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

If annual funding is approved at the first-year level, the initiative represents nearly $25 million in investment in rural Colorado over five years. Approximately $1.42 million of the first-year award is budgeted to support CU Anschutz Pharmacy’s role in the project, an investment that could total more than $7 million over the full five-year span, making STREAM one of the largest awards in the history of the Skaggs School. Denver Recovery Group serves as the lead grantee, working in partnership with CU Anschutz Pharmacy, The Steadman Group, and community and healthcare partners across the state to develop and implement the new model. The scale of the collaboration reflects a deliberate design choice: rather than building new infrastructure from scratch, STREAM aims to connect the healthcare resources and trusted relationships that already exist in Colorado’s small communities into a single coordinated network of care.

The scale of the problem the initiative confronts is stark. Nearly 722,000 Coloradans live in rural communities, and 47 of the state’s 64 counties are classified as rural or frontier. Many residents face chronic healthcare provider shortages, long travel distances and limited access to specialty and behavioral health services. Those barriers become particularly consequential for people seeking treatment for opioid use disorder, a condition for which rural communities often have few treatment providers and limited behavioral health resources, and where transportation difficulties and fragmented care can make it hard for patients to begin and remain in treatment. At the same time, rural populations carry significant burdens from chronic conditions such as diabetes, hypertension and cardiovascular disease, illnesses that demand consistent monitoring, careful medication management and ongoing clinical follow-up that distant clinics struggle to provide.

Colorado STREAM’s answer to this geography of scarcity is a hub-and-spoke architecture built around the local pharmacy. The model will create connections among regional treatment hubs, community pharmacy networks, telehealth services and coordinated whole-person care. Concretely, the initiative will work to expand access to evidence-based medications and support for opioid use disorder; connect patients and rural pharmacy teams with treatment specialists and other clinicians through telehealth and coordinated referrals; increase access to medication management for chronic diseases such as diabetes, hypertension and cardiovascular disease; and build rural healthcare workforce capacity by training pharmacists, pharmacy technicians, students, preceptors and collaborating healthcare professionals. The program will also develop sustainable models that allow community pharmacies to play a larger role in delivering and coordinating healthcare, and it will use data and evaluation to measure outcomes, improve care and refine a model that can be sustained and expanded over time.

The logic of placing pharmacies at the center of the network is grounded in both trust and logistics. Community pharmacists are among the most accessible healthcare professionals in rural America, often the only clinically trained providers physically present in a town, and they already hold medication expertise and established relationships with the patients they serve. By connecting them with treatment specialists, technology and coordinated care networks, the initiative aims to bring critical services closer to patients rather than asking patients to travel long distances to find care. Telehealth links and structured referral pathways are intended to extend the reach of regional treatment centers into communities where recruiting physicians and behavioral health clinicians has proven persistently difficult, converting existing pharmacy counters into access points for a far broader continuum of care.

The partnership behind the project is deliberately broad. Denver Recovery Group, led on the ground by Regional Director Denise Vincioni, served as the lead applicant and brings evidence-based treatment expertise for opioid use disorder, including medications for opioid use disorder, counseling, case management and care coordination. The Steadman Group, led on the project by JK Costello, MD, MPH, contributes program design and evaluation capacity, while the CU Anschutz team, led by Rob Valuck, PhD, RPh, Wes Nuffer, PharmD, and Dean Brian Tsuji, PharmD, adds academic depth in pharmacy practice, addiction science and experiential training. The collaboration also includes national and regional pharmacy operators Albertsons-Safeway and Kroger/City Market, independent rural pharmacies such as Downtown Drug in Glenwood Springs and Buena Vista Drug, and CPESN Colorado, a statewide network focused on expanding community pharmacy-based patient care. Emily Zadvorny, PharmD, Executive Director of the Colorado Pharmacists Society, brings additional statewide pharmacy leadership to the effort, a roster designed to ensure the model is informed by the realities of delivering care in communities of very different sizes and regions.

Leaders involved in the project have framed it as a rethinking of how healthcare can reach places the traditional system has left behind. Dean Brian Tsuji has described the investment as an extraordinary opportunity to rethink rural care delivery, noting that community pharmacists are already trusted professionals embedded in these communities and that connecting them with treatment specialists, technology and coordinated networks can bring services to patients instead of forcing patients toward services. Denise Vincioni has emphasized that people in rural Colorado should be able to receive high-quality treatment and coordinated healthcare closer to home, and that STREAM connects treatment expertise with trusted community pharmacies, academic partners, technology and local care resources so that distance is less of a barrier to recovery and better health. Rob Valuck has argued that where a person lives should not determine whether they can get the care they need, and that the strength of the hub-and-spoke model lies in not trying to recreate an entire healthcare system in every rural community, but in connecting regional expertise with pharmacists already caring for patients close to home.

Wes Nuffer has added a practical dimension to that vision, observing that for many rural Coloradans the community pharmacy may be one of the most accessible points of healthcare in their community, and that STREAM builds on that existing relationship rather than creating entirely new infrastructure. From the university’s perspective, the initiative also carries an educational mission: preparing future pharmacists to practice in rural and frontier settings and demonstrating how pharmacists can contribute more broadly to the healthcare team. Tsuji has noted that pharmacists have always been medication experts but that their potential contribution to rural healthcare extends much further, and that STREAM offers a chance both to improve access today and to train the next generation of pharmacists to become an integral part of the rural healthcare workforce, a tangible example of combining education, innovation, clinical expertise and community partnerships to tackle complex healthcare challenges.

The award sits within a much larger wave of federal investment. Colorado’s Rural Health Transformation Program is supported through the federal Rural Health Transformation Program administered by the Centers for Medicare & Medicaid Services, a five-year initiative authorized under Section 71401 of H.R. 1, Public Law 119-21, which provides grants totaling $50 billion in federal funding nationwide from Federal Fiscal Year 2026 through FFY 2030. Colorado is directing $169,587,181 in RHTP grants to rural healthcare providers across the state, and through a highly competitive application process, 91 applicants and approximately 250 projects were selected to receive funding across 52 rural or frontier counties and three rural census tract counties. Colorado’s first-year award totals $200,105,604.17 and is 100 percent funded by CMS. The state program’s priorities include expanding the rural healthcare workforce, strengthening rural healthcare networks, increasing preventive care capacity, integrating telehealth and technology, and developing new approaches to rural care delivery, priorities that STREAM touches on nearly every front.

For the communities involved, the measure of success will be practical: whether a person with opioid use disorder in a frontier county can start evidence-based medication without a multi-hour drive, whether a diabetic patient can get consistent medication management from a pharmacist they already know, and whether the network can sustain itself financially beyond the grant period. The award remains subject to execution of the Grant Agreement and annual funding is subject to continued approval, so the five-year horizon is not yet guaranteed. But if the model performs as its architects hope, Colorado STREAM could offer a template for a national question: how to convert the most trusted and most accessible healthcare professionals in rural America into the connective tissue of a system that has long struggled to reach them. The initiative’s own data and evaluation work will determine whether that template is ready to travel beyond the Rockies.

Subject of Research: Pharmacy-based rural healthcare access and opioid use disorder treatment in Colorado through the Rural Health Transformation Program

Article Title: $4.9M RHTP award will expand pharmacy-based healthcare access across rural Colorado

Article References: $4.9M RHTP award will expand pharmacy-based healthcare access across rural Colorado. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: rural health, community pharmacy, opioid use disorder, telehealth, Colorado, Rural Health Transformation Program, CU Anschutz, medication management, hub-and-spoke model, healthcare workforce, chronic disease, CMS