Rising hospital closures disproportionately affect disadvantaged communities

Over the past three decades, hospital closures have been on the rise in both urban and rural areas. Real-life consequences take many forms: creating barriers to accessing medical care, increasing transport times and potentially increasing morbidity and mortality for time-sensitive conditions. More recently, the COVID-19 pandemic highlighted the issue as many areas faced dire shortages of hospital beds.

Some studies have explored the effects of closures on patient outcomes, but recently, a group of experts at the University of Chicago set out to identify the risk factors that may be determining which hospitals close.

Past discussions frequently pointed to intrinsic factors like financial instability and low patient volume, but the researchers suspected there are also extrinsic risk factors rooted in social inequities at the population level.

“Among clinicians on the ground, there’s a sense that hospitals taking care of more vulnerable patients have a harder time making ends meet,” said Elizabeth Tung, MD, MS, Assistant Professor of Medicine at UChicago Medicine. “The existing literature explained some of the financial issues by pointing to straightforward practical factors like lower Medicare reimbursements. But there was a gap in empirical analyses examining whether structural or societal issues were associated with more hospital closures and loss of those resources in communities.”

Tung and her fellow UChicago researchers recently published a paper that filled this empirical gap by exploring the connection between hospital closures and the socioeconomic and racial composition of communities in the United States. They uncovered significant disparities that confirmed the “on the ground” impression Tung described, revealing that hospitals in areas burdened with higher levels of socioeconomic disadvantage and larger racial and ethnic minority populations faced disproportionately high rates of hospital closure.

Connecting closures with structural disadvantages

The researchers analyzed data from the American Hospital Association's annual survey of nearly 6,500 hospitals across the U.S. They broke down the population characteristics of hospitals that closed anytime between 2007 and 2018 and compared those characteristics with hospitals that remained open during that period.

Even after adjusting for a wide range of confounding variables, they found that both socioeconomic disadvantage and majority Black racial composition of a healthcare service area increased the likelihood of hospital closure in that area. In contrast, Hispanic/Latino racial composition and rural location did not have a significant impact on the likelihood of closure.

Are hospital closures really a bad thing?

Some commentators have suggested that closing low-performing hospitals may not be a bad thing, arguing that patients then get funneled into larger, higher-performing hospitals where they may receive better care. Tung, the study’s lead author, acknowledged the face-value logic of this reasoning but pushed back.

“Given that so many of the ‘low-performing’ hospitals that are closing are in poor and Black communities, it becomes an access issue,” she said. “Even if there isn’t a quantitative impact on overall mortality, it’s problematic if already-disadvantaged groups end up needing to make the extra effort to travel to get good healthcare. The solution isn’t closing these hospitals but making them better.”

Furthermore, she pointed out that factors like distance do have a quantitative impact on more granular outcomes such as patient satisfaction, emergency department volume at still-open hospitals, and mortality for time-sensitive and surgical conditions.

Evidence in favor of designing race-conscious policies

“Our initial hypothesis was that socioeconomic disadvantage would be the largest driver of disparities in hospital closure, but we actually found that race — specifically Black racial composition of neighborhoods — was the largest driver of those disparities,” Tung said.

Communities with the highest proportion of Black residents faced four times the odds of hospital closure compared to those with the fewest Black residents, demonstrating elevated closure rates regardless of socioeconomic status. Even among wealthy and middle-class neighborhoods, they found that more closures occurred in predominantly Black communities compared to those with other racial and ethnic compositions.

Tung said results like these should indicate to policymakers that economic-focused solutions alone are not sufficient to resolve persistent inequalities in healthcare outcomes and access.

“An ideal system would locate healthcare services where there is healthcare need, but current financing incentives have created a misalignment between what is good for healthcare corporations, and what is good for communities,” she said.

She and her collaborators recommended supplementing poverty-conscious policies such as public hospital funding with race-conscious solutions such as race-based adjustments in hospital reimbursement.

“Ours is just one of many studies that have shown over and over again that there are race-based disparities that aren’t driven by economic differences,” she said. “The larger body of research points to the fact that we need race-conscious policies in place to bridge gaps in healthcare equity.”

The article, “Associations of U.S. hospital closure (2007-2018) with area socioeconomic disadvantage and racial/ethnic composition,” was published in Annals of Epidemiology in March 2024. Authors included Elizabeth L. Tung, Joseph D. Bruch, Marshall H. Chin, Maxwell Menconi, Monica E. Peek and Elbert S. Huang.