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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 lea

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.

0xB31B1B 7y ago
It’s not just urban/rural divide, it’s young and old as well. The areas where hospitals are closing are disproportionately filled with retired folks who are on Medicare and will need more and more healthcare (Medicare pays out less than private insurance so these hospitals have less money coming in from patient care and need direct subsidy. I think the answer here is pretty clearly to close down the hospitals and highly encourage/enable older folks to move to urban areas where we can provide their care more cost effectively and they will be able to age safer (no driving, stronger social services etc). In the US, you have a right to live where you want but you don’t have an unlimited subsidy to age in place.
- wcunning 7y ago
  That would cause an even greater housing price crunch in the cities than we currently have. Much of the retirement advice out there is that once you're on a fixed income, you need to move out of a high cost area into a lower cost, typically at a minimum less dense one. Also, in practice, quite a few older folks move to be close to family members who can support them, which requires living wherever your children and grandchildren live... Even strongly encouraging the urbanization of the elderly strikes me as the wrong answer here for so many reasons, even beyond the ones I've listed above.
  - kiba 7y ago
    So we need to combine that with a plan of action that ameliorate urban problems we already have, such as building more medium and high density housing and creating more public transits instead of sprawling out.
  - bilbo0s 7y ago
    But as the previous poster said, you don’t have a right to infinite subsidy for the purposes of moving to your “low cost” area. We’re entering an era where these places are low cost for elderly people precisely because everyone else is subsidizing a lot of that infrastructure for you. From the hospitals and clinics, to the roads. This is just a really hard problem. The best likely solution is to build more housing in the urbanized areas. But, yeah, how do you get that done profitably? It’s tough.
    - rayiner 7y ago
      Even if you build more housing, having older people live in urban areas still increases the price of housing. Crucially, older people don't need to be near urban jobs, so it's much more socially practical for them to live in rural areas. At the end of the day, the question is which subsidy is harder to deal with? Cash payments to keep rural hospitals open seems a lot easier than wading into enormously expensive and distortionary urban housing policies like rent control.
      - 7y ago
DenisM 7y ago
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
- dgzl 7y ago
  The idea is interesting but your "minimum speed of 120mph and modern car requirement" is not. Remember, this is rural America we're talking about, that is having trouble keeping hospitals running.
  - DenisM 7y ago
    If it costs $100m/year to run a single hospital, it will probably cost, what, 1/10th of that to maintain a fleet of self-driving high-speed ambulances? The highways will need to be built on the state/federal level, most transportation is that way.
    - dgzl 7y ago
      The amount of construction needed for that kind of project that would only benefit a small number of people... It's just absurd. Rural people would rather that money go into more important projects.
      - DenisM 7y ago
        Did it seem equally absurd to build the East Coast - West Coast railroads in the 18xx? Only a small group of the Wild-West settler would benefit from it. And did it seem absurd 100 years ago to expect a nation-wide system of 55mph highways? I'm pretty sure that it did seem absurd, and yet we're all better off for it in the end. Transportation infrastructure has a huge long tail of benefits.
joshgel 7y ago
> Maintaining a fleet of doctors and facilities that are increasingly rarely used is expensive. I'm a physician working in NYC. I could make a full 75% more salary if I went to work in a rural area. Very inverse from most professions (I think) where people working in the city make the most. But I think it's that challenging to get physicians to work in rural areas.
- jandrewrogers 7y ago
  This. Staffing these hospitals requires paying very large cash compensation premiums compared to cities. I have a couple acquaintances that worked at these hospitals, and they all did it for the money. Even then, most of them wouldn't do it for any length of time because the sacrifice to their personal and social life is too high.
- fernmyth 7y ago
  Huh, if the pay is better, why is it challenging to get physicians to work in rural areas? If you don't mind sharing, why wouldn't you do it?
  - dlp211 7y ago
    Not the person you wanted a response from, but money isn't everything.
  - lotsofpulp 7y ago
    The pay is better, but not sufficiently better to offset benefits of urban life. Offer $5M per year, and it won't be challenging to get physicians to work in rural areas. So the problem is merely that there isn't enough funding to incentivize doctors to work in rural areas.
  - bilbo0s 7y ago
    “Money isn’t everything.” That’s the short answer. For instance, what about your husband/wife? They just put their career on hold to go live in the boonies for 5 or 10 years? That sort of thing will put an enormous strain on your relationship.
  - 7y ago
adrianN 7y ago
Another serious problem is that the care you get at rural hospitals is often much worse than at bigger hospitals. Doctors perform procedures less often and make more mistakes. A smaller variety of equipment is available. Often you're better of driving a bit longer to a larger hospital.

0xB31B1B 7y ago

It’s not just urban/rural divide, it’s young and old as well. The areas where hospitals are closing are disproportionately filled with retired folks who are on Medicare and will need more and more healthcare (Medicare pays out less than private insurance so these hospitals have less money coming in from patient care and need direct subsidy. I think the answer here is pretty clearly to close down the hospitals and highly encourage/enable older folks to move to urban areas where we can provide their care more cost effectively and they will be able to age safer (no driving, stronger social services etc). In the US, you have a right to live where you want but you don’t have an unlimited subsidy to age in place.

wcunning 7y ago
That would cause an even greater housing price crunch in the cities than we currently have. Much of the retirement advice out there is that once you're on a fixed income, you need to move out of a high cost area into a lower cost, typically at a minimum less dense one. Also, in practice, quite a few older folks move to be close to family members who can support them, which requires living wherever your children and grandchildren live... Even strongly encouraging the urbanization of the elderly strikes me as the wrong answer here for so many reasons, even beyond the ones I've listed above.
- kiba 7y ago
  So we need to combine that with a plan of action that ameliorate urban problems we already have, such as building more medium and high density housing and creating more public transits instead of sprawling out.
- bilbo0s 7y ago
  But as the previous poster said, you don’t have a right to infinite subsidy for the purposes of moving to your “low cost” area. We’re entering an era where these places are low cost for elderly people precisely because everyone else is subsidizing a lot of that infrastructure for you. From the hospitals and clinics, to the roads. This is just a really hard problem. The best likely solution is to build more housing in the urbanized areas. But, yeah, how do you get that done profitably? It’s tough.
  - rayiner 7y ago
    Even if you build more housing, having older people live in urban areas still increases the price of housing. Crucially, older people don't need to be near urban jobs, so it's much more socially practical for them to live in rural areas. At the end of the day, the question is which subsidy is harder to deal with? Cash payments to keep rural hospitals open seems a lot easier than wading into enormously expensive and distortionary urban housing policies like rent control.
    - 7y ago

DenisM 7y ago

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

dgzl 7y ago
The idea is interesting but your "minimum speed of 120mph and modern car requirement" is not. Remember, this is rural America we're talking about, that is having trouble keeping hospitals running.
- DenisM 7y ago
  If it costs $100m/year to run a single hospital, it will probably cost, what, 1/10th of that to maintain a fleet of self-driving high-speed ambulances? The highways will need to be built on the state/federal level, most transportation is that way.
  - dgzl 7y ago
    The amount of construction needed for that kind of project that would only benefit a small number of people... It's just absurd. Rural people would rather that money go into more important projects.
    - DenisM 7y ago
      Did it seem equally absurd to build the East Coast - West Coast railroads in the 18xx? Only a small group of the Wild-West settler would benefit from it. And did it seem absurd 100 years ago to expect a nation-wide system of 55mph highways? I'm pretty sure that it did seem absurd, and yet we're all better off for it in the end. Transportation infrastructure has a huge long tail of benefits.

joshgel 7y ago

> Maintaining a fleet of doctors and facilities that are increasingly rarely used is expensive. I'm a physician working in NYC. I could make a full 75% more salary if I went to work in a rural area. Very inverse from most professions (I think) where people working in the city make the most. But I think it's that challenging to get physicians to work in rural areas.

jandrewrogers 7y ago
This. Staffing these hospitals requires paying very large cash compensation premiums compared to cities. I have a couple acquaintances that worked at these hospitals, and they all did it for the money. Even then, most of them wouldn't do it for any length of time because the sacrifice to their personal and social life is too high.
fernmyth 7y ago
Huh, if the pay is better, why is it challenging to get physicians to work in rural areas? If you don't mind sharing, why wouldn't you do it?
- dlp211 7y ago
  Not the person you wanted a response from, but money isn't everything.
- lotsofpulp 7y ago
  The pay is better, but not sufficiently better to offset benefits of urban life. Offer $5M per year, and it won't be challenging to get physicians to work in rural areas. So the problem is merely that there isn't enough funding to incentivize doctors to work in rural areas.
- bilbo0s 7y ago
  “Money isn’t everything.” That’s the short answer. For instance, what about your husband/wife? They just put their career on hold to go live in the boonies for 5 or 10 years? That sort of thing will put an enormous strain on your relationship.
- 7y ago

adrianN 7y ago

Another serious problem is that the care you get at rural hospitals is often much worse than at bigger hospitals. Doctors perform procedures less often and make more mistakes. A smaller variety of equipment is available. Often you're better of driving a bit longer to a larger hospital.