
Nearly a quarter of U.S. rural hospitals are on the brink of closure – report - Ice_cream_suit
https://www.modernhealthcare.com/article/20190220/NEWS/190229999/nearly-a-quarter-of-rural-hospitals-are-on-the-brink-of-closure
======
jandrewrogers
This is a longstanding problem of geography and demographics. It is not
unexpected that many of the States with the worst problem are also the ones
that are least urbanized i.e. much of the population is diffused across a vast
region. The aging and decline of these populations makes the situation worse.

The rural hospitals typically serve a population that otherwise would be
several hours travel from the nearest "real" hospital, and typically have a
catchment area of 1-2 hours travel. Many of these hospitals are located in
towns with populations of a few thousand people. Even when heavily subsidized,
the economics of maintaining these hospitals is very poor, especially as
populations decline. Maintaining a fleet of doctors and facilities that are
increasingly rarely used is expensive. And even with the current distribution
of rural hospitals, it is not uncommon for people to live several hours from
the nearest hospital.

It is essentially a math problem. To ensure that virtually everyone lives
within N hours of a hospital, you would need to build an enormous number of
hospitals that each service a population of a few thousand people unless N is
quite large. This has an extremely high cost per capita, most of which is
wasted because they are often very underutilized, which does nothing to help
reduce healthcare costs. And you can't force these people to move to more
urbanized areas of the country either. The other challenge is finding enough
doctors willing to work in a tiny remote town. Few people want to live in
these areas and so many doctors that do work in these hospitals are
effectively required to commute from a city that is hours away -- it is not a
desirable assignment for most.

~~~
DenisM
We can also improve coverage by building faster roads. How about a dedicated
fast lane with a minimum speed of 120 mph and modern-car requirement? Add toll
to reduce congestion.

It might improve emergency response, local commerce, far-away commute,
tourism, and availability of all services, including healthcare.

Short of that, maybe next-gen VTOL aircraft (robotic octocopters) for
transporting the ill at a fraction of the cost of a helicopter.

Here’s one for $200k with a 70 mile radius.
[https://www.entrepreneur.com/article/307065](https://www.entrepreneur.com/article/307065)

~~~
jandrewrogers
Building new, faster roads in rural areas would be outrageously expensive per
capita and would rarely be used, there is no economy to justify the
expenditure. There are 2.2 million kilometers of _unpaved_ road in the US.
Even for the paved rural roads, many of them are relatively low-speed or
circuitous because it is cheaper to go around myriad engineering obstacles
than through them. It is difficult to justify tunneling 20 kilometers through
a mountain range with a high-speed road so that 100 people can shave an hour
off getting to the other side of that mountain range where there _might_ be a
fast highway.

Helicopters and similar have problems of limited range and operating ceiling,
which are particularly relevant in the western US, in addition to requiring
safe landing areas that may not be readily available. It is a challenging
problem to solve, the US is quite large and many areas where people live are
rugged and remote.

~~~
wcunning
I would beg to differ -- the vast majority of rural roads in this country west
of Pennsylvania are mile by mile grid, wide, and 55 MPH fast moving. They
don't get you anywhere nearly as fast as freeways, they often slow down
through tiny hamlets and they have lots of stop signs, but they're already
very fast compared to a lot of places.

Edit: Which is to say that I agree with you more than the grandparent.

~~~
jandrewrogers
Those grids are not a problem, they drive relatively fast for unpaved roads,
but the grids completely disappear once you reach the mountains in the western
third of the US, even in large unbroken crop areas like The Palouse with
proper rural roads. Many parts of the South are similar, though in those parts
the meandering rural roads are defined more by water obstacles.

The major highways in the rural west, on the other hand, are very fast (90 MPH
is normal) once you get to them, but the geographic distances between places
that resemble civilization on those highways are often quite large even at
that speed.

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pedasmith
Weirdly, the article didn't notice the very strong correlation between "states
that didn't accept the Medicaid expansion" and "places with under-payed rural
hospitals".

This seems like an absolutely elementary analysis to do -- places with the
Medicaid expansion are more likely to have people with health insurance;
places without are less likely.

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screye
I honestly wonder if any form of sparsely populated settlement would be
sustainable if it was not heavily subsidized by taxes from the urban regions.

Ironically, the worst predicament for any form of infrastructure is under-use.
In today's world where no town can be self-sufficient, low density can be the
bane of its existence.

It is sometimes irritating how heavily favored rural communities are (per
capita) in the way Govt.is structured.

~~~
jostmey
True. Rural areas might also be the source of the next generation, having
higher fertility rates.

[https://www.usnews.com/news/healthiest-
communities/articles/...](https://www.usnews.com/news/healthiest-
communities/articles/2018-10-17/as-fertility-rates-fall-across-us-gap-widens-
between-rural-and-urban-counties)

~~~
bilbo0s
More likely immigrants will be.

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luckydata
Wouldn't be better for pretty much everyone to just help the people in areas
where services are unsustainably expensive to move to denser areas where they
can be properly attended? At this point the less dense areas are a waste of
energy and resources that are worsening our climate outlook, we should be
starting to think about real solutions instead of some cockamamie telemedicine
patch - seeing a doctor over the phone is only a solution for trivial problem,
as soon as there's something serious the only option is a very long car ride
or a very expensive helicopter ride.

~~~
wcunning
Well, that depends. Will the urban area allow me to have a workshop? Will it
do like San Diego did and disallow any personal car repair even in my own damn
garage? Will I be able to even modify the way in which I enjoy my hobbies
without incurring literally 100x the cost in an urban area vs. a rural one?

The town I live in now has messed with zoning so much over the last 30 years
that any extant property is a minefield of exceptions and variances, so any
time you want to even repair what's there, you need a $500 zoning variance
application. Anytime you want to expand in place, you violate the setback
rules. Anytime you want to do anything other than stay exactly as is, doing
only the mowing the lawn and walking to the restaurants in town that the "City
Master Plan" expects, you are begging for permission from the high and mighty
civil masters _ahem_ servants. All of my friends that enjoy the same things as
I do, do what I'm working towards doing -- move out of the city and away from
the upper class zoning that intends to keep the working class out.

~~~
namdnay
> Will I be able to even modify the way in which I enjoy my hobbies without
> incurring literally 100x the cost in an urban area vs. a rural one?

I think the point the parent is making is that the people in urban areas are
the ones subsidising your extra-urban lifestyle, which would be unaffordable
if you had to pay the real cost of all your services

------
bwb
Interesting, you have to wonder if this will help accelerate a push from rural
voters for government-run health care where gov run hospitals have a mandate
to stay open and the cost is spared across the system.

~~~
dx87
I doubt it. My grandparents and inlaws both live in rural towns, and I think
they'd rather have the hospital close down than have to pay more taxes. I know
the news likes to show people from rural towns that want the government to
provide urban ammenities in areas that can't financially support it, but in my
experience, those people are in the minority. Most rural people I've met know
the risks of living far from government services, and they think the benefits
outweigh the risks.

~~~
Gusmann
Still even people living 'far from government services' should be able to get
emergency help when they need to and the closure of the hospitals might just
drop the general level of life in the area

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sho
Honestly I don't feel sorry for the USA any more. The rest of the world solved
these problems 50 years ago.

At some point you conclude that the USA _wants_ these problems. China could
not ask for a better boogeyman.

~~~
namdnay
Not really, the same questions are common in many large European countries
too. In France the “continuity of public service” is harder and harder to keep
going, as taxpayers balk at the cost of subsidising telecoms, post, hospitals
etc for sparsely populated areas

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a3n
Doesn't the free market say that however many hospitals we have is exactly the
right number? /s

~~~
pfdietz
The free market says if you are not worth keeping alive, you should be dead.

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panzagl
Does everyone here grow everything they eat in a windowbox? Dig their own ore?
Not everyone in a rural area is just sitting in their trailer living off
Social Security, and many of those that are were productive citizens in their
youth. All the stuff NIMBY urbanites care not to do gets done elsewhere, and
those people have just as much right to healthcare as anyone.

~~~
lotsofpulp
The voting record of most rural areas indicates they don't believe they have a
right to healthcare.

~~~
panzagl
You're conflating a right to healthcare with a right to have someone else pay
for it.

~~~
eropple
No, they're not, because implicit in a right to healthcare is access to
subsidy. There's literally no other way for it to be systemically provided.
Literally every other option results in provisioning failure. The former
requires and cannot not require the latter.

I have trouble understanding why social issues make nerds stop thinking
systemically, but there you have it.

~~~
panzagl
I'm not arguing against subsidy, everyone else is- most of the comments here
are that rural citizens are 'getting what they deserve' because they don't
vote correctly in national elections and burn too much carbon on the farm or
whatever. I don't believe someone in SF has to subsidize a hospital in
Alabama, but I do believe they have to subsidize a hospital in the Central
Valley, either through taxation or through higher food prices.

------
vidanay
Just more cracks in the facade on sick care here in the United States
obscuring the fact that it is an unsustainable sham.

------
mymythisisthis
The urban/rural divide is so great we really need to sets of laws. Aviation
laws should be different in rural areas; reducing cost by sacrificing safety.

Make it cheaper to fly people to hospitals, in slightly less safe craft.

------
fredgrott
hmmm not sure..the rural hospitals near me combined to save costs.

------
dantheman
It seems to make sense, as populations fall -- there would be less need for
healthcare. The more we subsidize rural living the more we distort their long
term viability. Towns and cities shouldn't be deploying infrastructure that
they can't support, it adds up over time and makes their situation even more
untenable in the future.

A classic example of this small towns implementing city like water/sewer
systems without the tax base to do the maintenance; the federal government
provides a grant for the initial installation and the town slowly goes
bankrupt trying to pay for it.

------
adrr
Why shouldn't they close? If it is not cost effective to support rural
communities why do we prop them up? Lot of these places have 20% unemployment
rates(areas listed in the article) yet there is a severe job shortage in urban
areas. How about we fund moving them to areas that have better economic
conditions/jobs?

~~~
saboot
The question is how to provide healthcare for rural communities, these
hospitals are it. The citizens often can't afford the healthcare, can't afford
to go to a doctor until it's an emergency, and now with many of these closures
they can't even get that.

The easiest answer for many states is to expand Medicaid to cover a larger
share of the low income population which can bring revenue to the hospitals
with visits etc, but that seems to be very difficult politics for some
individuals.

~~~
adrr
The example given in the article was in New Mexico which is a state that
expanded medicaid. The labor participation in that county is 30% with 14% of
working age people on disability. There aren't jobs in the county. Sante Fe on
the other hand has 70% labor participation.

Moving people to areas that have higher economic advantages and jobs is a long
term fix. On other solutions are just bandaids and doesn't solve the
underlying economic issues.

~~~
mymythisisthis
This is the least mobile generation, few people more around. We need to make
it easier for people to move around.

------
MaupitiBlue
Makes sense. Why would anyone choose to be inpatient at Hickville Memorial
Hospital when they could drive 45 minutes to go to State U Medical Center?

These communities need smaller facilities with fewer beds, not mid 20th
century style hospitals.

~~~
giggles_giggles
I just think you should know that "hick" is an offensive slur.

~~~
new2628
I agree with what you say, and I think it is wrong for the parent comment to
use such derogatory terms.

That being said, your comment also strikes me the wrong way, and I have
received similar comments in real life where I had the same reaction, so I
thought a bit about why I really feel that way.

More precisely:

1\. the patronizing "you should know", as if your goal was to educate the
person, as if not offending others would be a matter to be solved by
education, etc.

2\. pointing out in a lukewarm and passive-aggressive way that something is
offensive. What should the other person do? He clearly knows already, and his
goal is to offend. There is no right "not to be offended".

3\. that it is not directed at you, but you are offended on other people's
behalf.

All in all, while I am on your side, I would find it more heartfelt, if you
said "you call me a hick? I'll kick your ass!" then this type of reaction.

~~~
sudosteph
I agree that the wording isn't ideal, but I interpreted the commenter you
replied to as explaining why the original comment was getting downvoted
without real responses. That is a common occurrence on HN when someone steps
outside the bounds of civility in non-immediately obvious ways. It serves to
give context to both the original commenter, and readers who may wonder why it
was downvoted.

Also, why are you so sure that the responder is not offended on his or her own
behalf? Hopefully you don't think that just because someone is commenting on
HN that they would never be associated with "hicks". I find HN has people of
more backgrounds than most folks realize, and as a person with a family who
would certainly be categorized that way by many (southern, rural, working-
class), I find your insinuation that it would be somehow more "authentic" to
threaten violence as far more patronizing and stereotyping than the original
comment even.

~~~
giggles_giggles
I was offended on my own behalf. I grew up in a rural, Southern area where I
only ever heard 'hick' used by outsiders as a slur against locals. Certainly I
have also seen rural people "reclaim" the term, but that doesn't give
outsiders the right to use it.

I also find the insinuation that I should have threatened violence patronizing
and prejudiced. The parent comment also included an example of how I "should"
talk to sound more "authentic". Textbook prejudice.

