As Levees Collapse, Hospitals Shutter: How Climate Change is Fanning the Flames in Rural Healthcare

BY SEIN LEE

On a scorching June afternoon in Oregon in 2021, farmer Sebastian Francisco Perez collapsed while moving irrigation pipes at a plant nursery.¹ His coworkers tried desperately to resuscitate him, but it was too late—Perez had died from overheating and dehydration. The nearest hospital was a 30-minute drive away, far too distant to save him even if they had called for medical help immediately. 

Across America’s heartland, the very communities responsible for feeding and nurturing the nation rely on a fragile, fractured healthcare system. Rural areas, where many agricultural laborers like Perez live and work, are experiencing chronic shortages of medical providers, hospitals, and emergency services. As of September 2024, more than 66 percent of Primary Care Health Professional Shortage Areas (HPSAs) were in rural regions.² While several Midwestern states rank high in healthcare quality, that statistic means little to those living hours from the nearest clinic. Rural residents have far fewer specialty care providers and face significantly worse health outcomes than their urban counterparts.^3,4 Long travel distances, aging populations, and economic constraints make it difficult for these families to seek even basic medical care, let alone specialized treatment or emergency services.² 

Now, the effects of climate change are exacerbating these vulnerabilities and barriers. Given this harrowing reality, our nation’s leaders and policymakers must utilize this rapidly closing critical window to rethink rural health. 

The Heat is On and Rivers are Rising for Rural Communities 

Rising temperatures and frequent heat waves not only threaten crop cycles but also add an extra burden on the healthcare facilities that serve rural communities. As average temperatures in North America rise at an alarming rate,⁵ outdoor workers are 35 times more likely to die from heat-related causes compared to those in other sectors.⁶ Rural populations are particularly vulnerable: a study of North Carolina emergency department visits over a six-year period found that rural patients experience heat-related illnesses at five to ten times the rates of urban residents.⁷

The rise in heat strokes and similar conditions is straining rural hospitals, which are already seeing a faster rise in emergency visits compared to urban hospitals. This baseline increase is due to a burgeoning reliance on emergency rooms for routine care as local primary care facilities close.⁸ Rural residents are also more likely than urban residents to be uninsured and thus dependent on safety-net care at select hospitals.⁹ With limited treatment options, patients get funneled into the same few facilities, making even a small bump in heat-related emergency visits enough to overwhelm rural health systems. 

Beyond extreme heat, flooding can devastate the livelihoods and health of rural communities. Studies from 2015 show that the country’s largest flood disasters stem from intense rainfall caused by shifting weather patterns.¹⁰ These climate change-driven floods hinder essential healthcare as hospitals evacuate patients and repair damaged facilities.¹¹ Mold blooms and well water contamination with fertilizers, pesticides, and animal waste from nearby farms also pose acute health threats,¹² adding to healthcare costs and necessitating specialty care that may fall outside the scope of smaller rural clinics. 

Rural areas not only take longer to recover from natural disasters like floods¹³ but also suffer from long-standing inequities in infrastructure investment.¹⁴ Consequently, flood-related road damage is often slow to be repaired, creating significant roadblocks in healthcare. During the 

historic flooding of the Missouri River in 2019,¹⁵for example, the heavily-traveled Interstate 29 was forced to shut down. Employees at local hospitals like Community Hospital Fairfax in Montana saw their 30-minute commutes stretch to three hours, while supply deliveries and emergency response times suffered detrimental delays for months.¹⁶ Unlike in urban areas, where options for hospitals and clinics are plentiful, patients in rural areas often rely on the single closest healthcare center.¹⁷ They thus face longer wait times for emergency medical services, with response times averaging twice the national rate.¹⁸ In this context, when flooding shuts down highways and local roads, what might be a brief detour in a city can become a life-threatening delay in rural areas. 

The Fragile Solvency of Rural Hospitals

The growing threats of extreme heat, floods, and other climate-related issues highlight a critical reality: rural healthcare systems are struggling to meet the needs of their communities, and environmental pressures are pushing them closer to collapse. Without intervention, rural residents will have even fewer affordable and accessible care options. 

The biggest culprit in reduced rural healthcare access is hospital closures due to financial strain. Since 2005, 195 rural hospitals have shut down or downsized operations, with four out of five closures occurring in the Midwest or South.¹⁹ In the wake of these closures, small rural hospitals (SRHs) are particularly at risk. Defined as rural hospitals with total annual expenses below $42 million,²⁰ SRHs provide an essential umbrella of care for small, local communities—from primary and inpatient care to laboratory testing and rehabilitation services. Without them, most families would need to drive at least 30 minutes to the next hospital,²¹ making them a mainstay for community healthcare. 

One issue contributing to SRH closures is high fixed costs. Unlike urban hospitals, which profit from patient services, most SRHs operate at a loss because they need to maintain a baseline of staff, equipment, and overhead services regardless of patient volume.²² For instance, an emergency department must always have a physician on duty, even if only one or two patients arrive. The same applies to operating and maintaining diagnostic imaging equipment like MRI or CT scanners—the cost of a machine is high and unchanging no matter how many patients are scanned.²³ With fewer patients to offset fixed costs, rural hospitals face a higher average cost per patient than their urban counterparts.²⁴ 

Reimbursement gaps are also a major factor in SRH closures. In large and urban hospitals, the costs of delivering care to uninsured, Medicare, and Medicaid patients can be offset by revenue from privately insured patients.²⁵ However, SRHs generally receive insufficient reimbursements from private health insurance and Medicare Advantage plans—in many cases, even less than reimbursements from Medicaid and Medicare.^26,27 Although the explanations for lower private reimbursements are complex and varied, one theory is that factors unique to SRHs like smaller patient volumes make it difficult to negotiate rates and prior authorization denials with private insurers.²⁸ Rural areas also have more uninsured and publicly insured patients compared to urban areas, exacerbating deficits for SRHs.²⁹ Supplemental funding from grants or taxes can help SRHs to stay afloat, but these sources are subject to changes in state and local policies.²⁴ As a result, SRHs struggle to compensate staff and afford supplies, leading to downsizing, closures, or mergers with larger systems. 

Shoring Up Rural Healthcare 

A slew of policy interventions have been attempted to address the challenges facing SRHs, but they remain disjointed and fail to address key issues. The Rural Emergency Hospital Program, for example, eliminates inpatient services and prioritizes emergency care at designated hospitals.³⁰ While this cuts costs in the short-term, it leaves entire communities without routine primary and specialty care.³¹ Similarly, while the Critical Access Hospital (CAH) designation allows certain sites to receive additional Medicare reimbursements,³²it does little to alleviate the low reimbursement rates from private insurers and Medicaid Advantage. Other budget-based proposals, like implementing “global budgets” that provide fixed annual hospital funding,³³ have been tried in different states but often fail to account for patient volume volatility unique rural health needs.³⁴In many cases, the above approaches have often resulted in greater financial losses and closures.³⁵ 

In addition to better aligning federal initiatives with the needs of SRHs, our nation’s leaders must implement policies that better target reimbursement gaps and high fixed costs. One promising idea is to change how SRHs are reimbursed for the essential services they provide through “standby capacity payments,” where hospitals receive payments based on the population they serve rather than the number of patients treated.³⁶ This would help fund critical services like emergency and inpatient care even when patient volumes are low. Protecting the scope of Medicaid and Medicare coverage will also be essential in closing the reimbursement gap for SRHs.²⁴ Finally, on a more systemic level, making medical education more affordable and supporting rural schools will incentivize more clinicians to practice in rural areas. As the rural healthcare workforce grows, fixed costs related to employment shortages would decrease.³⁷ 

Supporting rural hospitals is not only feasible—it is incredibly cost-effective. According to the Center for Healthcare Quality and Payment Reform, preventing at-risk rural hospital closures would cost just $4 billion per year—only 0.1% of total national healthcare spending²⁰—and

benefit almost 20% of the U.S. population.³⁸ Although keeping rural hospitals open would have substantial local impacts, the benefits of investing in rural healthcare extend far beyond these regions. Health shocks inrural agricultural hubs, such as infectious diseases or escalating chronic conditions, can cripple the farming workforce and reduce harvest and livestock yields. This can lead to nationwide consequences like grocery price hikes and even pandemics.³⁹ Strengthening rural hospitals helps stabilize these communities, benefiting both local and national economies and public health. 

Shoring up rural healthcare will require immense support from the federal government. However, the early 2025 overhaul of long-standing programs and the dismantling of key institutions^40–42 place rural communities—and the broader public—in danger. Programs supporting emergency management and public health must remain adequately funded and staffed. Agencies like the Federal Emergency Management Agency, the Environmental Protection Agency, the Centers for Disease Control and Prevention, and the National Institutes of Health each play crucial roles in responding to climate emergencies, regulating pollutants, tracking disease outbreaks, and conducting groundbreaking biomedical research. Equally vital is the Centers for Medicare & Medicaid Services, which ensures access to healthcare for millions of Americans while keeping hospitals financially viable. While there is a case to be made for performance-driven reforms at every agency, a wholesale gutting of their capacity jeopardizes the livelihoods and health of rural Americans. 

Climate change is placing unprecedented pressure on rural healthcare, but it is also catalyzing a long-overdue reckoning with its weaknesses. By strengthening infrastructure and overhauling reimbursement models, we can ensure that rural communities not only survive but thrive in the face of future health challenges. Ultimately, rethinking rural health is not just a strategic investment—it is a responsibility to our nation’s most vulnerable patients and a commitment to the communities that sustain and nourish us.

Sein Lee is a recent graduate of Silliman College.

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