Hospital Closures Rise Across Rural and Urban America, Hitting Safety-Net Hospitals Hardest

The American hospital map is quietly shrinking, and the losses are not confined to the rural landscapes where policymakers have long focused their attention. A new analysis led by researchers at Harvard T.H. Chan School of Public Health, published as a research letter in JAMA on October 8, 2026, finds that hospital closures in the United States have accelerated steadily over the past fifteen years, that urban hospitals are closing at essentially the same rate as rural ones, and that the institutions most likely to disappear are those serving the most socially vulnerable communities. Between 2010 and 2025, the country lost a net total of 216 hospitals and more than 24,000 beds, a contraction that the study’s authors say demands a fundamental rethinking of how the nation protects access to inpatient care.

The numbers behind that headline are stark. Drawing on the American Hospital Association’s annual survey, the research team tracked every hospital closure and opening over the fifteen-year window and found that closures increased by roughly 4 percent year over year while openings declined by about 3 percent annually. In total, 432 hospitals closed during the study period, but only 216 new ones opened, meaning that for every two institutions that shut their doors, just one emerged to take their place. The arithmetic of that imbalance produced the net loss of 216 hospitals, and the accompanying loss of more than 24,000 staffed beds represents a substantial reduction in the country’s capacity to deliver acute care at precisely the moment when demand for hospital services continues to grow.

Perhaps the most consequential finding is what the data did not show. Despite a national policy conversation that has treated hospital closure as an overwhelmingly rural phenomenon, the researchers found no statistically significant difference between rural and urban closure rates. Both categories of hospitals experienced rising closure rates over the study period, and both exceeded the rate at which new hospitals were being established. That symmetry challenges a core assumption embedded in recent federal legislation, including the Rural Health Transformation Program, which directs billions of dollars in state grants specifically toward rural hospitals while leaving urban institutions serving similarly strained populations without comparable support.

The timing of the study gives its findings particular urgency. Since the passage of the One Big Beautiful Bill Act, which included significant changes to Medicaid policy, hospitals across the country have been preparing for the possibility of losing billions of dollars in funding, and anxiety about potential closures has intensified. Much of that anxiety has been channeled toward rural facilities, prompting Congress to create the Rural Health Transformation Program as a lifeline for small-town medical centers. Yet the Harvard analysis suggests that the financial stress now rippling through the hospital sector is not geographically selective, and that urban safety-net hospitals, which disproportionately care for Medicaid patients and uninsured patients, may be just as exposed to the coming fiscal pressure.

When the researchers examined which hospitals actually closed, a consistent profile emerged. For-profit hospitals, small hospitals, safety-net hospitals, and facilities located in the counties with the highest levels of social vulnerability were the most likely to shut down, and that pattern held in both rural and urban settings. Safety-net hospitals and those serving a high volume of Medicaid patients were also rarely the sites of new openings, meaning that the communities most dependent on these institutions were least likely to see replacement capacity emerge. The result is a compounding dynamic in which the places with the greatest health and social needs lose hospital beds fastest and gain them slowest.

Corresponding author Thomas Tsai, associate professor of health policy and management at Harvard Chan School and co-director of the Healthcare Quality and Outcomes Lab, framed the findings as a direct challenge to the prevailing policy narrative. Many policymakers have been treating hospital closures as a rural problem, he observed, but the data show it is a national problem. In his view, the country must shift away from asking only how to save rural hospitals and begin asking how to protect access to hospital care for vulnerable communities wherever they are located. That reframing, if it takes hold in Washington and in state capitols, could reshape how federal and state dollars are targeted in the years ahead.

From a methodological standpoint, the study is notable for its comprehensiveness and its recency. By characterizing closures and openings from 2010 through 2025 using the American Hospital Association annual survey, the team captured the full arc of a turbulent era that included the Affordable Care Act’s coverage expansions, the COVID-19 pandemic, pandemic-era relief funding, and the recent Medicaid policy changes. Observational analyses of this kind cannot by themselves establish why particular hospitals close, but the year-over-year trend lines and the consistent characteristics of closing institutions provide a robust descriptive foundation for policy debate, and the publication in JAMA places the evidence before the clinical and policy communities in a form designed to influence practice and legislation alike.

The financial mechanics behind the pattern are not difficult to reconstruct, even though the study itself does not model them. Small hospitals operate with thin margins and limited ability to absorb reimbursement cuts. For-profit facilities face investor pressure that can accelerate decisions to exit unprofitable markets. Safety-net hospitals, by design, serve patients whose care is reimbursed at low rates or not at all, making them structurally dependent on public funding streams such as Medicaid supplemental payments and disproportionate share allocations. When any of those streams tighten, the institutions at the bottom of the revenue hierarchy are the first to reach the point of insolvency, and the communities they serve, which already face elevated rates of chronic disease and reduced access to primary care, bear the consequences in longer travel times, crowded emergency departments, and delayed treatment.

The loss of more than 24,000 beds over fifteen years is more than an accounting figure. Bed capacity functions as a ceiling on a health system’s ability to respond to surges, whether from pandemics, natural disasters, or seasonal respiratory waves, and the pandemic demonstrated how quickly even well-resourced systems can be pushed past their limits. A national bed supply that is both shrinking and concentrating away from vulnerable communities raises the prospect that the next public health emergency will land hardest on the very populations that lost their local hospitals. The study’s finding that closures outpaced openings in both rural and urban areas suggests this is a systemic contraction rather than a regional reallocation of capacity.

The research, authored by Joshua E. Calianos, Julia H. Song, E. John Orav, Jose F. Figueroa, and Thomas T. Tsai, was supported by the Commonwealth Fund, and its authors’ disclosed funding relationships span federal agencies and major health philanthropies. Its central message, however, is simple enough to survive the disclosures: hospital closure in America is neither a rural story nor an urban one, but a national one that tracks social vulnerability. As Medicaid policy changes begin to flow through hospital balance sheets, the evidence suggests that policymakers who want to preserve access to care will need to look beyond geography and toward the financial fragility of the safety-net institutions, large and small, that hold the health care system’s last line of defense.

Subject of Research: Longitudinal trends in U.S. hospital closures and openings from 2010 to 2025

Article Title: Hospital closures on the rise in both rural and urban areas—particularly among safety-net hospitals

Article References: Hospital closures on the rise in both rural and urban areas—particularly among safety-net hospitals. (n.d.). Original publication

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Keywords: hospital closures, rural hospitals, urban hospitals, safety-net hospitals, Medicaid, health policy, JAMA, Harvard Chan School, hospital beds, social vulnerability, healthcare access, Rural Health Transformation Program