Since 2010 alone, nearly a hundred rural hospitals have closed across the nation, per studies at the Center for Health Services Research at UNC Chapel Hill.

Research points to a common thread: “In fact, the closures and at-risk hospitals are heavily clustered in the 14 states that have not expanded [Medicaid],” a Pew Trust article notes. Rural hospitals operate on tight margins, and sorely-needed funds that Medicaid expansion would provide are nowhere to be found.

Complete closure is not the first move for many hospitals. In fact, as seen in the North Carolina mountains, for example, less-frequented wards will shutter. Maternity and labor departments are quick to close, given the lower frequency of their use in rural areas.

A driving factor is uncompensated care. Rural, low-income adults are less likely to be insured, yet hospitals cannot refuse care. That leads to less preventative care, since people are either uninsured or have high deductibles, and more reliance on emergency rooms. Hospitals provide care irrespective of coverage, but Medicaid expansion would mean the previously uninsured could get care and the hospitals could get compensated.

North Carolina has not yet expanded Medicaid; Democratic Governor Roy Cooper continues pushing for expansion, while Republican leadership in the General Assembly has opposed it.

Read more about Medicaid expansion and rural states here.