹⁸ The current trend for hospitalist-based inpatient care is expensive for rural communities. Instead, we should allow this system to erode and have more sustainable emergency/urgent-care facilities, as well as cost-effective outpatient and prenatal care facilities.^15,18 

Current Medicare hospital guidelines and rules are limiting because they are based on maintenance of the current infrastructure. Instead of focusing on crisis management, community outpatient hospitals could focus on wellness, prevention, long-term care, and acute-care interventions, which would lead to fewer hospital admissions and reduced cost of maintenance. 

Implementing these strategies could provide a long- and short-term workforce with appropriate infrastructure. Rural communities would “grow their own” health care professonals to administer emergency, preventive, and long-term care in financially sustainable outpatient hospitals.