In more ways than one, the health of rural areas depends on their hospitals. And throughout the country, the diagnosis is grim.

Caring for a population that is increasingly old and poor, rural hospitals are struggling. Since 2010, 88 of them have at least ended inpatient services, with many closing altogether. Nearly 41 percent of the hospitals that remained open operated at a loss in 2016.

Along with schools, hospitals are the centers of rural communities, and when they close they leave a hole that can’t be easily filled. Indeed, the mass closure of rural hospitals – which provide both health care and jobs – is both an indication that many rural areas are in danger of fading away and a contributing factor in that decline. As other factors drive people from rural areas, hospitals are more likely to close, leading more people to move away.

It’s a cycle that has to be stopped if rural America is to flourish again.

We’ve seen how some of this plays out in Maine. Some rural hospitals have closed, while others are struggling, and dropping services as a result.

Obstetrics is one of those services. Maternity care is often a money loser for hospitals. Small rural hospitals increasingly cannot afford to operate a program at a loss, so they are closing maternity units.

Calais Regional Hospital did just that last year, making Eastern Maine Medical Center in Bangor – 95 miles away – the closest maternity unit.

They are not alone. Nine percent of rural counties lost their maternity ward in the last decade, and now more than half of rural counties don’t have one. Fewer than half of rural women live within 30 miles of a maternity unit.

That not only makes the area a tough sell to young families, it is unhealthy for children and mothers – a lack of nearby obstetrics services has been linked to a higher risk of pre-term births and higher infant mortality rates, among other poor outcomes.

At rural hospitals, that dynamic is repeated in other services. It’s not very lucrative to treat the kind of chronic conditions that many rural residents deal with, and the procedures with larger margins are now mostly handled by bigger urban hospitals. The system is simply stacked against rural hospitals.

The best immediate action one can take is to vote for candidates on Nov. 6 who support Medicaid expansion, which was passed in Maine by voters but has been held up by Gov. Paul LePage and a small group of Republican legislators.

Expanding Medicaid to more poor Americans means less uncompensated care for rural hospitals that are now drowning in it. A Northwestern study found that expansion states have saved $6.2 billion in uncompensated care, while the rural hospital closings have occurred mainly in states that have so far refused to expand Medicaid.

Likewise, voters should elect politicians who will protect Medicaid – further cuts to the program would devastate rural health care.

Longer term, the model of rural health care must be reconsidered. Small hospitals should not have to provide every service. In fact, when some services are transferred to larger hospitals with more resources, health outcomes improve.

The key is figuring out which services rural communities most need – say, chronic illness treatment and emergency services – and adjusting reimbursement rates and other parts of the financial system to make sure hospitals can provide those services and stay in business.

Rural communities need hospitals, yet many cannot support one. Solve that puzzle, and give rural America a shot.

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