Mergers, Medicaid & the Math Behind Rural Hospital Endurance

When a rural hospital closes, it’s rarely the result of one bad decision. More often, it’s because the numbers no longer add up.

Oct. 1, 2025 | | Written by Jim Kendrick, CHC President and CEO

Declining reimbursements, workforce shortages, and policy shifts have caused many hospitals to operate at a loss. With fewer mission-driven partners available to help, these organizations are left with limited options. Some may need to make difficult decisions like service and staff reduction, bankruptcy or cease all operations.

The Medicaid Maze and Rural Hospital Vulnerability

Jim R. Kendrick, FACHE - Texas Hospital Association — Jim R. Kendrick, FACHE

The Big Beautiful Bill Act introduced new funding for rural healthcare, including $50 billion through a Rural Health Transformation Fund. However, the details of how and when that funding will be distributed remain unclear. At the same time, changes to Medicaid eligibility rules are expected to reduce the number of covered individuals.

This creates significant risk for rural hospitals, where Medicaid often represents a large portion of reimbursement. When patients lose coverage, hospitals are still obligated to provide care, but with no compensation. Over time, financial pressures escalate.
In non-expansion states like Texas, the impact may be somewhat lessened by tools like Local Provider Participation Funds (LPPFs). These allow hospitals to self-fund and draw down federal matching dollars. While these mechanisms are sometimes criticized, they remain a vital way for hospitals to access needed support.

A Shift Away from Critical Access

Recent policy changes are also affecting critical access hospitals, which have traditionally received cost-based reimbursement from Medicare. Today, more than half of Medicare beneficiaries are enrolled in Medicare Advantage or similar replacement plans. Patients covered under these plans no longer count toward cost-based reimbursement formulas.

As a result, some hospitals are seeing declining payments despite consistent patient volumes. Leaders are now evaluating alternatives, such as conversion to Rural Emergency Hospital status as one path.

Making Difficult but Informed Decisions

In today’s environment, rural hospital leaders must have a clear and detailed view of their organization’s financials. They need to understand every revenue stream and evaluate whether each service line is financially sustainable.

Sometimes that analysis leads to eliminating services. In other cases, leadership may decide to continue a service that loses money, as long as the organization sees value for the community and can cover the loss.

Economic Ripples and Community Impact

Closing a rural hospital has far-reaching effects. In many communities, the hospital is one of the largest employers. Its loss affects jobs, local businesses, and the ability to attract new industry. Maintaining local healthcare helps preserve the economic and social fabric of a community.

Hope Through Collaboration

There are reasons for optimism. Some hospitals are recovering through strategic partnerships and operational discipline. Huntsville Memorial Hospital in Texas is one example. After emerging from bankruptcy, the hospital stabilized operations through cost savings, vendor renegotiations, and closer collaboration with partners. Today, Huntsville Memorial Hospital is financially stable and growing.

In other communities, public-private partnerships are enabling new construction. Valencia County, New Mexico, will soon open a hospital thanks to collaboration between the County, CHC and Lovelace Health System. These stories demonstrate that with the right support, rural hospitals can endure as local health resources.

This article is sponsored by CHC.