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’s central conclusion is stark: many hospitals that still maintained obstetric services as of 2023 may be at high risk of losing them in the near future. That projection matters because obstetric care is not a discretionary service. When a hospital stops delivering babies, pregnant patients must travel farther for prenatal visits, labor and delivery, and emergency obstetric interventions, and the consequences of delayed care can be severe. Researchers have long documented that rural communities experience the sharpest effects, with longer travel distances linked to worse outcomes for both mothers and infants. But the new analysis makes clear that urban hospitals are not immune, and that the forces eroding obstetric access operate differently in different settings.

Birth volume emerged as one of the most consequential predictors of obstetric loss. Hospitals that deliver relatively few babies each year face a structural dilemma: maintaining a round-the-clock obstetric team, including physicians, nurses, anesthesiology coverage and surgical capacity for cesarean sections, is expensive regardless of how many patients walk through the door. When deliveries are infrequent, the fixed costs of staffing a labor and delivery unit are spread across fewer cases, driving up the per-birth cost and making the service difficult to sustain. Low-volume units also raise clinical concerns, because clinicians who rarely manage obstetric emergencies may have fewer opportunities to maintain the skills and team coordination that safe childbirth care demands. The study’s finding that lower volume was associated with subsequent obstetric loss fits this economic and clinical logic, and it suggests a self-reinforcing cycle in which declining births push hospitals toward closure, which in turn pushes patients to travel elsewhere, further reducing local volume.

Financial performance was a second major thread in the analysis. Hospitals whose obstetric services were unprofitable were more likely to lose them, a result that underscores the uncomfortable reality that childbirth care often operates on thin or negative margins. Obstetric units generate costs that are not always matched by reimbursement, particularly for facilities serving large shares of patients covered by Medicaid, which typically pays less than private insurance. Payers and administrators frequently describe obstetric care as a loss leader, a service a hospital absorbs because it draws patients and families into its system, or because community need demands it. When overall hospital finances deteriorate, or when ownership priorities shift toward profitability, obstetric services become vulnerable. The finding that unprofitability predicted obstetric loss provides quantitative support for what hospital administrators have long said anecdotally: money, or the lack of it, sits at the heart of many closure decisions.

Geography played a subtler but equally important role. Hospitals located near another hospital offering obstetric care were more likely to lose their own obstetric services. This proximity effect can be read in two ways. From a system-planning perspective, a nearby alternative may make closure seem tolerable, because patients have somewhere else to go, and administrators or health systems may consolidate services to concentrate volume and expertise at one site. From a patient’s perspective, however, even a seemingly short distance can become a meaningful barrier, particularly for people without reliable transportation, for those who go into labor unexpectedly, or for those in areas where weather, road conditions or traffic can turn a short drive into a long one. The study’s attention to proximity highlights that closure decisions are shaped not only by what happens inside a hospital but by the competitive and geographic landscape surrounding it.

Ownership status also mattered. For-profit hospitals were more likely to experience obstetric loss than their not-for-profit counterparts. This association is consistent with a broader body of health services research showing that for-profit facilities face stronger pressure to eliminate services that do not generate returns for shareholders or owners. Childbirth care, with its unpredictable timing, high staffing requirements and frequent reliance on public insurance, fits poorly with that pressure. The finding does not mean that every for-profit hospital will abandon obstetrics, but it flags ownership as a structural risk factor that policymakers and regulators can observe in advance, potentially allowing earlier intervention in communities where access is threatened.

One of the study’s most valuable contributions is its recognition that obstetric loss is not a single phenomenon. The researchers distinguished between hospitals that closed their obstetric units while remaining open for other services and hospitals that shut down entirely, and they found that the importance of specific risk factors varied by type of loss. A hospital that closes its obstetric unit but continues operating is making a service-line decision, often driven by the economics of the obstetric service itself. A hospital that closes entirely removes all inpatient care from a community, and obstetric services disappear as part of a broader collapse. The predictors of these two outcomes are not identical, and treating them as interchangeable risks obscuring the different policy responses each requires. Similarly, the analysis found that risk factors operated differently in rural and urban hospitals, reinforcing that a one-size-fits-all approach to sustaining obstetric care is unlikely to succeed.

The rural-urban distinction deserves particular emphasis. Rural hospitals have faced a well-documented wave of closures and service reductions, driven by low patient volumes, chronic financial strain, workforce shortages and payer mix. In rural areas, the loss of obstetric care often means that the nearest delivery hospital is dozens of miles away, and some counties are left with no local obstetric services at all. Urban hospitals, by contrast, may close obstetric units in the context of dense hospital markets, where consolidation and competition shape service lines, and where patients can usually reach alternative facilities more easily. Yet even in urban settings, closure can concentrate burdens on specific neighborhoods, often those with higher poverty rates and historically limited access to care. By analyzing rural and urban hospitals separately, the study provides a more granular map of vulnerability than earlier work that lumped all closures together.

The policy implications of the findings are significant. If lower birth volume, unprofitability, proximity to alternatives and for-profit status reliably signal elevated risk, then regulators, state health departments and health systems can use these characteristics to identify hospitals that may be approaching an obstetric closure decision, potentially before it happens. Early identification opens the door to interventions ranging from payment reforms that better compensate low-volume obstetric care, to regionalization strategies that pair smaller units with larger referral centers, to workforce programs that ease staffing burdens. The study also suggests that closure decisions should not be evaluated solely on hospital-level finances, since the community consequences of losing childbirth services, including longer travel times and potentially worse maternal and neonatal outcomes, extend well beyond the balance sheet of the facility making the decision.

For the many hospitals that still deliver babies, the study’s warning about future risk lands at a moment when maternal health outcomes in the United States remain a source of national concern and when access to timely obstetric care is increasingly recognized as a determinant of those outcomes. The research by Interrante and colleagues does not predict which specific hospitals will close their doors or their delivery units, but it identifies the characteristics that place facilities on a higher-risk path and shows how those characteristics differ across settings and types of loss. As health systems, insurers and policymakers weigh how to preserve childbirth access in vulnerable communities, the study offers a data-driven starting point: pay attention to volume, margins, geography and ownership, because those are the factors most closely tied to whether a community’s next baby is born nearby or hours away.

Subject of Research: Risk factors associated with the loss of hospital-based obstetric care in rural and urban U.S. hospitals

Article Title: Risk factors for loss of hospital-based obstetric care in rural and urban hospitals

Article References: Risk factors for loss of hospital-based obstetric care in rural and urban hospitals. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: obstetric care, hospital closures, rural health, birth volume, hospital finances, for-profit hospitals, maternal health, health policy, JAMA Health Forum, healthcare access, rural hospitals, urban hospitals