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

Image Credits: AI Generated

DOI: Not provided

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

The study examined Burundi, Ethiopia, Malawi, Mozambique and Namibia, five countries that differ enormously in wealth, food security and education system maturity, yet all of which operate national or large-scale school feeding programmes. The researchers combined nationally representative household surveys with administrative education data, comparing children who received school meals with children who did not, both at the national level and across subnational regions, and separately for boys and girls. Their central finding is striking: beneficiaries of school feeding would gain, on average, 1.3 additional years of schooling compared with non-beneficiaries, with country-level estimates ranging from a low of 0.6 years to a high of 2.3 years.

The logic behind these gains is grounded in decades of nutrition and education research. Chronic food insecurity pushes families toward painful trade-offs, and one of the most common responses is to withdraw children from school, either because the family cannot afford the indirect costs of attendance or because a hungry child cannot concentrate, walk long distances to class or sustain the physical demands of the school day. School meals act as a form of social protection, transferring resources directly to households while strengthening the incentive to keep children enrolled. When a nutritious meal arrives reliably at school, the marginal cost of sending a child falls, and the marginal benefit rises, making dropout less likely and grade progression more likely.

Translating additional schooling into money is where the study becomes an economic argument as much as an educational one. The researchers estimated the returns to education using adapted Mincer equations, the workhorse framework of labour economics that relates log earnings to years of schooling and experience, supplemented where appropriate by published estimates from the global literature. Across the five countries, each additional year of education was associated, on average, with 13.3 per cent higher earnings, with estimates ranging from 9.5 per cent to 19.5 per cent. Combining the schooling gains with these returns, the team projected that school feeding beneficiaries would see lifetime earnings approximately 25.6 per cent higher than comparable children who did not receive meals, an enormous cumulative effect originating from what is often regarded as a modest, routine intervention.

The disaggregated analysis reveals where those benefits concentrate. Because the researchers modelled impacts both nationally and subnationally, they could identify the regions within each country where school feeding is likely to deliver the largest educational payoffs. Unsurprisingly, the greatest gains appear in disadvantaged areas, where baseline dropout rates are high, food insecurity is severe and alternative social protection is thin. In such settings, the meal programme effectively compensates for broader gaps in the social safety net. The analysis by sex also allows the programme’s role in closing gender gaps in schooling to be examined, an important consideration given that girls in low-income settings are often the first to be withdrawn from school when household resources tighten, and given the well-documented downstream benefits of girls’ education for fertility, child mortality and intergenerational health.

The methodological machinery behind these estimates is worth unpacking, because the authors are candid about its limits. In Ethiopia and Malawi, where rich household survey data were available, including the Ethiopian Socioeconomic Survey and multiple rounds of the Malawi Integrated Household Survey, the team estimated transitions between schooling states directly from observed data. For Burundi, Mozambique and Namibia, they constructed a documented transition-matrix framework, using education management information system data and national statistics to model how beneficiary and non-beneficiary cohorts progress through the school system. The schooling gains were then propagated through Mincerian or literature-based returns to produce projected earnings differentials. The analytic code, along with processing and estimation pipelines for the countries with public data, has been released openly on GitHub, an unusually transparent step that allows other researchers to reproduce, stress-test and extend the modelling.

That transparency matters because the authors themselves label their headline numbers as observational plausible upper bounds rather than causal guarantees. Beneficiaries and non-beneficiaries are not randomly assigned; school feeding programmes are typically targeted, deliberately or otherwise, toward needier regions, which complicates naive comparisons. The team ran extensive sensitivity analyses, visualised in their published heat maps, to explore how alternative assumptions about returns to education, transition probabilities and programme coverage affect the results, and the qualitative conclusion, that school feeding meaningfully increases retention and lifetime earnings, is robust across specifications. Even so, they explicitly call for new longitudinal quasi-experimental studies, ideally exploiting staggered programme rollouts or sharp eligibility thresholds, to pin down causal estimates with the precision that policy commitments of this scale deserve.

Even interpreted as upper bounds, the findings arrive at a consequential moment. School feeding has expanded dramatically worldwide, reaching hundreds of millions of children, and is increasingly championed not merely as a nutrition intervention but as a cross-sectoral investment spanning health, education and social protection. Previous systematic reviews and meta-analyses have found positive but heterogeneous effects of school meals on enrolment, attendance and learning, and value-for-money studies have been completed or are underway in each of the five study countries under the Research Consortium for School Health and Nutrition, funded through an original grant from the Norwegian Agency for Development Cooperation with follow-on support from the World Food Programme and other partners. The new Nature Health analysis adds a lifetime-earnings dimension to that evidence base, converting years of schooling into the currency that finance ministries ultimately weigh.

The economic framing also reframes the cost debate. School feeding programmes require sustained procurement of food, logistics and administration, and critics have long questioned whether the resources might deliver more if spent on textbooks, teacher training or direct cash transfers. But the earnings projections here suggest that the benefits of keeping children in school compound over entire working lives, and that they accrue disproportionately to the poorest regions, where the marginal social value of a retained pupil is highest. There are broader dividends as well, beyond the individual wage premium: parental education is strongly linked to child survival, and education shifts fertility patterns and population health in ways that markets do not fully capture. A meal that keeps a girl in school for two extra years may influence the health and schooling of the next generation.

For the five countries studied, and for the many others watching, the message is that school meals should be evaluated with the same seriousness as any major public investment, using data on who benefits, where the gains are largest and what the long-run returns look like. The Harvard-led team’s open data and code make that kind of evaluation more feasible than ever. What remains is the harder scientific task they themselves identify: following real cohorts of children over time, with designs that isolate the causal effect of the meal from the poverty that motivates it. Until then, the numbers stand as a provocative estimate that one of the oldest interventions in the development toolkit, feeding hungry children at school, may quietly be one of the highest-return investments a government can make.

Subject of Research: Estimated effects of school feeding programmes on educational attainment and lifetime economic returns in Burundi, Ethiopia, Malawi, Mozambique and Namibia

Article Title: Impact of school feeding programmes on educational attainment and economic returns in five African countries

Article References: Forzy, T., Ramponi, F., Iversen, I., Durizzo, K., Kim, S., Gautam, P., Avallone, S., Memirie, S. T., Habtemichael, M., Getnet, F., Wogasso, Y., Peterson, H., Masamba, K., Saka, A., Nkengurutse, J., Ndayitwayeko, W.-M., Ntunzwenimana, M., Bigirimana, L., Mbengue, M., … Verguet, S. (2026). Impact of school feeding programmes on educational attainment and economic returns in five African countries. Nature Health. https://doi.org/10.1038/s44360-026-00176-0

Image Credits: AI Generated

DOI: 10.1038/s44360-026-00176-0

Keywords: school feeding, educational attainment, lifetime earnings, sub-Saharan Africa, returns to education, dropout, social protection, Mincer equation, food security, Nature Health, Harvard Chan School, education economics