According to Navigant, a report on Mississippi’s rural hospitals found that 31% (or 48%) are at “high financial risks,” according to an independent survey. This is nearly twice the national rate, which is only 21 percent. Mississippi Today has obtained a list of 31 at-risk Mississippi hospital facilities. It includes public and private hospitals from every corner of Mississippi, including Rush in Meridian and Merit Health in Natchez, and North Sunflower Medical Center, Ruleville. A combination of low profits, high debt, and low cash reserves is considered “high financial risk”. Some hospitals are listed with only a few days’ cash. I worry about them. Ryan Kelly, executive director, Mississippi Rural Health Association, said that he knows there are many good people there. He just wants to keep their doors open. “A billing clerk is out sick for a week and they are out of money. Kelly cautioned that this report is not a death sentence for hospitals at high financial risk. Kelly said that although the report is not the whole story, it does paint a picture about the struggles that rural hospitals are facing right now. The study examined 2,045 rural hospitals in the United States, and used data from the Centers for Medicare & Medicaid Services to assess financial viability. It measured three factors: operating margin, cash on hand, and debt and capital. They found that 430 rural hospitals were at high risk of financial ruin. The report looked at risk and also assessed how important each hospital was to the community. It considered factors such as the hospital’s ability to provide trauma care, geographic isolation, and the ratio of hospital employees to the population. The report found that thirteen of the 31 Mississippi hospitals with high financial risk were considered “critically important” for their respective areas. It’s hard to discern a pattern in the 31 Mississippi at-risk hospitals. These hospitals are both public and private, with more than 100 beds and with fewer than 25. Some are standalone facilities, while others are part of larger systems like the University of Mississippi Health Center. These hospitals share one commonality: they are located in Mississippi, which has seen four rural hospitals declare bankruptcy within the past six months. Five rural hospitals in Mississippi have closed their doors since 2010, tying it for fourth place in closing rural hospitals nationwide. David Mosley, Navigant’s managing director and co-author of this study, said, “This is an issue everywhere, but it’s a big problem here.” Experts say it is difficult to answer why this problem exists. According to national studies, hospital closures are linked to state decisions not expanding Medicaid. Mississippi is not an expansion state. Eight of the 15 states with high percentages of rural hospitals at risk have not expanded Medicaid. Only 15 states have yet to expand Medicaid, and that is just the national average. All states have felt the effects of the national push for expansion. The Affordable Care Act has resulted in the reduction of federal funds that were used to reimburse hospitals for providing care for uninsured patients. This was because the Affordable Care Act assumed that increased coverage would decrease the need for funding. Richard Roberson, vice-president of the Mississippi Hospital Association which advocates for Mississippi hospitals, said that Mississippi has suffered all the negative effects of Medicare cuts. Mosley stated that expansion would not solve the problem. According to U.S. Census data, Mississippi had approximately 12 percent of its residents uninsured in 2017. This is the seventh highest rate in the nation. The Mississippi Delta is one of the most rural areas in the country. This can cause problems for hospitals because they aren’t allowed to refuse patients who cannot pay. Mosley stated that expansion would be a good idea. But it won’t solve the problem completely because even if all of these people were on Medicaid, Medicaid doesn’t cover cost. Kelly also pointed out that Mississippi patients are often more sick than those in other states, making them more costly to treat and insure. According to America’s Health Rankings, Mississippi ranks dead last in terms of the health of its citizens for all but four years. In those years, Mississippi was second-to-last. Kelly stated that Connecticut could not have expanded Medicaid, had hospitals that were healthy and never faced a crisis. Kelly stated, “We will have a hospital emergency regardless of how we handle Medicaid.” It’s expensive. But that’s not the only reason that so many rural hospitals in Mississippi are at risk of closing. Alabama’s rural population is just over 2 million, while Mississippi has 1.5 million. Alabama, however, has 42 rural hospitals, while Mississippi has 64. Nearby Tennessee has 2.25million rural residents, but only 37 rural hospitals are available to them. Arkansas has 49 rural hospitals, 1.4 million of whom live in rural areas. Mosley stated that technology has made it possible for hospitals to treat patients in a more efficient way. Larger medical centers are better equipped to handle more invasive procedures. They have fewer surgeries and more volume, which is how they make their money. According to the Kaiser Family Foundation’s 2013 national report, rural hospitals had on average 50 beds and 321 workers, but only seven inpatient visits per day. Mosley stated that the community will eventually have the hospital it can afford. Mosley also warned that the hospital a community is able to support may not be the one it requires. Rural hospitals are often the biggest employers in a community. When they leave, they can create problems in employment and health care. Rural areas of the country account for at least 60% of all trauma deaths. This is despite the fact that only 25% of the country’s population lives in rural areas. According to a University of Kentucky study, rural communities lose their hospital and spend more time in ambulances. Mosley stated, “If you live outside of a major city and have to drive 25 more minutes to get to a hospital, what happens to you?” “If you have to revive someone that takes a lot of time, it’s going to be a lot of work.”