Crisis in Rural Healthcare: Dialysis, Mental Health, and Emergency Services Face Collapse

A range of rural healthcare services across the United States have faced disruptions due to financial pressures, including the closure of a hospital dialysis unit in Nebraska, the shutdown of mobile mental health crisis teams in Montana, and continued service gaps in North Carolina following a hospital closure. These events highlight ongoing challenges in funding and sustaining care in rural areas.

Nebraska: Chadron Hospital Dialysis Unit Closure

Closure Details

Chadron Hospital in Nebraska ended its outpatient dialysis service at the end of March 2024. The decision affected 17 patients who relied on the service for life-sustaining treatment.

Hospital CEO Jon Reiners stated the unit was losing approximately $1 million annually, attributing the losses to operational costs that exceeded reimbursement rates. The hospital is designated as a critical access hospital, a federal program that provides increased Medicare reimbursement, but Reiners noted this program does not cover outpatient dialysis services.

The hospital contacted four private companies about taking over the dialysis center; all declined after determining the service would not be profitable.

Patient Impact

Patients now travel longer distances for treatment at other facilities:

• Mark Pieper travels to Scottsbluff, Nebraska, for dialysis, a drive of approximately 1.5 hours each way. Pieper stated his doctors have told him he is not a candidate for home dialysis or a kidney transplant.
• Jim and Carol Wright have rented a temporary residence in Rapid City, South Dakota, to reduce travel time during weekdays.
• Linda and Alan Simonson face a round trip of over four hours from their ranch to Scottsbluff for dialysis.
• Some nursing home residents have relocated to facilities closer to dialysis centers.

Federal Funding Context

The closure occurred as Nebraska received $219 million in first-year funding from the federal Rural Health Transformation Program, a $50 billion initiative launched in fall 2023. The five-year program is designed to explore new methods for improving rural health. According to program rules, states can use up to 15% of funding to pay providers for patient care.

A KFF Health News review found at least 11 states have proposed using program funds for rural dialysis initiatives, such as mobile units or home-based treatment support. Nebraska is not among these states.

Broader Health Disparities

A 2024 study in the American Journal of Nephrology indicates people in rural America face higher rates of end-stage kidney disease and higher mortality rates after diagnosis. Data from the National Institutes of Health shows rural dialysis patients use home dialysis at a higher rate (nearly 18%) than urban patients (about 14%).

Nephrologist Mark Unruh stated the closure reflects wider staffing and funding challenges in rural healthcare. He suggested prevention programs, increasing kidney transplantation rates for rural patients, and recruiting more staff to train patients for home dialysis as potential solutions.

Patient Advocacy

Patients and family members, including the Wrights and Linda Simonson, have contacted politicians and hospital officials to express concerns about the closure. Simonson stated she spoke with aides for the governor and state representatives but did not receive calls back from the officials themselves.

Montana: Mobile Crisis Team Closures

Program Model and Impact

Mobile crisis response teams are specialized units deployed to respond to individuals experiencing psychiatric crises, often as an alternative to law enforcement. There are at least 1,800 such teams operating nationwide, a model that originated in the late 1980s in Eugene, Oregon.

In Bozeman, Montana, a mobile crisis team operates 12 hours daily, seven days a week, with an annual budget of $1 million. Program manager Ryan Mattson reports that the majority of calls conclude without police intervention. The program has reduced the time police officers spend on mental health calls by nearly 80%.

Funding Instability

The cities of Great Falls and Billings, Montana, have ceased their mobile crisis programs, reducing the state's total to six active units. The pioneering program in Eugene, Oregon, has also closed.

Funding challenges cited include:

• Insurance gaps: Many private insurance companies do not reimburse for mobile crisis services.
• Medicaid limitations: Medicaid covers mobile crisis services in two-thirds of states, but reimbursement often covers only active time on a call, excluding documentation or standby periods.
• Inconsistent sources: Programs rely on a combination of grants and short-term funding, described by Heather Saunders of KFF as a "patchwork" model.
• Higher costs: Montana's mobile crisis programs have incurred higher costs than initially projected.

State and Local Responses

Some states have taken action to support these services:

• Eight states mandate private insurers cover mobile crisis calls.
• Ten states have implemented fees on cellphone bills to fund these services.

Montana provides approximately $2 million annually in supplemental state funds, though program managers report challenges in accessing these funds. State officials are reportedly evaluating an increase in Medicaid reimbursement rates for service calls.

Montana plans to participate in a federal pilot program by 2026 to open Certified Community Behavioral Health Clinics (CCBHCs), which will require 24/7 mobile crisis services. Casey Schreiner, an executive at Alluvion Health, which operated the Great Falls program, advocates for a comprehensive reform of the payment system.

North Carolina: Martin County Hospital Closure

Closure and Community Impact

Martin County, North Carolina, lost its only hospital in 2023. The closure has been linked to the death of a resident who suffered a heart attack and could not receive timely advanced care. The county lacks paramedics on ambulances, and the nearest emergency rooms are over 20 miles away.

Federal Fund Limitations

Martin County cannot use the $50 billion federal Rural Health Transformation Program funds to reopen its hospital because the facility is not operational. North Carolina is distributing its $213 million allocation through a hub-and-spoke model to existing health organizations, with restrictions on construction spending.

County officials have spent approximately $2.9 million on maintenance and utilities in hopes of reopening. ECU Health signed a letter of intent to reopen the facility as a rural emergency hospital, contingent on $210 million from the state legislature.

Emergency Department Strain

ECU Health's Greenville hospital, the only Level 1 trauma center east of Raleigh, has seen a 132% increase in daily ER visits since the closure. Median ER wait times exceed 4.5 hours, longer than 96% of hospitals nationally. The hospital attributes delays to shortages of inpatient and behavioral health beds.

Local Perspectives

Residents reported long travel times for emergency care and difficulty accessing timely treatment. County Manager Drew Batts stated the rural fund will not directly help Martin County reopen its hospital.

ECU Health Chief Operating Officer Brian Floyd described the situation as a "real healthcare crisis" that has led to preventable deaths.

Federal Program: Implementation Concerns

The $50 billion Rural Health Transformation Program, created by Congress, has raised concerns that it could lead to hospital service reductions. The program emphasizes new approaches to improve rural health access, with state applications mentioning initiatives such as community gardens, paramedic home visits, school-based clinics, and mobile clinics.

Right-Sizing and Service Reductions

Several states, including Montana, Oklahoma, and Wyoming, have included language in their funding applications about "right-sizing select inpatient services," a term interpreted differently but often implying reducing unprofitable or duplicative service lines.

Some states, including Nebraska, North Dakota, Tennessee, Kansas, Nevada, South Carolina, and Washington, plan to use funding to help hospitals convert to Rural Emergency Hospitals, a designation requiring facilities to halt inpatient services in exchange for enhanced payments for emergency and outpatient care.

Disagreement on Implementation

Rural hospital leaders advocate for local control over service decisions. Monique McBride from the Wyoming Department of Health indicated that right-sizing might involve limiting elective procedures to maintain essential services like emergency departments and labor and delivery units.

Tony Shih, a senior adviser at the Commonwealth Fund, noted that removing high-margin services without offering alternative financial support could be detrimental.

Brock Slabach of the National Rural Health Association warned that cutting services could contribute to depopulation in rural areas.

Colorado's plan to classify rural health facilities as "hub, spoke, or telehealth node" has raised worries about potential service reductions. State spokespeople, including Oklahoma's Rachel Klein, affirm that facilities will not be forced to end services but may choose to shift them to regional providers. Some hospital CEOs, such as Ron Weins and Darrell Messersmith in Montana, expressed concern that funding access may be contingent on cutting services. Ed Buttrey of the Montana Hospital Association expressed belief that the state's plan could aid rural hospitals in achieving financial stability.