Recent Rural Hospital Closures and Service Disruptions in the United States: A Rapid Systematic Review

Abstract

Rural hospitals are essential access points for healthcare delivery in the United States, yet they continue to experience disproportionate rates of closure and service disruption that threaten community health, economic stability, and equity. This rapid systematic review synthesizes recent peer-reviewed evidence examining rural hospital closures and service disruptions, with emphasis on financial, policy, workforce, and performance-related factors and their downstream impacts. Guided by PRISMA methodology, four databases were searched for U.S.-based studies published between January 2024 and June 2025. Following screening and consensus-based review, 59 articles met inclusion criteria. Across studies, financial vulnerability, characterized by revenue instability, low patient volumes, unfavorable payer mix, and reliance on non-operating revenue, emerged as a dominant precursor to closure and service reductions. Policy context, particularly Medicaid expansion status, telehealth and broadband infrastructure, and reimbursement adequacy, strongly shaped hospital sustainability. Closures and service disruptions were consistently associated with increased travel distances, reduced access to maternal, surgical, mental health, and chronic care services, higher prices at surviving hospitals, and increased strain on remaining providers. Workforce shortages further compounded these challenges. Collectively, findings demonstrate that rural hospital closures reflect interconnected structural weaknesses rather than isolated organizational failure. Coordinated policy action, targeted financial stabilization, workforce development, and technology-enabled care models are necessary to mitigate continued erosion of rural healthcare access.

1. Introduction

1.1. Rationale

Rural hospitals play a critical role in ensuring access to essential healthcare services for nearly 60 million Americans living in rural and frontier communities across the United States. Beyond providing acute and preventive care, rural hospitals serve as economic anchors, major employers, and hubs for public health preparedness within their communities [1]. Despite this essential role, rural hospitals have faced mounting financial, operational, and workforce pressures over the past decade, resulting in an accelerating pattern of hospital closures and service disruptions. In the rural hospital setting, service disruptions refer broadly to any reduction, reconfiguration, pause or loss of healthcare services that limits the availability, accessibility, timeliness, or continuity of care for any given population [1,2]. This includes not only full hospital closures, but also partial or incremental changes such as the elimination of key service lines (for example, obstetrics, emergency services, or surgery), reduced hours of operation, diversion of patients, staffing shortages that constrain capacity, temporary suspensions of services, or the transition of facilities to alternative care models (such as outpatient-only or rural emergency hospital designations). Service disruptions may be episodic or sustained and often reflect underlying financial, workforce, policy, or operational pressures, with significant implications for care access, patient outcomes, and health equity in rural communities. These trends have intensified in recent years due to compounding factors such as reimbursement instability, declining patient volumes, workforce shortages, uneven Medicaid expansion, and system-level shocks including the COVID-19 pandemic and cybersecurity threats [1,2,3].

While prior studies have examined rural hospital closures, the rapidly evolving healthcare policy environment, coupled with emerging financial, workforce, and technological stressors, has created a need for an updated and focused synthesis of the literature. Recent federal and state policy changes, including new rural hospital designations, reimbursement adjustments, and targeted stabilization programs, alongside the post-pandemic transition from Coronavirus Disease relief funding, have substantially altered the operating landscape for rural hospitals in the United States. Earlier reviews, conducted prior to these developments, are therefore limited in their ability to reflect current conditions, including increased financial volatility, workforce constraints, and especially ongoing, evolving care delivery models such as telehealth expansion and hospital restructuring or conversion.

Existing reviews often emphasize isolated factors, such as financial performance or workforce shortages, without fully integrating how recent policy shifts, service reductions, and organizational vulnerabilities intersect to influence hospital viability. Also, evolving definitions of access loss or “care deserts,” partial closures, and service line discontinuations have gained greater prominence but remain inconsistently examined, despite their significant implications for access, outcomes, and health equity in rural populations. Service disruptions that fall short of full hospital closure, including the loss of obstetric, surgical, or emergency services, are particularly underrepresented in earlier literature. Such industry-specific segmentation of prior reviews and their findings, in conjunction with ongoing policy changes and emerging financial, workforce, and technology initiatives, creates the need for a current and timely assessment to inform industry decision-making.

Given these limitations, a rapid review approach allows for a timely synthesis of the most recent evidence, incorporating newly available data sources and reflecting the current policy and operational environment. Focusing on the January 2024 through June 2025 period enables a more accurate assessment of emerging trends and supports more relevant policy discussions and organizational decision-making during a period of ongoing rural healthcare transformation. The review was not registered and a protocol was not prepared because it was conducted primarily as a preliminary investigation into rural hospitals, using more recent and current publications on closures and related terms to identify knowledge gaps and inform areas for future research in this field.

1.2. Objectives

The objective of this systematic rapid review is to synthesize peer-reviewed literature addressing rural hospital closures and service disruptions in the United States, with a specific focus on identifying underlying financial, policy, workforce, and performance-related factors associated with these events. This review aims to (1) characterize common financial and operational conditions preceding rural hospital closures or service reductions; (2) examine the role of federal and state health policy, including Medicaid expansion, telehealth policy, and infrastructure investment, in shaping rural hospital sustainability; and (3) assess the documented impacts of closures and service disruptions on healthcare access, costs, workforce capacity, and patient outcomes. By consolidating current evidence across these domains, this review seeks to inform policymakers, healthcare leaders, and researchers about the systemic challenges facing rural hospitals and to highlight opportunities for targeted, sustainable interventions to preserve access to care in rural communities.

2. Materials and Methods

This systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and a PRISMA checklist is provided as a Supplementary Materials File S1 reference to this article. Literature for this review related to rural healthcare organizations was obtained from four separate databases: (CINAHL) Complete, Academic Search Ultimate, Business Source Ultimate via the Ebson B. Stephens Company (EBSCO host), Ipswich, MA, USA and PubMed (which queries MEDLINE). Overall, four databases were utilized to broaden the search due to an initial observation of limited publications meeting the search criteria.

The researchers focused exclusively on articles addressing rural hospital facility closures in the United States and/or those describing service disruptions within the rural healthcare industry. Boolean search operators were used to ensure appropriate combinations of words and phrases captured all relevant literature, including follow-on “exploded” terminology specific to rural healthcare and related organizations. Search terms within the search string were truncated using an asterisk to allow inclusion of multiple variations in each term. The final search string that produced the highest number of relevant published articles is presented in Figure 1 below:

Figure 1. Research database search string and Boolean search operators yielding the highest database search results.

The authors clarify that, in addition to the primary search string reported in the manuscript, multiple search strings and combinations of keywords, phrases, and Boolean operators were systematically tested across databases, including the use of controlled vocabulary such as Medical Subject Headings (MeSH). These expanded strategies, however, did not yield additional eligible studies within the defined inclusion criteria. Accordingly, the final search string presented was intentionally broad in scope, allowing for a more comprehensive and less restrictive approach that was determined to be more inclusive of relevant topics and articles. The authors also acknowledge that the intentionally narrow and recent date range applied in this review, designed to capture the most current evidence, may have further limited the number of studies identified despite these broader search efforts.

2.1. Inclusion Process

To be included in the sample, publications must have occurred between 1 January 2024 and 19 June 2025. This specific publication date range criterium was utilized to ensure studies identified were appliable to the most-recent rural health organization closures or related service disruptions occurring in the rural healthcare sector. Editorials, government reports, letters to the editor, or other studies not based upon empirical evidence were not initially considered in this review. Full text was a required search criteria in the initial search criteria in order to identify only complete published articles for the review team to assess. The researchers were able to locate 100% of the final sample in full-text format for follow-on extensive review.

Studies in this review had to involve the closure of rural healthcare organizations, related occurrences, or rural health service disruptions. Qualification as a rural organization in this review initiative remained as stated/declared in the identified articles without further assessment of criterial or qualifications. Specific, recent facilitators of closure or service disruptions in the rural healthcare industry sector in the United States were intended themes to be identified, as previous reviews of literature in this specific industry segment (since 2024) remain limited.

This study’s information came from secondary data sources (library research database). All literature included in this research is publicly available and any individual research subjects (if present) are unidentifiable. As a result, this systematic review qualifies under “exempt” status in 45 Code of Federal Regulations (CFR) 46. An institutional review board review was not required, and no consent was necessary.

2.2. Exclusion Process

Figure 2 demonstrates the article exclusion process, beginning with the initial research database searches and concluding with the final literature sample (n = 59). Initially, 7980 articles met the primary search criteria, addressing variables related to both hospital closures (or service disruptions) and rural categorical status. Although four research databases were utilized to increase the potential literature sample size, a consequence of this approach was a high frequency of duplicate articles identified (32 total duplicates). After applying additional filters, including the study’s specified date range, rural U.S.-based hospital closures, English-language publications, and academic/peer-reviewed journals, 7872 articles were excluded, leaving 76 articles in the study sample. These remaining 76 articles were then downloaded in full text and thoroughly reviewed by the research team. All researchers independently reviewed the literature to ensure each article was germane to the study’s initiative.

Figure 2. Preferred reporting items for systematic reviews and meta-analysis (PRISMA) figure that demonstrates the study selection process.

3. Results

Upon completion of the final screening process, the research team removed an additional 16 articles from the sample for the following reasons: systematic reviews (n = 5), not germane to rural health and/or hospital closure or service disruption (n = 9), and not U.S.-based studies (n = 3). These determinations were made through multiple research team meetings conducted via webinar, during which all authors reviewed exclusion decisions and reached full consensus (100% agreement), resulting in a finalized literature sample of 59 articles.

Table 1 also includes columns that summarize the underlying themes, or constructs, identified in the literature. Healthcare policy context, financial constraints, outcomes related to and/or contributing to hospital closures, and workforce challenges were the primary themes identified by the research team during the literature review.

Table 1. Summary of findings (n = 59).

Article #	Author(s) & Journal	Participants/Setting	Method(s)/Design	Key Finding(s)	Policy Context	Financial Constraints	Outcomes Related to Closure	Workforce Challenges
[1]	Hoffman, G. et al. (2025) Health Services Research	Medicare fee-for-service beneficiaries age ≥ 65 hospitalized in rural counties (USA); 2014–2018 utilization window; 32 rural hospital closures (2015–2017 discharges).	Quasi-experimental observational study using 100% Medicare claims (MedPAR); rural county defined via Federal Office of Rural Health Policy/Sheps RUCA ≥ 4; counties marked by first closure; pre/post analysis with exclusions near closure.	Assessed whether rural hospital closures changed acute and post-acute utilization and outcomes; final analytic sample 3,043,101 discharge-level observations across 32 rural closures.	Uses federal rural definitions (RUCA-based) and Sheps Center closure data; implicitly tied to rural access policy monitoring.	Closures included Critical Access Hospitals and short-term acute facilities; closure pressure implied but not primary analytic focus.	Access/utilization and outcomes for acute and post-acute care after closure (county-level exposure).	Not primary focus.
[2]	Carroll, C. & Chang, J.Y. (2025) Health Affairs	Hospitals near rural hospital closures (USA); closures 2014–2018; matched nearby hospitals within 50 miles; inpatient stays priced via HCCI.	Difference-in-differences with propensity score matching; price index risk-adjusted; subgroup by system affiliation (AHA) and market competition (HHI).	Rural hospital closures associated with increased inpatient prices at nearby surviving hospitals; effects evaluated over 2 years pre and 4 years post closure; heterogeneity by competition/system affiliation.	Highlights competition/market structure implications for antitrust/regulatory oversight in rural markets.	Price increases suggest market power shifts post-closure; financial incentives and market concentration are central.	Inpatient price (allowed amount per stay) at surviving hospitals after closure.	Not primary focus.
[3]	Shepherd, M. et al. (2025) Journal of Rural Health	~200 million registered U.S. voters (L2 voter file, 2020) matched to all open acute hospital locations (Sheps + HHS).	Nationwide geospatial distance calculation (straight-line distance to nearest open acute hospital); stratified by demographics, region, and Medicaid expansion status.	Substantial disparities in distance to hospitals for rural residents, Native Americans, lower-income, older adults, and Republicans; closures in non-expansion states exacerbate distance inequities.	Directly ties access disparities to state Medicaid expansion decisions and hospital closures.	Implicit: non-expansion states and closure exposure linked to reduced access; financial drivers not quantified.	Distance to nearest open hospital; inequity measures; implications for utilization/mortality risk.	Not primary focus.
[4]	Durrance, C. et al. (2024) Health Services Research	All births in rural U.S. counties (NVSS restricted birth + linked infant death data), 2005–2019; county-level hospital closures (Sheps).	Staggered difference-in-differences + event study methods accounting for timing; outcomes include prenatal care initiation, birth outcomes, delivery outcomes, infant death.	Closures reduced in-county deliveries (especially most rural); moderately rural counties saw worse prenatal/infant outcomes (e.g., higher low birth weight); most rural counties showed small improvements and possible infant death reductions.	Relevant to rural maternal health service planning and closure mitigation; rurality stratification informs targeted policy.	Closures represent service loss; financial drivers not directly analyzed.	Prenatal care timing, birth outcomes, delivery practices, infant mortality after closures; heterogeneous by rurality.	Not primary focus, but implies access to obstetric services.
[5]	Keesee, E. et al. (2025) Journal of Rural Health	Nursing homes in counties with and without rural hospital closures (USA), 2012–2019; linked LTCFocus + Medicare + closure datasets.	Difference-in-differences with staggered treatment timing; compares NH occupancy, payer mix, ADL dependence, hospitalizations per resident-year.	No significant changes in occupancy, % Medicare residents, or ADL dependence; small reduction in downstream hospitalizations per resident-year after closure.	Supports understanding of long-term care impacts of rural hospital closures for county-level planning.	No major occupancy/payer shifts detected; financial impact on NHs not primary.	NH utilization/health proxies; reduced hospitalizations post-closure (mechanism unclear).	Not primary focus.
[6]	Dong, J. et al. (2024) Health Economics	Hospitals near rural hospital closures (USA), 2014–2019; AHA Annual Survey.	Propensity score matching + difference-in-differences; outcomes: LPN/RN/APN staffing; inpatient/outpatient surgeries; ED visits.	Nearby rural hospitals experienced significant increases in nurse staffing (~37% over 4 years) and increased surgical volume; no change in ED visits; no significant effects for nearby urban hospitals.	Implications for regional capacity planning after closures.	Shift toward higher-volume/‘profitable’ services (surgeries) suggests financial rebalancing in surviving hospitals.	Staffing levels and service volume changes in nearby hospitals post-closure.	Yes—reallocation/relocation of nursing workforce to nearby rural hospitals.
[7]	Xiao, David et al. (2025) Journal of Prevention & Intervention in the Community	14 stakeholders from 5 rural Tennessee hospitals (stakeholder interviews).	Semi-structured interviews; rapid qualitative analysis to identify themes on hospital survival.	Six themes supporting survival: government policy, commercial factors, internal business strategy, community engagement, ongoing challenges, behavioral health/substance use needs.	Government policy identified as key protective factor; advocacy/policy levers emphasized.	Commercial factors and internal business strategies central to sustainability.	Protective strategies associated with remaining open (qualitative).	Ongoing challenges include workforce pressures; behavioral health needs discussed.
[8]	Gruessner, R. (2025) Hospitals	Narrative review/U.S. hospital closure trend analysis (AHA, CMS, state databases, industry reports).	Narrative review synthesis.	Closures linked to reduced access, higher costs for insurers/patients, and local economic decline; suggests insurer/government interventions (timely payments, standby capacity payments) may mitigate closures.	Discusses insurer and government roles; proposes payment policy mechanisms to sustain capacity.	Central focus—claims, network disruption, out-of-network costs, payment adequacy, standby payments.	Access disruption and cost increases associated with closures.	Not primary focus.
[9]	Turbow, S.D. et al. (2024) Journal of Hospital Medicine	Metropolitan hospitals (closed vs open) and closed micropolitan/rural hospitals; AHA Annual Survey 2010–2021; closures verified.	Cross-sectional comparison + logistic regression of closure risk factors.	Metropolitan closures more likely among small, for-profit hospitals and in non-Medicaid expansion states; argues for tailored policies for metro hospitals.	Medicaid expansion status and differentiated policy approaches highlighted.	For-profit status and size suggest financial vulnerability/market pressures.	Closure risk predictors; comparison across geography types.	Not primary focus.
[10]	Letheren, A. et al. (2024). Journal of the American Rural Health Association and the National Rural Health Care Association	24 community residents in distressed Appalachian Tennessee county; interviews (May–August 2020).	Qualitative descriptive; semistructured interviews; content analysis using Penchansky & Thomas access framework.	Themes: accessibility, availability, affordability, accommodation, acceptability; most common: longer travel times, reduced emergency/specialty access, higher ambulance costs, longer waits.	Supports community-driven, multi-level solutions and local leader/policymaker action.	Affordability issues and ambulance cost burden discussed.	Perceived access barriers and service availability post-closure.	Implied via reduced availability; not direct.
[11] *	Thompson, D. (2025) Consumer Health News	News article; interviews with rural hospital CEOs; secondary data (CHQPR, CBO).	Journalistic report/interviews + cited reports.	Warns proposed Medicaid cuts could increase rural closure risk and reduce services (e.g., maternity care) especially in high-Medicaid reliance areas.	Medicaid funding/cuts central; policy risk framing.	Medicaid reliance and revenue vulnerability emphasized.	Projected risk of closures and service loss.	Not primary.
[12]	Battaglia, E. (2025) American Journal of Health Economics	U.S. counties losing all maternity services vs matched counties; Vital Statistics births 1996–2018.	Matched difference-in-differences at county level.	No adverse infant health consequences; fewer C-sections among low-risk women after closures; suggests prior overuse of cesareans in closing wards.	Implications for maternal care organization and quality oversight.	Not primary; service line viability implied.	Cesarean rate changes; infant outcomes largely null.	Not primary.
[13]	Malone, T. et al. (2025) The Journal of Rural Health	Rural hospitals nationwide; Medicare FFS claims (2019) and hospital datasets (HCRIS).	Conditional logit models of hospital choice; ZIP-code market delineation for inpatient + ED utilization; market defined to capture ≥ 50% volume.	New approach identifies primary markets with average 3 ZIP codes; correlates with observed utilization; useful for predicting distress and populations affected by closure.	Provides tool to target policy support to critical-access areas/markets.	Supports forecasting financial risk and distress predictors.	Improved market definition for analysis of closure risk/impacts.	Not primary.
[14]	Cendoma, P. et al. (2024) Heath Care Management Review	U.S. rural hospitals; AHA, CMS cost reports, AHRF; years 2015 and 2019.	Pooled cross-sectional OLS regression with robust SEs; association between service lines and total margin.	Obstetrics and alcohol/substance abuse services associated with higher total margins; psychiatry and long-term care services associated with lower margins; calls for nuanced service mix decisions.	Supports policy and strategic planning around which services to sustain in rural settings.	Direct focus—service mix linked to operating margins and closure risk.	Financial performance (total margin) by service line.	Not primary.
[15] *	Mundell, E. (2025) Consumer Health News	Summarizes studies led by Cody Mullens; rural patients and surgical services (2010–2020).	News summary of research using Medicare/Medicaid/AHA data; access defined as within 1 h of quality/affordable surgical hospital.	Closures contribute to limited surgical access; by 2020 ~40% rural surgical patients traveled ≥ 55 min; ~7% rural patients had insufficient access vs ~2% urban.	Highlights need for surgical access policy and rural service planning.	Affordable out-of-pocket costs included in access definition.	Travel time/distance and access classification for surgical care.	Not primary.
[16]	Serchen, J. et al. (2025) Annals of Internal Medicine	American College of Physicians policy committees; review of peer-reviewed research and reports; approved 11 February 2025.	Position paper; evidence review and stakeholder input; policy recommendations.	Policy recommendations for rural disparities: access, workforce, telehealth, payment models, etc.	Explicit policy guidance for improving rural health and healthcare.	Payment model recommendations included.	Not empirical; policy positions.	Workforce challenges and recommendations central.
[17]	Roush, K. (2024) American Journal of Nursing	Descriptive synthesis; CHQPR data on >400 maternity ward closures (2006–2020) and county classification.	Report-style summary of research and organizational findings.	~60% of rural hospitals lack labor/delivery; 6.9 M women face limited access; 1119 counties are maternity care deserts (two-thirds rural); workforce shortages emphasized.	Highlights need for targeted obstetric policy support and training capacity.	Service line viability implied; not quantified.	Access gaps and ‘maternity desert’ prevalence.	Clinician shortages identified as key barrier.
[18]	Ashworth, M. et al. (2024) Journal of Substance Use	U.S. recovery house leaders; cross-sectional survey June–July 2020; 1342 valid responses; rural/suburban vs urban.	Convenience sample survey (REDCap); analysis of closure-risk correlates during COVID-19.	8% at risk of closing; serving economically vulnerable increased risk; donations protective; nonurban houses less likely to report distress than urban.	COVID-era policy environment relevant; not hospital-specific.	Financial distress predictors central (contracts, donations, population served).	Closure risk (self-reported) for recovery housing, not hospitals.	Not primary.
[19]	Cooper, J. (2024) Neonatology Today	Descriptive/policy article on national obstetric unit closures; focus on rural/low-income/minority communities.	Narrative/advocacy-oriented synthesis; cites federal initiatives (Keep Obstetrics Local Act).	Obstetric unit closures reduce access and raise risks; proposes federal policy support to keep services local.	Explicit—Keep Obstetrics Local Act and federal intervention discussion.	Financial challenges of rural providers emphasized as driver.	Access to maternity services and projected risks.	Implied (staffing/coverage challenges).
[20]	Rastogi, S. (2024) Emory Bankruptcy Developments Journal	Legal/financial analysis of nonprofit bankruptcies and community impacts (USA).	Doctrinal/legal analysis of bankruptcy framework and stakeholder impacts.	Bankruptcy system may not protect public access needs; calls for reforms to better safeguard essential services and equitable outcomes.	Policy/legal reform oriented (bankruptcy framework).	Central—financial distress, nonprofit bankruptcy proceedings.	Implications for service continuity/access during bankruptcy/closure.	Not primary.
[21]	Tiwari, S. et al. (2024) Rural Sociology	Rural hospitals in six Michigan counties; key stakeholders interviewed/surveyed; excludes long-term/outpatient facilities.	Interviews + short survey; purposeful and snowball sampling; resilience assessment.	Reliable electricity critical; dependence on imported fuels; need proactive planning aligned with rural values for disaster resilience.	Emergency preparedness and infrastructure policy relevant; not closure-specific.	Energy reliability has cost implications; not primary.	Preparedness for energy disruptions; resilience.	Not primary.
[22]	Bambury, E. et al. (2025) The Journal of Rural Health	U.S. rural access indicators via AHRF (1990–2020, 10-year intervals); older adults.	Secondary data trend analysis using AHRF over time.	Hospital closures—especially in non-expansion and economically unstable areas—reduce access; aging rural population increases need; many studies show higher mortality after closures though mixed.	Medicaid expansion and rural access policies implicated.	Economic instability and non-expansion context linked to closure patterns.	Access decline, travel time, emergency services availability, health outcomes (mixed mortality findings).	Implied via reduced service availability.
[23]	Planey, A. et al. (2025) Cancer Causes & Control	Rural-dwelling adults in 13 Southern states (2018); multiple national datasets; hospitals in the South.	Cross-sectional analysis relating acute-hospital travel times to cancer screening; rural defined by RUCC 4–9; considers primary care shortage areas.	Longer travel times to acute hospitals associated with lower likelihood of cancer screening; partial-county shortage areas worst screening and longest distance.	Relevant to rural access and preventive care policy.	Notes CDC cancer detection programs may affect screening among uninsured.	Cancer screening receipt vs travel burden.	Primary care shortage context relevant; not direct workforce study.
[24]	Sharma, H. et al. (2024) The Journal of Rural Health	Medicare-certified nursing homes; closures 2008–2018; rural/urban ZIP codes; ACS population data.	Linked datasets (POS, NHC, HCRIS, LTCFocus); geospatial travel distance to nearest PAC/LTC providers using ZCTA data.	Closures reduce access to PAC/LTC; rural ‘care deserts’ have smaller populations but higher % age 65+ and White; closures linked to equity concerns.	Long-term care access planning; rural equity implications.	Lower-income ZIP codes more associated with closures; financial vulnerability implied.	Travel distance/access to PAC/LTC services after closure.	Not primary.
[25]	Smith, J. et al. (2024) Online Journal of Rural Nursing & Health Care	Nursing students; rural self-identification; two-group pre/post design.	Online simulation vs non-simulation interventions; pre/post testing for empathy, confidence, knowledge, advocacy.	Both approaches improved confidence/knowledge; minimal empathy change; no advocacy change; educational intervention not closure-specific.	Not closure-specific; rural workforce education relevance.	Not primary.	Learner outcomes (confidence/knowledge).	Yes—addresses preparedness of nursing students to serve rural communities.
[26]	Tung, E. et al. (2024) Annals of Epidemiology	U.S. hospitals in AHA Annual Survey (2007–2018); area-level socioeconomic and racial/ethnic composition.	Cross-sectional analysis + logistic regression; exposures include unemployment, Area Deprivation Index, rurality, ownership.	Closures more likely in areas with higher unemployment and socioeconomic disadvantage; suggests financial risk from serving lower-income populations.	Supports targeting policy support to disadvantaged areas; equity lens.	Socioeconomic disadvantage and unemployment central to closure risk—financial vulnerability implied.	Probability of closure by area characteristics.	Not primary.
[27]	Miller-Matero, L. et al. (2024) The Journal of Rural Health	Patients in three health systems; EHR + claims; rurality via geocoded data; pre/post COVID onset.	Secondary analysis of disruptions in psychotherapy; comparison rural vs nonrural; subgroup by age/education.	Disruptions decreased in both groups, larger reduction among nonrural; rural patients still face greater challenges; younger/lower-education rural improved most.	Telehealth policy implications for rural mental health access.	Not primary.	Psychotherapy disruption rates by rurality.	Not primary.
[28]	Lin, Y.C. et al. (2025) Cancer Medicine	3797 cancer patients with scheduled treatment within 6 weeks of COVID-19 diagnosis (March 2020–September 2022); mostly urban.	Registry analysis; multivariable regression; treatment delay/disruption defined as >2-week delay.	Assessed predictors of treatment disruption in rural vs urban; provides demographic and area-level predictors; not closure-specific.	COVID-era care disruption context; not closure-focused.	Not primary.	Treatment delay/disruption by rurality.	Not primary.
[29]	Anderer, S. (2024) JAMA	Report-style summary; CHQPR findings on rural labor/delivery unit closures; national context.	Journalistic synthesis of CHQPR report and expert commentary.	Widespread closures of rural birthing services; staffing model challenges; recommends team-based training, remote specialist support, new staffing approaches; urges government investment.	Calls for government investment and service-support policy changes.	Service line sustainability and investment needs emphasized.	Reduced access to birthing services; crisis framing.	Yes—staffing challenges central.
[30]	Goldsmith, J.P. & Muraska, J.K. (2025) Neonatology Today	Narrative/clinical-legal discussion; closure/discontinuation of obstetric services (2010–2023) including rural facilities.	Descriptive review and medico-legal discussion.	Closures increase maternal/neonatal risk and may worsen disparities; discusses standards for small-volume services and recommends safety strategies (risk assessment, preparedness).	Regulatory/standard-setting and safety oversight implications.	Not primary; closures noted as trend.	Perinatal safety risks and disparities; implications of service discontinuation.	Implied challenges for small-volume staffing; not direct.
[31]	Miller-Hammond, K. & Anderson, D. (2025) The American Surgeon	Narrative review of rural surgical workforce and closures; U.S. context.	Review of research and workforce data; strategy synthesis.	Declining rural surgical access driven by aging surgeon workforce and hospital closures; proposes pipeline strategies (rural student recruitment, mentorship, exposure) and financial incentives (loan repayment).	Workforce and incentive policy recommendations.	Loan repayment and incentive programs noted.	Surgical access barriers and proposed solutions.	Yes—surgeon workforce pipeline and retention.
[32]	Strickland, C.L. et al. (2024) Rural and Remote Health	Rural parturients delivering in urban vs rural hospitals; Vizient Clinical Database; distances via ZIP centroids.	Comparative observational analysis; considers teaching status and delivery volume; sensitivity analysis excluding transfusion-only SMM.	Rural patients had better maternal outcomes when delivering at local rural hospitals; maintaining local access requires addressing rural-specific challenges.	Supports policies sustaining local rural obstetric capability.	Not primary.	Severe maternal morbidity differences by hospital location/type.	Implied need to sustain rural capacity.
[33]	Wilbanks, B.A. & Effinger, B. (2025) Journal of Nursing Administration	Nurse anesthetists in Mississippi (rural focus); mailed survey August–November 2023.	Cross-sectional exploratory survey; workforce retention and participation factors.	Flexible scheduling and work–life balance reduce intent to leave and improve participation; recruitment focus on female providers.	Workforce policy implications for rural anesthesia coverage.	Not primary.	Intent to leave; labor participation.	Yes—retention and recruitment strategies.
[34]	Trombetta, M. et al. (2025) The Journal of Rural Health	Adult patients of a rural health center (Alsea Health) post-closure; 131 respondents; median age 63.	Cross-sectional telephone survey (19-item) at 6 months post-closure.	Most transitioned to new providers; quality perceived unchanged; access worsened (esp. chronic pain and mental health); increased urgent care use.	Supports community planning for continuity and access after closure.	Not primary; access barriers may increase urgent care costs.	Patient-reported access, chronic condition management, quality perceptions post-closure.	Not primary.
[35]	Pitcher, A. et al. (2024) The Journal of Rural Health	2462 U.S. rural hospitals; HCRIS 2011–2019; CAH and R-PPS hospitals; ownership categories.	Descriptive statistics + regression models; NOR reliance as % total revenue.	Both CAH and R-PPS rely on NOR; government-owned rely more; system affiliation matters; NOR may improve margins but is not guaranteed; underscores need for stable reimbursement.	Implications for public funding approaches and targeted subsidies.	Central—NOR sources (investments, contributions, appropriations) and margin support.	Financial stability/profitability via NOR reliance.	Not primary.
[36]	Nikpay, S. et al. (2025) Health Services Research	Medicare beneficiaries age ≥ 65 with STEMI (2011–2020).	Observational cross-sectional comparison of transfer identification methods using 100% inpatient/outpatient files and carrier files.	Proposed method identifies substantially more transfers and better captures rural and lower-income patients; existing method undercounts rural transfers and understates travel burden.	Important for monitoring rural emergency cardiac care access and transfer policy performance.	Not primary.	Transfer identification accuracy; travel distance to ED/trauma/ICU for transferred patients.	Not primary.
[37] *	Lyttle, T. (2024) Virginia Nurses Today	Narrative/advocacy article with examples and expert opinion.	Descriptive synthesis of trends and stakeholder perspectives.	Calls for policy changes and funding to protect rural access; cites low reimbursement, staffing shortages, and financial problems as drivers of closures.	Explicit call for coordinated policy response.	Low payment and financial distress central.	Access and community health impacts framed.	Workforce shortages emphasized.
[38] *	Kliff, S. (2024) The New York Times	News summary of nationwide study on maternity service discontinuation.	Journalistic synthesis.	Maternity ward closures common in rural/underserved areas; linked to longer travel distances, delayed care, and worse maternal outcomes.	Highlights need for maternal service access policy interventions.	Not primary.	Access and maternal health impact framing.	Implied; not direct.
[39]	Neprash, H.T. et al. (2024) The Journal of Rural Health	U.S. hospitals (rural/urban) with ransomware attacks; linked Tracking Healthcare Ransomware database + AHA + Medicare FFS (2016–2021).	Stacked event study at hospital-week level; outcomes: volume and revenue in inpatient/outpatient/ED.	Ransomware caused sharp short-term drops in admissions/visits and revenue; effects similar magnitude rural vs urban; rural patients face much greater travel distance to alternative hospitals; disruptions may be more financially harmful in rural settings.	Cybersecurity preparedness and response policy implications; rural vulnerability highlighted.	Central—lost volume and revenue; rural financial fragility.	Utilization and revenue disruption; travel burden to alternative care.	Not primary.
[40]	Johnson, E.A. & Hellem, T.L. (2024) HERD	Framework development; being tested with a Critical Access Hospital project in Montana.	Conceptual/middle-range framework adapted from participatory research model; theory integration.	Framework guides engagement of rural community and clinical voice across facility project phases to improve relevance and sustainability.	Supports community-engagement best practices for rural facility planning.	Not primary.	Not empirical; provides design process tool for resilient facilities.	Engages clinical teams/stakeholders; not workforce outcomes.
[41]	Nazari, J.L. et al. (2024) Journal of Evaluation in Clinical Practice	15 academic detailing groups (Canada n = 3; U.S. n = 12).	Semi-structured interviews; framework method using CFIR.	Virtual detailing expanded reach and flexibility (including rural areas) but faced tech and engagement challenges; continuing education used as incentive; established networks helped.	Telehealth/virtual outreach policy and implementation relevance.	Not primary.	Implementation facilitators/barriers; potential equity benefits for rural reach.	Yes—provider engagement and training considerations.
[42]	Hill, H. et al. (2024) Morbidity and Mortality Weekly Report	U.S. children (NIS-Child) born 2020–2021; vaccination coverage by age 24 months.	Survey analysis 2021–2023; stratified by race/ethnicity, insurance, poverty, urbanicity, jurisdiction.	Vaccination coverage declined for pandemic birth cohorts; lower coverage among Medicaid/uninsured, lower income, and rural children; widening inequities.	Public health policy implications for immunization and access in rural areas.	Insurance/poverty status associated with coverage differences.	Vaccine coverage rates and disparities.	Not primary.
[43]	Carroll, C. et al. (2024) Health Affairs	Policy review/discussion of rural hospital support approaches (USA).	Narrative policy analysis.	Public support programs exist but poorly targeted; recommends better targeting of funds to critical hospitals; recognizes need for regulation to limit negative effects of reduced competition when markets cannot support multiple hospitals; discusses Rural Emergency Hospital designation.	Direct focus on federal/state policy approaches, targeting, and regulation.	Central—financial distress, targeted funding, reimbursement, competition and price effects.	Access to affordable, high-quality care; policy tradeoffs.	Workforce issues acknowledged as ongoing challenge.
[44]	Freytes, I.M. et al. (2025) Community Mental Health Journal	Hispanic Veterans in rural areas (VISN 8); needs assessment via mixed methods.	Mixed methods needs assessment; thematic analysis.	Identified gaps: info access, social support disruptions, limited services, risky behaviors, natural disasters; need culturally respectful services and outreach.	Veterans’ mental health and rural access policy implications.	Not primary.	Service gaps relevant to suicide prevention.	Not primary.
[45]	Pati, D. et al. (2024) HERD	Symposium with 65 professionals from 18 West Texas institutions; qualitative capture of deliberations.	Symposium data capture and analysis; cluster themes.	Identified challenges/opportunities across delivery, infrastructure, community health, public administration; telemedicine as future promise; resiliency highlighted.	Public administration and policy opportunities for rural health systems.	Funding constraints noted; community collaborations suggested.	Not closure-specific but addresses system challenges, including closures as context.	Workforce resiliency themes implied.
[46]	Keesee, E. et al. (2024) Medical Care Research and Review	U.S. hospitals (2019 vs 2014 comparisons); rural vs urban; Medicaid expansion status.	Financial analysis using hospital data; uncompensated care as % operating expenses; state-level comparisons.	Rural hospitals had higher uncompensated care; gap much larger in non-expansion states (e.g., 6.28% vs. 2.55%); uncompensated care increased in non-expansion rural between 2014–2019; suggests expansion reduces burden.	Medicaid expansion policy central; state variation emphasized.	Central—uncompensated care burden and profitability risk.	Uncompensated care burden linked to closure risk.	Not primary.
[47]	Xu, L. et al. (2025) Medical Care Research and Review	U.S. nursing homes (2009–2019) in markets with and without closure; rurality stratification.	Callaway & Sant’Anna DID; outcomes: occupancy, net profit margin, operating margin.	Nearby nursing homes in rural markets saw higher occupancy and improved financial indicators after closures; little effect in metro/micro areas; raises access concerns.	Regulatory implications for long-term care market interventions and rural heterogeneity.	Central—profit and operating margins post-closure.	Market consolidation effects; access tradeoffs.	Not primary.
[48]	Kirkland, D.A. & Lindley, L.C. (2024) Contemporary Nurse: A Journal for the Australian Nursing Profession	Policy discussion; Appalachia; notes rural hospital closures since 2010 with ~20% in Appalachia.	Discussion paper; PubMed search January 2023; policy review of broadband legislation and telehealth implications for advanced practice nursing.	Broadband legislation expanded telehealth capacity; ongoing infrastructure/funding issues persist; telehealth may mitigate closure-related access gaps.	Federal broadband and COVID-era telehealth policy central.	Funding/infrastructure barriers noted.	Telehealth access improvements; remaining gaps.	Yes—advanced practice nursing care via telehealth.
[49]	Weeks, W.B. et al. (2024) The Journal of Rural Health	Conceptual/implementation plan; rural U.S. communities.	Implementation plan narrative; proposes infrastructure/workforce/partnership actions.	Technology and AI can improve health/economic outcomes; emphasizes rural-urban disparities, closures, and telehealth potential; calls for coordinated efforts.	Policy and implementation recommendations for digital infrastructure and AI use.	Addresses financial challenges and closures; focuses on sustainability via technology.	Projected access and economic benefits; not empirical.	Workforce development a major pillar.
[50]	Pampati, S. et al. (2024) Annals of Family Medicine	Parents of children age 5–12 (COVID Experiences Survey waves 2020–2021), national sample.	Longitudinal survey analysis; logistic regression; outcomes: forgone care, forgone well-child visits, no well-child visit.	Unmet pediatric needs common; disparities by income, insurance, race/ethnicity, urban–rural classification, and primary care supply; racism associated with some outcomes.	Public health and access policy implications, including rural access barriers.	Income/insurance barriers central.	Unmet care indicators during COVID.	Primary care availability context; not direct.
[51]	Ko, E. et al. (2025) BMC Women’s Health	47 participants (Latina patients n = 21, caregivers n = 14, professionals n = 12) in rural agricultural U.S. region.	Qualitative cross-sectional; in-depth interviews; thematic analysis; descriptive stats for demographics.	Financial toxicity driven by employment disruption and medical/non-medical costs; impacts include unmet basic needs, distress, family conflict, and care delays; calls for culturally appropriate interventions.	Equity and support program policy relevance for rural oncology care.	Central—out-of-pocket, co-pays, transport, childcare; financial distress impacts care.	Care delays/discontinuation, quality of life, psychosocial impacts.	Not primary.
[52]	Fontenot, J. et al. (2024) BMC Pregnancy and Childbirth	U.S. women of childbearing age; national hospital data; mapping of obstetric facility access.	Geospatial mapping and travel time/distance analysis; examines deserts and disparities.	Substantial disparities in obstetric access, especially rural and southern states; many must travel >30 min; closures and workforce shortages worsen inequities.	Maternal health equity and service distribution policy relevance.	Not primary.	Travel distance/time to obstetric hospitals; access inequities.	Workforce shortages referenced as contributing factor.
[53]	Tai, M. et al. (2024) International Journal of MS Care	36,599 Medicare FFS MS patients receiving infusion DMTs (2017–2022).	Claims-based travel distance/time estimates from ZIP codes to infusion facility; rural vs urban comparisons; outliers excluded.	Mean total travel per visit 54 miles; large rural residents more likely to travel > 120 miles (22% vs. 7% urban); greater travel time burden; future research on outcomes proposed.	Access and equity implications for specialty infusion services.	Not primary.	Travel distance/time burden for treatment access.	Not primary.
[54]	McDaniel, C.E. et al. (2025) Academic Pediatrics	256,947 hospitalizations for rural-residing children (0–17) across 8 states, 2002–2017; excludes birth/psychiatric/surgical.	HCUP State Inpatient Databases; trend tests; rurality via RUCA; outcomes include hospital location, interfacility transfers.	Rural pediatric hospitalizations declined; interfacility transfers increased (6.7% → 26.5%); more care shifted to metropolitan hospitals; local-area agreement decreased.	Implications for regionalization of pediatric care and rural preparedness/disaster planning.	Not primary.	Shifts in care location and transfers; access burden.	Not primary.
[55]	Hayirli, T.C. et al. (2024) International Journal for Quality in Health Care	26 interviews with leaders/emergency managers from 12 U.S. hospitals; varied geography/rurality/size/resources.	Qualitative interviews; analysis of formal vs informal practices during COVID-era crises.	Both formal plans and informal adaptations needed; identified emergent capabilities (imaginative planning, recombinant teaming, transformational exchange) supporting resilience.	Emergency preparedness policy and hospital resilience planning.	Addresses precarious finances as crisis context; not closure-specific.	Operational resilience and safe care during crises.	Yes—teaming, staffing adaptations during crisis.
[56]	Johnson, S.M. & Miller-Hammond, K. (2025) The American Surgeon	Narrative review; national surgical access disparities and solutions.	Review and synthesis of national data and policies.	~1 in 3 Americans lack access to quality surgical care; barriers include rural geography, closures, disasters, bias; suggests telemedicine, workforce training, policy changes.	Policy and solutions overview for surgical access disparities.	Mentions preventable spending and affordability barriers.	Access to timely/affordable surgical care; morbidity/mortality implications.	Yes—workforce training emphasized.
[57]	Englum, B.R. et al. (2025) Annals of Surgical Oncology	VA Health Care System cohort 2018–2021 (~900 k colonoscopies; 1.4 M FOBT; >30 k CRC diagnoses).	Cohort analysis comparing pre-COVID vs COVID era; trends by demographics and rural-urban/SES; logistic regression adjustment.	Early COVID saw dramatic drops in colonoscopy and new CRC; modest temporary disparity increases; no persistent adjusted disparities in VA; suggests system strengths.	Health system resilience policy implications; VA as model.	Not primary.	Screening and diagnosis volumes and disparity trends.	Not primary.
[58]	Pamplin, J. et al. (2024) Critical Care Explorations	Case analysis of national leaders/stakeholders (>50) supporting NETCCN during COVID-19.	Case analysis + consensus white paper approach; barriers/solutions categorized minimum/better/best.	Key barriers: cross-state licensure and privileging; challenges in regulation, tech integration, and training; flexible teamwork enabled expansion of critical care capacity, especially in underserved/rural areas.	Licensure/credentialing and telemedicine regulation central.	Financial model for long-term success noted as major barrier/need.	Implementation feasibility and capacity expansion via tele-critical care.	Yes—training, staffing models, and remote expert deployment.
[59]	Kang, Y. et al. (2024) Preventive Medicine	U.S. vaccine ordering data (Merck), January 2018–December 2022; stratified by public/private funding, urbanicity, state.	Time-series comparison vs baseline years; deficit estimation by month and stratifiers.	Ordering recovered but deficits remained; larger deficits in publicly funded doses and HPV ordering in rural counties; encourages vaccination at every visit and gap-reduction strategies.	Immunization program policy and rural equity implications.	Public vs private funding differences central.	Vaccine ordering deficits and recovery patterns.	Not primary.

* not peer-reviewed but included by the research team due to significant contribution to the review objective.

The research team employed a structured, multi-stage analytical approach using Microsoft Excel to systematically identify and synthesize underlying themes across the included studies. Following full-text review, key findings, variables, and outcome measures from each article were extracted into a standardized Excel matrix, with individual rows representing studies and columns capturing relevant data elements (for example, financial indicators, policy references, operational challenges, workforce factors, and service-level impacts). In an initial round of independent screening in groups of two, open coding was conducted in which the team assigned descriptive labels to each extracted finding, allowing patterns to emerge inductively across studies. These codes were then iteratively reviewed and refined through constant comparison, with similar or overlapping concepts grouped together using Excel sorting, filtering, and pivot table functions to assess frequency and co-occurrence. Throughout this process, clusters of related codes were collapsed into broader analytical categories, enabling the research team to move from granular observations to higher-order constructs. Financial duress emerged as an identifiable category capturing revenue instability, cost pressures, and margin decline; policy implications reflected regulatory changes, reimbursement shifts, and external funding influences; performance challenges encompassed operational inefficiencies, quality concerns, and organizational constraints; and service reductions and workforce shortages represented access limitations, staffing deficits, and care delivery disruptions. This systematic coding and aggregation process enhanced analytic rigor and transparency, ensuring that the four primary constructs were grounded in consistent patterns observed across the literature.

Agreement was also reached regarding cost-influencing and cost-prevention variables, as well as article assignments, or coding. All researchers were required to agree on each article’s inclusion within the relevant thematic categories. Article inclusion across thematic categories was not mutually exclusive, and a single article frequently met the criteria for multiple cost-influencing and/or cost-reducing categories (Figure 3).

Figure 3. Occurrences of underlying themes (constructs) identified in the literature on hospital closures and/or service disruptions in rural healthcare organizations [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59].

4. Discussion

The findings from this systematic review underscore the persistent and interconnected challenges facing rural healthcare systems in the United States, particularly as they relate to hospital closures, service disruptions, and long-standing structural inequities. Across the reviewed literature, rural hospitals consistently emerge as financially fragile institutions operating within constrained policy, workforce, and geographic environments. These vulnerabilities are not historical artifacts but rather reflect ongoing, present-day realities shaped by revenue instability, low patient volumes, unfavorable payer mixes, and dependence on external funding sources. Compounding these challenges are uneven policy decisions, most notably Medicaid non-expansion, inconsistent reimbursement, and fragmented broadband and telehealth implementation, that continue to undermine the financial sustainability of rural healthcare organizations and exacerbate disparities in access to care.

Collectively, the reviewed evidence highlights how financial constraints/duress, policy limitations, workforce shortages, and declining hospital performance reinforce one another, accelerating the creation of care deserts across rural America. Hospital closures and service reductions have tangible consequences for communities, including increased travel distances, reduced access to maternal, surgical, mental health, and chronic care services, and increased strain on remaining healthcare facilities and providers. These dynamics disproportionately affect low-income populations, marginalized racial and ethnic groups, and residents of geographically isolated regions. As rural hospitals continue to close at alarming rates, the literature emphasizes that without coordinated, sustained policy action and investment, particularly in Medicaid expansion, workforce development, and technology-enabled care delivery, rural health inequities will persist and deepen. The following sections examine these challenges in greater detail, organized around financial duress, policy implications, hospital performance outcomes, and service and workforce constraints shaping the current rural healthcare landscape.

4.1. Financial Duress

Of the 59 articles included in the review, 26 (44%) discussed the financial vulnerability of rural hospitals as either a primary factor or a consequence of systemic disruption. It is cited that rural hospitals rely heavily on non-operating revenue (e.g., government subsidies, donations, investment income) to remain viable [35]. The balance sheet is also discussed as being more destabilized in states that did not expand Medicaid [46]. The following four elements have been identified as common characteristics of rural healthcare facilities and contributors of a challenging financial structure:

• Revenue instability
• Low patient volumes
• Unfavorable payer mixes
• Reliance on external funding sources

In times of crisis (e.g., ransomware attacks, COVID-19 pandemic), operational shutdowns due to financial inability become imminent [46,58]. Financial toxicity refers to the difficulties patients face related to the cost of medical care and has been discussed as extending beyond the organization to patients [60]. In one article, rural Latinas with breast cancer reported delays in care and adverse health effects due to the cost of treatment [51]. National vaccine ordering trends also indicated that access to routine healthcare is compromised when funding sources are inconsistent or delayed [59]. Collectively, these findings suggest that financial instability not only leads to hospital closures but also erodes patient trust, therefore posing a threat to the long-term viability of the healthcare system.

4.2. Rural Health Policy Implications

Since 2024, federal policy responses have been an important source of influence on healthcare access in rural America through broadband expansion and virtual care. Legislative actions, such as the CARES Act, the American Rescue Plan, and the Infrastructure Investment and Jobs Act, have invested resources into broadband expansion in areas such as Appalachia [48]. This expansion has been a tremendous support for telemedicine and advanced practice nursing as interventions for lost services as a result of hospital closures. Furthermore, there is a significant concern about the approaching withdrawal of the telehealth services that were originally provided by the Centers for Medicare and Medicaid Services (CMS) during the COVID-19 public health emergency and the limitation of continuity of care among marginalized communities. Moreover, while broadband was classified as a social determinant of health, private providers are often unwilling to build in under-resourced rural areas and thus limit the reach of the broadband policy. While broadband policy holds promise for reducing health disparities, the impact is uneven and contingent upon significant compliance, accountability, and further funding. Without comprehensive policy actions that bundle broadband subsidies and telehealth reimbursement, as well as regulating broadband rollout, many rural residents will continue to lose access to basic care. Although federal policies have led to a meaningful foundation to promote systematic change, health systems will need a stronger commitment to structural, long-lasting change to ensure rural communities benefit equitably.

In addition to infrastructure issues, systemic inequities in Medicaid expansion and healthcare workforce allocation are factors in the decline and closure of hospitals in rural areas and instability in care network delivery. When a state does not expand Medicaid, and Medicaid participation is limited, large numbers of populations remain uninsured, reducing hospital revenue and exacerbating financial instability and operational closure [56]. This issue is a key concern in rural areas currently experiencing surgical and specialty workforce shortages. Additionally, the pool of available surgeons is narrowing due to attrition rates in surgical residency training, along with high rates of attrition for some specialty training programs. Moreover, women and underrepresented minorities graduate from surgical training at a much higher rate than men and underrepresented others, and these populations are also underrepresented in surgical leadership [56]. Although some academic institutions are developing regional rural training programs or rural training rotation sites, they are not coordinated as a movement to start bridging the workforce gap. Additionally, policy choices have frequently not supported racially or geographically diverse providers, diminishing the pipeline of clinicians willing to engage as practitioners in rural communities. For example, census tracts with higher proportions of American Indian and Alaska Native residents incur travel distances for obstetric care at disproportionately high rates and illustrate an intersection of race and space in health inequity and inequitable care situations [52]. In conclusion, rural health access will measurably improve if policy support addresses Medicaid expansion, resources and incentives for diverse rural training, and removes structural barriers in workforce planning and development.

Moreover, geographic trends of hospital closures illustrate how policy decisions create care deserts. Travel distances to get to obstetric hospitals are extremely far in many states, particularly in the Great Plains and Mountain West [52]. Most Americans can access care 30 min away from a hospital. However, people who live in maternity care deserts often travel four times that distance. In reality, travel distances are even further for communities characterized by a majority of American Indian and Alaska Native census tracts, where the average travel distance is over 50 miles or 100 min long [52]. These distances highlight geographic realities and policy neglect. Policy neglect is exemplified by poor Medicaid reimbursement, the consolidation of hospitals, and a lack of support for rural clinicians that has all contributed to declining rural healthcare infrastructure. Using trauma-informed legal care frameworks provides a different perspective to demonstrate how traditional policy models do not adequately incorporate what rural people experience on the ground level, especially regarding trauma [51]. The Community Justice Worker program in Alaska is an example of a program that centers place-based care and culturally informed care [51]. Thus, it is important for policymakers to not only stop using one-size-fits-all approaches but to also actively seek out sustainable rural care models, increase training in the community, and ensure that policies address geographic and social realities.

4.3. Rural Hospital Performance-Related Challenges

The problem of rural hospitals closing in the United States has had effects on healthcare access, costs, and outcomes. Articles have shown that these closures have led to a decrease in both acute care and post-acute care in rural areas. As a result, nearby hospitals often raise their prices because there is less competition or fewer care options in the area [1,2]. While all rural communities are affected, people living in Medicaid non-expansion states and low-income areas are hurt the most [3,26]. Maternal and infant health care is also impacted. Expecting mothers often have to travel much farther to give birth, while some are unable to get early pregnancy care at all [4]. This problem causes mothers and other patients to miss important doctor visits and health screenings because they have to travel long distances to get help [23]. Nursing homes have also reported that even though they did not lose residents after a nearby hospital closed, their patients visited the hospital less often than before [5].

Hospitals that are still open are now overwhelmed with work because they must care for more people. This puts more pressure and stress on nurses, doctors, and other staff during work [6]. Some parents have said it’s become harder to get help for mental health and chronic conditions [35]. At the same time, local jobs are disappearing, hospitals are having trouble keeping staff, and ambulance rides are taking longer, which makes it even harder for small communities to stay healthy and strong [11,37]. If rural hospitals continue to keep closing and nothing is done to prevent these closings, people in small towns will face even more serious health problems in the future [16,19,37].

4.4. Service Reductions and Workforce Shortages in Rural Healthcare

Across rural America, declining access to healthcare is placing millions of residents at increasing risk. Hospital closures, clinician shortages, and financial instability create challenges that compromise service delivery and the well-being of communities. Many rural hospitals face unsustainable operating conditions due to heavy reliance on Medicaid, lacking sustainable federal support causing uncompensated care burdens, or lack of Medicaid expansion [11,17,37,43]. These financial stressors often lead to closures, particularly in places with high unemployment and socioeconomic disadvantages [26].

Closures have led to reduced access to services, overburdened remaining facilities, and longer travel distances for patients in need of essential care. The reduction in essential services greatly relates to maternal care; the closure of obstetric units and delays in prenatal and maternal care are worsening health outcomes, forcing expecting mothers to travel greater distances for vital care, putting them at greater risk [4,19,23,29,52]. Shortages in qualified clinicians, an aging workforce, and lack of specialty services—such as chronic pain and mental health care—compound this crisis [6,35]. Surveys from rural citizens and providers reveal the growing dependence on urban facilities and the difficult trade-offs patients make when financial strain forces them to prioritize cost over timely treatment [54]. Despite these challenges, researchers suggest coordinated, technology-driven interventions show promise for reducing disparities and strengthening service delivery in underserved regions [49,56,58]. Attempts such as telehealth expansion and regional collaboration show promise in restoring these gaps in healthcare access for rural communities.

4.5. Summary of Findings

This rapid review identified four main constructs in the recent literature surrounding rural hospital closures and related service disruptions in the U.S. While the primary aim of a systematic literature review is to identify and synthesize themes present in the existing evidence rather than to infer causality, the research team recognizes the value in providing a conceptual interpretation of how these themes may relate within the context of recent rural hospital closures. Across the included studies, four central constructs—financial duress, policy implications, performance challenges, and service reductions/workforce shortages—were consistently identified. Financial constraint often appears as a foundational condition, shaped by reimbursement structures and policy decisions, which in turn influence organizational performance and operational capacity. Policy implications, including funding mechanisms and regulatory changes, may either alleviate or intensify such financial pressures. As these constraints mount up, hospitals experience performance challenges, such as reduced efficiency, limited capital investment, and declining service quality. These conditions then frequently contribute to service reductions and workforce shortages, directly affecting access to care and further weakening hospital viability. Although these relationships are not presented as causal determinations, the findings suggest that these factors interact in a reinforcing and compounding manner, forming a cyclical pattern associated with increased risk of service disruption and eventual closure.

5. Study Limitations

As with any study and systematic literature review, limitations exist. A lack of peer-reviewed research surrounding rural healthcare facilities exists in the United States, especially surrounding recent (2024, forward) industry occurrences. This led to a small sample size (n = 59) for the review team to investigate. Further related to this challenge, construct identification was identified at a broad, thematic synthesis level across rural health organizations, versus a more precise quantitative synthesis being conducted with a greater number of identified articles. Variation across identified rural health facilities in the study has been identified as an excellent opportunity for future research by the review team—to include regional differences surrounding state policy, economic structure, and even service availability. Assessment of healthcare equity across identified rural organizations in the U.S. would also provide additional insight and support leadership in rural healthcare management moving forward. This organizational heterogeneity and within-U.S. regional level investigation may identify additional industry trends surrounding rural health cost, quality and access as assessed by this review’s identified constructs. Further heterogeneity, observed in the included sources (ranging from empirical studies to legal analyses and narrative reports) while broadening scope, also introduces variability in evidence that may affect consistency of findings. Such differentiation in sources identified by the review team to assess most-recent publications in this topic could possibly provide additional insight and interpretation information to the reader if level of evidence was further assessed and reported by the review team.

6. Conclusions

This rapid systematic review synthesizes recent U.S.-based evidence demonstrating that rural hospital closures and service disruptions are driven by interconnected financial, policy, workforce, and performance-related vulnerabilities rather than isolated organizational shortcomings. Across 59 identified peer-reviewed studies, rural hospitals consistently emerge as financially fragile entities characterized by revenue instability, low patient volumes, unfavorable payer mix, and heavy reliance on non-operating revenue. Such structural weaknesses are intensified by uneven Medicaid expansion across the 50 states in the U.S., inadequate rural health reimbursement, limited broadband infrastructure, and variable telehealth policy environments. Collectively, such forces create a compounding risk pathway that accelerates closures and service line reductions, particularly in already disadvantaged rural regions of the U.S.

Consequences of rural hospital closures extend well beyond the loss of physical facilities. Literature review indicates associations with increased travel distance/challenges, reduced access to maternal, surgical, mental health, chronic disease, and preventive services, rising prices at nearby surviving hospitals, and a heightened strain on remaining healthcare organizations and personnel. These effects disproportionately burden low-income populations, older adults, racial and ethnic minorities, and geographically isolated communities, thereby widening existing health inequities. At the same time, workforce shortages, aging clinician pipelines, and limited specialty availability further constrain rural care delivery capacity, reinforcing a cycle of access erosion and organizational instability.

Findings from this review underscore the need for coordinated multi-level strategies to stabilize rural healthcare systems. Policy efforts that expand Medicaid, strengthen reimbursement adequacy, protect and extend telehealth flexibilities, and accelerate broadband deployment represent foundational steps toward sustainability. Complementary investments in rural workforce recruitment, training, and retention, as well as targeted financial stabilization mechanisms for high-risk hospitals and essential service lines, are equally critical to support these important institutions. The review team suggests future research prioritize longitudinal, region-specific analyses and evaluate the effectiveness of emerging care models and policy interventions at the community level, such as:

• How do longitudinal trends in rural hospital financial performance, service availability, and workforce capacity vary across regions, and what factors most strongly predict closure or stabilization over time?
• What is the effectiveness of emerging care delivery models (for example, rural emergency hospitals, telehealth expansion, and hospital-to-outpatient conversions) in maintaining access to care and improving patient outcomes at the community level?
• How do state and federal policy interventions influence rural hospital sustainability and community health outcomes, and what regional differences exist in their implementation and impact over time?

Findings from this review have important implications for hospital administrators, particularly those leading rural organizations operating in resource-constrained environments. Administrators should prioritize strategic alignment with evolving policy opportunities, such as Medicaid expansion, enhanced reimbursement programs, and telehealth flexibilities, to strengthen financial stability and expand access to care. Proactive engagement in broadband-enabled service delivery and digital health initiatives can further support sustainability and patient reach. Administrators must also invest in workforce strategies that emphasize recruitment, training, and retention, including partnerships with academic institutions and the development of flexible staffing models. Targeted financial planning is also essential, with a focus on stabilizing high-risk service lines and identifying alternative care delivery models where appropriate. Collectively, these approaches underscore the need for administrators to adopt a coordinated, forward-looking strategy that integrates policy, financial, and operational considerations to sustain rural healthcare delivery.