Rural hospital closures
Why do rural hospitals collapse in some states and stabilize in others?
Since 2010, 154 rural hospitals have stopped providing inpatient services. Texas and Tennessee have lost the most, and hospitals often shed obstetrics and chemotherapy first as an early warning of distress before a full closure.
The problem
Rural hospital closures are a national infrastructure risk, not just a facility-level finance issue. When a rural hospital loses inpatient, emergency, obstetric, or surgical capacity, the community loses a platform for care coordination, transfer stabilization, workforce anchoring, and local economic resilience.
The recommendation
Create an early-warning and stabilization model for rural hospitals. The recommended approach is to combine margin distress, Medicaid expansion status, vulnerable-hospital rankings, and service-line losses into a watchlist, then target support before closure eliminates the community access point.
The toll
How many rural hospitals have stopped inpatient care and whether the pace is accelerating or easing.
Cumulative rural hospitals that stopped inpatient care since 2010
Running total of Sheps Center annual closures and conversions. Reconciles to 154 since 2010.
Read it this way The line's slope flattens noticeably after 2020, rising from 125 that year to 154 by 2026, a much slower pace than the run-up to 125 in the decade before, so the sharpest years of rural closures look to be behind this count. Sheps excludes Rural Emergency Hospital conversions and marks 2025 and 2026 as provisional, so the most recent segment could still shift upward. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat Sheps excludes Rural Emergency Hospital conversions from this count. 2025 and 2026 are provisional and may rise as closures are confirmed.
⊞ data table⬇ CSV
| Year | Closures that year | Cumulative since 2010 |
|---|---|---|
| 2010 | 3 | 3 |
| 2011 | 5 | 8 |
| 2012 | 9 | 17 |
| 2013 | 13 | 30 |
| 2014 | 14 | 44 |
| 2015 | 17 | 61 |
| 2016 | 10 | 71 |
| 2017 | 8 | 79 |
| 2018 | 13 | 92 |
| 2019 | 17 | 109 |
| 2020 | 16 | 125 |
| 2021 | 2 | 127 |
| 2022 | 7 | 134 |
| 2023 | 7 | 141 |
| 2024 | 5 | 146 |
| 2025 | 6 | 152 |
| 2026 | 2 | 154 |
UNC Cecil G. Sheps Center for Health Services Research, Rural Hospital Closures tracker · 2010-2026 · source
Rural closures each year by severity, 2010 to 2026
Permanent shutdown means no services remain. Converted means some care, such as a clinic or emergency department, stays open.
Read it this way Compare the permanent-shutdown segment to the converted segment within each bar. In peak years like 2015 and 2019 to 2020, permanent shutdowns made up the larger share, meaning communities lost all care, not just inpatient beds. The two most recent years are provisional counts that may still rise as more closures are confirmed. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat 2025 and 2026 counts are provisional and may rise as closures are confirmed. Sheps excludes Rural Emergency Hospital conversions.
⊞ data table⬇ CSV
| Year | Permanent shutdown | Converted | Total |
|---|---|---|---|
| 2010 | 2 | 1 | 3 |
| 2011 | 2 | 3 | 5 |
| 2012 | 4 | 5 | 9 |
| 2013 | 5 | 8 | 13 |
| 2014 | 8 | 6 | 14 |
| 2015 | 11 | 6 | 17 |
| 2016 | 5 | 5 | 10 |
| 2017 | 6 | 2 | 8 |
| 2018 | 9 | 4 | 13 |
| 2019 | 10 | 7 | 17 |
| 2020 | 8 | 8 | 16 |
| 2021 | 0 | 2 | 2 |
| 2022 | 3 | 4 | 7 |
| 2023 | 5 | 2 | 7 |
| 2024 | 4 | 1 | 5 |
| 2025 | 3 | 3 | 6 |
| 2026 | 1 | 1 | 2 |
UNC Cecil G. Sheps Center for Health Services Research, Rural Hospital Closures tracker · 2010-2026 · source
Rural hospital closures and conversions by state, 2005 through 2026
Sheps Center counts. Narrower definition than Chartis, so counts run lower than broader tallies.
Read it this way Texas's 25 closures and conversions sit well above every other state shown, nearly double Tennessee's 14, so rural closure risk is not evenly spread across the country. This list only shows the states with the most closures, so a state's absence here does not mean it has had none. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
⊞ data table⬇ CSV
| State | Closures and conversions |
|---|---|
| Texas | 25 |
| Tennessee | 14 |
| North Carolina | 12 |
| Oklahoma | 10 |
| California | 10 |
| Missouri | 10 |
| Alabama | 9 |
| Kansas | 9 |
| Georgia | 9 |
| Florida | 8 |
| Pennsylvania | 7 |
UNC Cecil G. Sheps Center for Health Services Research, Rural Hospital Closures tracker · 2005-2026 · source
The money
The financial distress driving closures, whether the margin recovery is real, and the Medicaid-expansion divide behind it.
Share of rural hospitals operating in the red, 2024 to 2026
The share losing money has fallen for two straight Chartis reports.
Read it this way The share of rural hospitals operating in the red fell in both of the last two Chartis reports, from 50 percent in 2024 to 41.2 percent in 2026, which reads as real improvement on this one measure. Each point is a single annual snapshot from a different report year, not a smoothed multi-year trend, so three data points is a short base for calling a durable turnaround. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat Chartis report years 2024 to 2026. Each report reflects the most recent full year of hospital financial data available at publication.
⊞ data table⬇ CSV
| Report year | Percent operating in the red |
|---|---|
| 2024 | 50 |
| 2025 | 46 |
| 2026 | 41.2 |
Chartis Center for Rural Health, 2026 Rural Health State of the State · 2011-2024 · source
Rural hospitals vulnerable to closure, by report year
The at-risk population rose before easing and remains near the 2024 level, even as margins improved.
Read it this way The count of vulnerable rural hospitals rose to 432 in 2025 before easing back to 417 in 2026, landing almost exactly where it started in 2024, so the at-risk population has not meaningfully shrunk even as the margin figures elsewhere improved. This measures the count of hospitals modeled as vulnerable, not which specific hospitals those are. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
⊞ data table⬇ CSV
| Report year | Vulnerable to closure |
|---|---|
| 2024 | 418 |
| 2025 | 432 |
| 2026 | 417 |
Chartis Center for Rural Health, 2026 Rural Health State of the State · 2011-2024 · source
Share operating in the red: Medicaid-expansion versus non-expansion states, 2026
Rural hospitals in non-expansion states are far likelier to be losing money.
Read it this way Non-expansion states have 52.2 percent of rural hospitals in the red versus 34.9 percent in expansion states, a 17-point gap, which lines up Medicaid coverage decisions with current-year financial distress. This is one year of data and does not by itself establish that expansion status is the only reason for the difference. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat Non-expansion figure covers 10 states. Chartis 2026 report.
⊞ data table⬇ CSV
| Group | Percent operating in the red |
|---|---|
| Expansion states | 34.9 |
| Non-expansion states | 52.2 |
Chartis Center for Rural Health, 2026 Rural Health State of the State · 2011-2024 · source
Median operating margin: expansion versus non-expansion states, 2026
The typical non-expansion rural hospital runs a negative margin, not just the worst ones.
Read it this way Because these bars start at zero, the negative 0.7 percent bar for non-expansion states is visibly below the line, meaning the typical, not just the worst, rural hospital in those states is losing money, while the typical expansion-state hospital is profitable at 2.9 percent. Paired with the share-in-the-red chart, the non-expansion gap shows up both in how many hospitals struggle and how much the typical one struggles. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat Bars start at zero. The non-expansion median of negative 0.7 percent means the typical non-expansion rural hospital operates at a loss.
⊞ data table⬇ CSV
| Group | Median operating margin % |
|---|---|
| Expansion states | 2.9 |
| Non-expansion states | -0.7 |
Chartis Center for Rural Health, 2026 Rural Health State of the State · 2011-2024 · source
Who loses care
Which states carry the deepest risk and which communities lose specific services first.
States with the most rural hospitals vulnerable to closure, 2026
Raw exposure: where the largest number of rural hospitals could fall.
Read it this way Texas's 50 vulnerable hospitals and Kansas's 44 are the two largest raw counts shown, but this ranking favors states with more rural hospitals overall, so a large state can top this list without a majority of its system being at risk. Compare against the share-based ranking below to see whether a state's exposure is about scale or concentration. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat Chartis publishes the top states only, not all 50, so this is a partial ranking.
⊞ data table⬇ CSV
| State | Vulnerable to closure |
|---|---|
| Texas | 50 |
| Kansas | 44 |
| Tennessee | 27 |
| Georgia | 25 |
| Mississippi | 24 |
Chartis Center for Rural Health, 2026 Rural Health State of the State · 2011-2024 · source
States where the most rural hospitals are operating in the red, 2026
Current distress, not modeled future risk. Fifteen states have more than half their rural hospitals in the red.
Read it this way Kansas's 86.2 percent operating in the red is more than double the 41.2 percent national figure, and all four states shown sit well above the national line, so this identifies current, not projected, distress concentrated in a handful of states. Chartis only publishes the worst states, so this is a partial ranking, not a full state-by-state picture. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat Chartis publishes the top states only, not all 50, so this is a partial ranking. The line marks the national 41.2 percent.
⊞ data table⬇ CSV
| State | Percent operating in the red |
|---|---|
| Kansas | 86.2 |
| Alabama | 67.6 |
| Arkansas | 59 |
| Wyoming | 58.3 |
Chartis Center for Rural Health, 2026 Rural Health State of the State · 2011-2024 · source
States where rural maternity care has collapsed most, 2011 to 2024
Share of rural obstetrics units eliminated. Florida has lost 71 percent of its rural OB units.
Read it this way Florida's 71 percent of rural OB units eliminated is well over double the 27 percent national share, meaning maternity-care loss in the worst-hit states is far more severe than the national figure alone suggests. This is a partial ranking of the worst states Chartis publishes, so most states are not shown here at all. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat Chartis publishes the worst states only, not all 50. The line marks the national 27 percent.
⊞ data table⬇ CSV
| State | Percent of rural OB units eliminated |
|---|---|
| Florida | 71 |
| Illinois | 48 |
| Pennsylvania | 42 |
Chartis Center for Rural Health, 2026 Rural Health State of the State · 2011-2024 · source
Rural service lines eliminated, cumulative
Rural hospitals shed high-cost service lines well before they close. Chemotherapy is the single largest loss.
Read it this way Chemotherapy's 448 eliminated services outpaces obstetrics's 331, and both dwarf the Texas-only general surgery figure of 38, so service-line loss is not evenly distributed across service types either. The three bars cover different time windows and the general surgery figure is a single-state count standing in for a missing national total, so read them as three separate facts, not a sum. Use this chart to determine whether the rural risk is historical closure, current financial distress, policy environment, or service-line loss, and why the recommendation emphasizes early intervention.
Caveat General surgery has no national total in this source, so the largest single-state figure, Texas, is shown. Windows differ: obstetrics 2011 to 2024, chemotherapy 2014 to 2024.
⊞ data table⬇ CSV
| Service line | Hospitals eliminated | Window |
|---|---|---|
| Chemotherapy | 448 | 2014-2024 |
| Obstetrics | 331 | 2011-2024 |
| General surgery (Texas only) | 38 | 2014-2024 |
Chartis Center for Rural Health, 2026 Rural Health State of the State · 2011-2024 · source
Geography
The same question, state by state and then county by county. Pick a state in the filter above to drill into its counties.
Hospital closure-risk score
County · direct countEach tile is a state. Pick a state in the Scope control above to drill into its counties.
CMS Hospital Cost Report / HealthPulse county summaries · 2024 · source
Average hospital operating margin
County · direct countEach tile is a state. Pick a state in the Scope control above to drill into its counties.
CMS Hospital Cost Report / HealthPulse county summaries · 2024 · source
Why this matters
The divide between Medicaid-expansion and non-expansion states is stark and consistent across every financial measure: non-expansion states have 52.2 percent of rural hospitals in the red versus 34.9 percent in expansion states, and their median operating margin is negative, minus 0.7 percent, versus positive 2.9 percent in expansion states. Before hospitals close outright, they eliminate high-cost service lines first: 331 rural obstetrics units, 27 percent of the national total, and 448 chemotherapy services have been eliminated, giving policymakers an earlier warning signal than the closure count alone.
Recommended actions
- Track service-line eliminations, obstetrics and chemotherapy, as a leading indicator, since these losses precede full closures.
- Prioritize Medicaid expansion or equivalent payer-mix support in non-expansion states, where the financial gap is largest and consistent across every measure.
- Direct targeted support to states with the highest raw exposure, Texas and Kansas, and the highest share exposure, Tennessee and Arkansas, since these represent different kinds of risk.
- Do not read the 2026 margin recovery as resolved risk, since the count of vulnerable hospitals has not fallen alongside it.
- Monitor state-level in-the-red rates, Kansas at 86.2 percent and Alabama at 67.6 percent, as the most acute near-term intervention targets.
The recommendation
Therefore, create an early-warning and stabilization model for rural hospitals. The recommended approach is to combine margin distress, Medicaid expansion status, vulnerable-hospital rankings, and service-line losses into a watchlist, then target support before closure eliminates the community access point.
Demographic slice geography (state/county) only. Sheps Center data has no native race/income field.
Sources