Rural Hospital Closures in Tennessee: Centering Community Residents’ Voices to Identify Public Health Ethical Issues and Inform Policy Strategies

Abstract

The US is witnessing rapid hospital closures in rural communities, with devastating consequences for community residents beyond decreased access to health care services. Hospital closures have been associated with outmigration of younger generations due to loss of employment opportunities and economic decline, and with creating uncertainty and a sense of powerlessness among residents. While great efforts have been undertaken to document the effects of hospital closures on health care access, particularly during the COVID-19 epidemic, limited attention has been given to the public health ethics associated with dismantling health care for populations in greatest need. Drawing on the narratives of community stakeholders and residents, several themes evolved around processes, structures, and spillover effects of hospital closures on their daily lives, including decision making processes of when and how to close hospitals. Concerns arose regarding lack of transparency and disregard for alternative health care services to meet the needs of rural communities. The researchers analyzed participants’ stories using the six core values of the American Public Health Association’s code of ethics to determine the extent to which the multilevel crisis emerging from rural hospital closures contradicts the public health ethical responsibility of ensuring access to health care in rural communities. Centering the voices of rural community stakeholders and residents is critical to inform and guide public health strategies and in turn address health care needs of rural communities.

Introduction

Addressing Rural Health Equity and Access in Rural Tennessee

Approximately 60 million people in the United States currently live in rural America (U.S. Census Bureau, 2019). Rural communities, historically, present challenges for residents that are uniquely different from their counterparts who reside in urban areas, including lack of access to employment and educational opportunities, with greater risk for poverty (Newacheck et al., 2000; Tickamyer & Duncan, 1990). In addition, rural residents are at elevated risk for numerous health disparities, including obesity and other chronic diseases (Tickamyer & Duncan, 1990). These conditions have been further exacerbated by recent hospital closures spanning all across the United States. For example, since 2010, 134 hospitals have closed across the US, with the majority occurring in the Southeast (The Cecil G. Sheps Center for Health Services Research, 2020).

One major contributing factor in the health care access shift for rural residents is residing in states without expanded Medicaid. Rural residents are highly dependent on medicaid expansion benefits, as outlined in the Affordable Care Act (ACA), and are left to manage their health-related expenses without sufficient coverage. Thus, health care costs for vulnerable populations place a financial burden on hospitals, and subsequently weaken the sustainability of hospitals, leading to closures (Brame, 2017; Wishner et al., 2016) and other community level spillover effects. In addition to lack of Medicaid expansion, lack of funding to improve technological equipment in rural hospitals has been associated with decreased use of rural hospitals by residents, who are in need of more advanced testing and healthcare services (Wishner et al., 2016).

Health care access is critical for not only preventing, promoting, and maintaining health but for managing disease. Additionally, it is an indicator of social justice for achieving health equity for all, including vulnerable populations, such as rural residents, who are more often populated by aging and lower-income subgroups (Carroll, 2019). Barriers to accessing quality health care services has taken a toll on rural residents. With the advent of hospital closures, rural residents are tasked with seeking alternative health care outlets, often located in urban centers, requiring travel times of 30 minutes to an hour (Center et al., 2013). Though this length of travel may address non-urgent medical needs, it heightens uncertainty and fear in emergency-related situations in the absence of more proximal access to emergency care in rural communities (Adams, 2019; Kelman, 2019). Mortality rates have greatly increased among rural patients with critical conditions, such as strokes or acute myocardial infarction (MI) or unintentional injuries, substantiating the urgent need for concern among rural residents (Buchmueller et al., 2006).

For many communities, hospitals serve as a main source of employment and income. Christianson and Faulkner (1981) found that hospitals greatly contributed to the per capita income of rural communities, creating high salaried jobs above and beyond that of other employment sectors in the local economy. Thus, hospital closures in rural communities are not only offsetting a great source of employment but are also causing noticeable out-migration patterns among residents, including physicians and other essential medical staff seeking employment (Germack et al., 2019). The spillover effects of rural hospital closures portray a circular flow linking economic decline to population shift (McDermott et al., 1991). For example, as physicians leave and hospitals close, rural communities lose essential consumers and strain the local economy due to decreased taxable income from suspended salaries and wages (McDermott et al., 1991). Out-migration and community infrastructure changes deem rural communities less attractive to businesses or new residents, further impacting the vitality and survival of these communities (Brame, 2017; Wishner et al., 2016). This cyclic process served as the impetus for documenting the spillover effects of hospital closures on rural counties in the state of Tennessee. The Tennessee Rural Health Equity Project sought to identify key factors associated with potential predictors of rural hospital closures in Tennessee. These would be utilized to identify community engagement strategies to assist rural communities in developing alternative health delivery services to continue providing hospital-based health care or to make a successful transition to another model that would serve the needs of their residents. Tennessee holds the second highest rate with about 14 hospital closures and the highest rate of hospital closures per capita, which served as the impetus for targeting this state (The Cecil G. Sheps Center for Health Services Research, 2020).

While great efforts have been undertaken to document the effects of hospital closures on health care access, particularly during the COVID-19 epidemic, limited attention has been given to the public health ethics associated with dismantling health care for populations in greatest need. The current study expanded the original study design of the Tennessee Rural Health Equity Project and reviewed transcribed narratives from focus group sessions, recorded through digital or handwritten notes, to identify potential contradictions with the public health code of ethics in light of hospital closures in rural communities.

Hospital Closures as a Public Health Ethical Issue

Studies of the impact of hospital closures in rural communities have largely ignored a major critical and urgent matter – public health concern surrounding rural hospital closures in limiting access to care for vulnerable populations. The current state and consequences of hospital closures in rural communities may have occasioned contradiction of public health ethics, suggesting the relevancy for further examination. The American Public Health Association (APHA, 2019) outlines six core values that guide the public health code of ethics, including: 1) professionalism and trust, 2) health and safety, 3) health justice and equity, 4) interdependence and solidarity, 5) human rights and civil liberties, and 6) inclusivity and engagement. A brief overview of each core value is provided in the following section.

The first core value of the APHA code of ethics, professionalism and trust, states that public health professionals must engage in practices that are honest, transparent, and guided by an ethical framework (2019). This core value is fundamental in garnering public trust, especially in decision-making processes that affect communities’ healthcare access. The second value is promoting health and safety, which is paramount in public health practice. This core value emphasizes procedures to guide the decision-making process of public health organizations that have implications for the community’s well-being, noting the importance of giving meaning to decisions by reflecting on how decisions will affect the everyday life experiences of constituents. Furthermore, in the spirit of implementing the code of ethics, ethical practitioners should advocate for health justice and equity by promoting equal access to quality care for all people, in this instance, regardless of demographic differences. Ethical practitioners also recognize that each individual’s health is linked to others’ in the community, demonstrating the interdependence and solidarity of public health. This is especially evident in rural populations, as they consider their hospitals to be vital stimulators of social and economic capital in their communities.

Additionally, as public health professionals, there is an expectation that human rights and civil liberties will be respected with evidence of promoting autonomy and self-determination in public health practices. In other words, health care professionals’ responsibilities extend beyond being health care providers, but to be cognizant of the role of hospitals in communities as social institutions that protect and ensure the rights of its members. Finally, ethical public health practice focuses on the value of fostering inclusivity and engagement through involving stakeholders in their processes. This ensures that individuals are included in important decisions affecting their own community, holding public health organizations accountable for their well-being. The six core values of the American Public Health Association were used in the researchers’ analyses of community residents’ narratives of their experiences associated with hospital closures to determine the extent to which this multilevel crisis contradicts public health ethical responsibility of ensuring access to healthcare in rural communities. The Vulnerable Populations Conceptual Model (Flaskerud & Winslow, 1998) informed and framed the research analyses. A brief overview of the model is described in the following section. In particular, the disparity in health care quality and access in rural areas, as well as the interdependence of individuals’ health within the community, are of concern to public health practitioners as vulnerable populations continue to experience reduced services and hospital closures.

The Vulnerable Populations Conceptual Model (Flaskerud & Winslow, 1998) contends that socioeconomic and environmental resource availability is directly connected to the relative risk of poor health outcomes and health status for a community. Thus, a reduction in resource availability for a population heightens the risk of poor health outcomes and decreases overall health status. The model specifically addresses the healthcare needs of vulnerable populations as they are more likely to experience both economic and environmental resource scarcities that in turn affect health access, quality and equity (Flaskerud & Winslow, 1998). This model is applicable to rural communities in particular, as they are considered vulnerable populations given historical positionality with regards to lack of structural resources that are often available to families in urban settings (Proctor & Dalaker, 2003). Consequently, rural residents must deal with a restricted range of employment, great distances to businesses and services, limited public transportation (Murry et al., 2009) and more recently, lack of proximal access to medical services due to hospital closures. The connections among resource scarcity, elevated risk of hospital closures, relative risk for poor health outcomes, and decreased health status of rural residents and communities represent a challenge to public health ethics in promoting health equity and justice as a priority area for public health practice.

Methods

Study Design and Sample

To examine potential public health ethical concerns, transcripts from five focus groups in six diverse rural communities in Tennessee were reviewed and analyzed. The current study is part of a larger study conducted by the Tennessee Health Care Campaign (THCC) to document the impact of hospital closures in Tennessee. THCC was founded in 1989 with a vision that all Tennesseans have access to affordable, quality, and equitable healthcare and a mission to advocate for policies and programs that improve the health and wellbeing of Tennesseans.

Through the collaboration of researchers and community partners, THCC conducted focus group sessions in the three regions of the state of Tennessee representing geographic and racial ethnic diversity. The participating counties included Haywood County and Carroll County (West Tennessee), Clay County (Middle Tennessee) and Scott County (East Tennessee), and a Tri-county virtual focus group session with Campbell, Scott and Fentress Counties in Middle and East Tennessee.

Each of the communities had experienced a hospital closure previously, or had a hospital that was deemed at-risk for closure. In Haywood County, Haywood Park Community Hospital in Brownsville, TN closed in 2014. Pioneer Community Hospital, located in Oneida, TN in Scott County, closed in 2016. This hospital has since been purchased and reopened as Big South Fork Medical Center; however, it has closed to new patients and closed its emergency department periodically. In 2019, Cumberland River Hospital closed in Celina, TN in Clay County. The THCC research team interviewed community residents and stakeholders in Clay County soon after the closure, and were able to gather information about the immediate after effects within the community. Since the focus group, the hospital reopened in April 2020 and closed again in August 2020. McKenzie Regional Hospital, located in McKenzie, TN in Carroll County, closed in 2017. Participants in this focus group provided the research team with details on the longer term effects of a hospital closure on a community. The Fentress County hospital, located in Jamestown, TN, also closed in 2019. Similar to Scott County, the hospital in Campbell County also closed its emergency department and closed to new patients periodically.

Overall, 40 individuals participated in the focus groups. Focus group participants were residents who lived in communities that had experienced a hospital closure or were at elevated risk for a hospital closure. They were recruited by members of THCC’s Rural Health Equity Committee and by leaders in the local community. Participants included patients, educators, elected officials, and health care providers (See Table 1). The in-person focus groups were held in community locations recommended by community stakeholders. Prior to focus group sessions, the research team held a lunch meet and greet session to establish rapport, provide instructions, and obtain informed consent from participants.

Table 1.

Roles of Focus Group Participants

Role	#
Total participants	40
Elected officials	11
County Mayors	3
City Mayors	5
Sheriff	1
City Council	1
Local Government Agency Representatives	6
Emergency Medical Services	2
Police	1
Fire	1
Schools	2
Health Providers	8
Hospitalists	2
Primary Care	4
Long Term Care	2
Current or Former Hospital Administrators	6
Current of Former Hospital Board Members	3
Business Leaders	5
Civil Rights Leaders	2

The study was approved by the Vanderbilt University Institutional Review Board. During consent procedures, participants were assured that all efforts would be made to ensure confidentiality, but that it could not be guaranteed because of the shared group setting inherent in focus group data collection format. Focus group participants received a $50 gift card as compensation for their time.

The focus group sessions were facilitated through open-ended questions developed through the collaboration of researchers and community stakeholders. Focus group questions centered on who was impacted the most by hospital closures; how hospital closure decisions were made and communicated to community residents; perceptions of what could have helped to prevent a closure within a community; and what helped mitigate the effects of a closure on the community. Members of the Rural Health Equity Committee served as focus group facilitators. Each session was audio recorded and transcribed or recorded through handwritten notes. All audio files and transcripts were kept on a secure drive.

Procedure

Community-engaged research methods informed and guided the data collection procedures, which included partnering with a community organization for the integration of principles of Participatory Action Research (PAR). PAR is evident in the intent and design for the research to produce action or change for the community and include members of the community in the research process (Baum et al., 2006). The research team designed focus group questions to produce data and inform the study design. In addition, the Rural Health Equity Committee and THCC were involved in the planning and implementation of the research study, as well as in the analysis of data and interpretation of results.

Data Management and Quality Control

A qualitative hypothesis-generating research approach, as explained by Auerbach and Silverstein (2003), was employed in this exploratory study. In accordance with the approach, there was no predetermined hypothesis to this study and the themes that were generated were done through the means of theoretical open-coding. Theoretical coding consisted of finding patterns within the five transcriptions that were important in narrating the answers to the research questions (Auerbach & Silverstein, 2003), which included the impact of hospital closures, process of closure decisions and notification, community response to closure, and strategies for prevention of closure. Two reviewers surveyed through the transcriptions and analyzed the responses that were given by the participants in the focus groups and decided whether the text would serve a greater purpose or if it was of importance. When an answer repeated itself, the reviewers would formulate a theme, which would become one of the categories.

Common themes were coded based on Strauss and Corbin’s (1998) guidelines for construct formation, as evidenced by the following: 1) level of awareness of key community stakeholders in closure decisions; 2) concerns and dissatisfactions on the process of informing residents about the closure; 3) disparate impact of eliminated services on everyday life experiences; 4) varying sense of responsibility of hospital ownership to the community; 5) impact on economic well-being; and 6) other organizations/services having to assume additional responsibilities. The analyses were then compared to determine a final set of themes. These themes were reviewed by the Rural Health Equity team and THCC to ensure accuracy and consistency with focus group participants’ views.

Results

Through thematic coding, several themes emerged that have implications for contradicting the public health code of ethics. Most noticeably were narratives about the significance of structural and contextual factors in shaping the differential experiences of community residents. Results of community residents and stakeholders’ stories with implications for public health ethical issues are presented in the section below. Table 2 includes the six themes, representative quotes, and the public health core values that were examined.

Table 2.

Themes, Corresponding Quotes, and Associated Public Health Core Values

Themes	Evidence	Public Health Core Values
Level of awareness of key community stakeholders in closure decisions	“You know, I wasn’t given any notice that our hospital was vulnerable too. That I can say, nobody called or notified us. I started hearing rumors of the hospital not admitting patients and so forth. So, I made the call to find out what was going on.”	Professionalism and Trust Inclusivity and Engagement
Concerns and dissatisfactions on the process of informing residents about the closure	“People were told, ‘well we’re critical access and as long as we have one patient, we’re good.’ And they made them believe that, as long as you had that, we’re okay and everybody’s jobs are fine. And then they walk in and say, ‘March 1st we’re closed. See y’all later.’”	Professionalism and Trust Inclusivity and Engagement
Disparate impact of eliminated services on everyday life experiences	“By our hospital being closed it sent us from a 20 minute delivery to a three hour, there and back.”	Health and Safet Health Justice and Equity
Varying sense of responsibility of hospital ownership to the community	“Yeah, I think too, because this was a corporate hospital, they didn’t have to tell us anything that was going on and [if] this had been [owned] by the city like it was at one time, or the county, then you might can change strategy and decide what to do.”	Professionalism and Trust Human Rights and Civil Liberties
Impact on economic well-being	“From my understanding and what I’ve been told, is that for every dollar that is created by employee’s salary, it turns over seven times locally in that town, whether it’s spent buying gas, or groceries, or whatever. And you take this town right here that just lost 140 employees.”	Health and Safety Interdependence and Solidarity
Other organizations/services having to assume additional responsibilities	“We [police department] have changed our protocols, procedures and everything else. We’re a small department anyway, that you know, now [we] will get any mental illness patients, the suicide stuff and things like it takes manpower...we have to sit with them, we have to do stuff. And so we don’t have the coverage. So that really affects us quite a bit.”	Health and Safety Interdependence and Solidarity

Level of Awareness of Key Community Stakeholders in Closure Decisions

One of the major themes described the level of awareness of key community stakeholders in closure decisions. In our focus groups, there were patterns of board members not being notified about the decision until immediately before the closure or were misinformed about the financial stability of the hospital, leaving them blindsided. In reference to this, one participant said,

“You know, I wasn’t given any notice that our hospital was vulnerable too. That I can say, nobody called or notified us. I started hearing rumors of the hospital not admitting patients and so forth. So, I made the call to find out what was going on.”

Another participant recounted being assured that the situation with the hospital was fine, only to walk in on a meeting where the closure was being announced,

“She called me and invited me to a meeting up there and I said, ‘what’s going on?’ And she said, ‘no, it’s good mate.’ I said, ‘okay.’ She said that like [Julie] said, ‘We’re doing some upgrades. We’re re-doing the paths and step and say their thing, it looks good.’...And so, myself, and I guess [John, Steve, and Will] and the mayor was there. So, we went and we walked in on it. They had just got through informing the employees that they were going to be closing.”

A third participant identified that hospital profit loss seemed to be hidden until after the closure,

“And much to my surprise, when the hospital closed, they claimed that we had lost an excess of $3 million per year for the last four years. We were never given that information. And I don’t know why. But I guess corporate was including some expenses and the overall hospital operation that we’ve been seeing.”

The lack of community stakeholders’ awareness of an impending closure or the financial status of their hospitals could lead to a lack of trust in health care, which contradicts the public health ethics value of professionalism and trust, and demonstrates low inclusivity and engagement of stakeholders in their local health care systems.

Concerns and Dissatisfactions on the Process of Informing Residents about the Closure

The second theme is concerns and dissatisfactions on the process of informing residents about the closure. This includes hospital staff who were told that as long as they admitted one patient, they wouldn’t have to doubt their job stability. Many of them came to find out that that was important and had doctors brought in more patients, it would have made a difference to the closure decision. One participant said,

“People were told, ‘well we’re critical access and as long as we have one patient, we’re good.’ And they made them believe that as long as you had that, we’re okay and everybody’s jobs are fine. And then they walk in and say, ‘March 1st we’re closed. See y’all later.’”

Another participant highlighted how abrupt the closure seemed given recent hospital spending,

“I think everyone was caught off guard that it was going to happen. They had that two weeks before, some $60,000 in re-doing the physical therapy department for a grand opening... Employees thought their investing were okay, things are alright, community had no high end. I mean people had no clue. And then the agenda comes out of what the meeting’s supposed to be at the [city], and then when they get there and walk in, and it’s like, «well that’s not really what it is. Here’s really what it is and we’re closing you.”

A participant also shared how unaware even city officials and hospital administrators can be about a hospital closure,

“Well, how could the city and the County mayor not know this is going on and they weren’t involved in that way.» Because when you’re CEO or CFO doesn’t even know, then how do you expect anybody else to know? When I say that this hospital closing is different than any other one in this state of Tennessee. I think I could probably validate that this situation, and how it went down is a lot different than some of the others.”

Similar to the first theme, community stakeholders could develop a lack of trust in their local health care systems, given the ways in which they were notified about impending closures. Furthermore, the lack of inclusivity of the larger public in these conversations contradicts expectations of including communities in decisions that ultimately affect them. This carries ethical importance for public health practitioners in ensuring that communities trust these institutions and will further engage with health care.

Disparate Impact of Eliminated Services on Everyday Life Experiences

The third theme is about the disparate impact of eliminated services on everyday life experiences, including the loss of obstetrics care, emergency, and specialty services as well as dramatic increases in travel time to a hospital. Multiple participants described the distance to the nearest hospital after their local hospital closed and the accessibility for those without transportation,

“By our hospital being closed it sent us from a 20 minute delivery to a three hour, there and back.”

“And, you know, this is something that affects folks who are living at the poverty level, not having access to that hospital, especially when they don’t have transportation to go to other facilities 30 – 40 – 60 miles away.”

Other participants described how the loss of services at the hospital impacted particular vulnerable populations, including pregnant women and older adults,

“The mothers, expectant mothers...That’s right, because they lost …. a source of obstetric caregivers in general.”

“I think the nursing home residents. They were so close to the hospital that they could be wheeled over there. But now they have to go [the] distance for whatever problems.”

This theme has implications for the public health values of health and safety and health justice and equity. As a result of decreased services and longer transportation times, many rural residents do not have access to the health care they need when a hospital closes. As reflected in the representative quotes, these changes disproportionately impact vulnerable populations such as expectant mothers and the elderly.

Varying Sense of Responsibility of Hospital Ownership to the Community

The fourth theme encompasses the varying sense of responsibility that a hospital can have towards the community. Regarding the hospital closures, many participants identified that corporate hospitals do not seem to feel that they owe the community any input in the closure process, while that would not have been the case with a public-owned hospital. Furthermore, this brought up conflict around the lack of transparency in disclosing details of the hospitals’ status or forthcoming problems to the rest of the community, including hospital staff.

“Yeah, I think too, because this was a corporate hospital, they didn’t have to tell us anything that was going on and [if] this had been [owned] by the city like it was at one time, or the county, then you might can change strategy and decide what to do.”

Furthermore, community members felt that the corporations did not have the hospital’s interest at heart and rushed into the buying process without planning for long-term sustenance of the hospital. One member recalled,

“The main thing that I see that’s causing these problems seems to be these companies like lab companies that are jumping into hospitals. But they’re undercapitalized. When they don’t have the initial capital to support the operation to begin with, and they don’t have the capital to grow that business and draw those patients into the hospital to sustain the financial viability of the facility.”

Concomitantly, many felt that it was also the responsibility of individuals at the state level to be informed about potential buyers and make decisions that would reflect the best interests of the community, rather than allowing anyone to purchase the hospital. One participant stated,

“But [the hospital corporation] being a public Corporation about three years before they bought [the hospital], their stock or public stock was... selling for about $50 a share. And when they were trying to buy [the hospital], their stock had gone down to be worth about three cents per share. So, it was very evident that they were crashing, and we tried our best to get with the bankruptcy court and judge that was gonna make a decision who was going to get the hospital. And we tried to sway them to not let [the hospital corporation] have the hospital...So it seems to me like that from the very beginning someone at the State level should have been better informed and getting involved in who got the hospital, who did not get the hospital.”

Similarly, to previous themes, this theme also highlights the sense of distrust that community stakeholders develop when they feel that hospital leadership is not acting with their best interest in mind. Public health practitioners have an ethical interest in addressing this lack of trust and promoting ways in which hospitals can engage community members in meaningful and substantial processes. Particularly in rural communities, corporations are charged with the responsibility to prioritize rights to health care and consider the close-knit culture among residents when deciding how to involve the community in these conversations.

Impact on Economic Well-Being

The fifth theme demonstrates the residents’ concern about the long-term impact of the hospital closure on the community’s economic well-being, including real estate, tourism, and other industries.

“From my understanding and what I’ve been told, is that for every dollar that is created by employee’s salary, it turns over seven times locally in that town, whether it’s spent buying gas, or groceries, or whatever. And you take this town right here that just lost 140 employees.”

Moreover, without a local hospital, employees and patients are spending less money in local businesses; thereby, demonstrating the repercussions on the whole community and their spending routines.

“Money spent by the employees within the community for lunches and shopping or at lunch or whatever? Its sales tax rolls. I know two nurses that went to [another hospital] because of the loss of jobs. So now they’re going to Kroger state to shop. They’re doing all their shopping in [other county].”

Just as concerning, have been the spillover effects on the education system in these rural counties. Participants expressed that due to the economic shift following a hospital closure, there has been a high rate of outmigration of families, impacting the enrollment rates in school. By reducing the number of children in these schools, communities are also impacted by how much assistance they receive from the state,

“It also affected our school system with the employees. Moving on, no one had to go to [different state]to get a job. Well, they pulled their children out of school later. So our enrollment figures, right, which impacts the amount of state assistance.”

Rural hospital closures have led to several secondary impacts on communities. This is pertinent to the broader sense of health and safety within public health ethics, as well as demonstrative of how the health and wellness of a community is interdependent. A loss of resources in one area can lead to other resource scarcity, all compounding into poorer health outcomes for community residents. Furthermore, as stated by the APHA, public health practitioners should always strive to promote relationships among members of their community and their environments, noting how decisions can impact their well-being. In addition to decreased access to health care, public health institutions and stakeholders should pay close attention to how communities are further impacted by hospital closures.

Other Organizations/Services Having to Assume Additional Responsibilities

The sixth theme highlights the ways in which other organizations or services have had to compensate for the lack of a local hospital. Police officers are responding more to mental health issues than they previously did.

“We [police department] have changed our protocols, procedures and everything else. We’re a small department anyway, that you know, now [we] will get any mental illness patients, the suicide stuff and things like it takes manpower...we have to sit with them, we have to do stuff. And so we don’t have the coverage. So that really affects us quite a bit.”

Furthermore, law enforcement has been indirectly and negatively affected by the lack of emergency care access, as many of them are called to respond to crises they often do not feel adequately trained for. One police officer noted,

“I’m trained in CPR, but that’s all that I can legally do. When I’m the only one standing there until EMS gets to me, and that’s all I can do for that person. You know how it feels to watch them die in front of you because you can do CPR or you can apply a tourniquet and that’s all that I know to do. And so a lot of people don’t realize what law enforcement’s going to have to deal with, that they have not been trained to look at that because that’s not what they do.”

Similarly, EMS personnel are forced to engage in more emergency care due to the increasing distance to hospitals. One participant added,

“Of course our hospital is shut down at this time, has been since June 2019. So, our ambulance service is actually our emergency room.”

This theme demonstrates again how rural hospital closures can lead to additional resource strain within a community. This can be linked back to the core value of interdependence and solidarity, as members of rural communities have had to assume additional, and often stressful, roles in the absence of adequate care. For ethical public health practice, it is critical to consider how this depletion of resources can further exacerbate declines in health and well-being for a community.

Discussion

Prompted by a concern that Tennessee’s rural communities are experiencing a rapid decline in access to high-quality hospital services, the THCC research team sought to study the effects of rural hospital closures on the affected communities and present recommendations for policymakers based upon their findings. Further motivated by the public health ethical imperative of addressing vulnerable rural communities’ health inequities, the authors approached the focus group data using the Vulnerable Populations Conceptual Model (Flaskerud & Winslow, 1998).

As previously outlined, Flaskerud and Winslow (1998) assert in their framework that a change in the environmental resources of health care quality and differential access to care will create a shift in the relative risk level and ultimately lead to a change in the population’s health status. The increased relative risks associated with hospitals’ closures may include a change in obtaining needed health care services, such as recommended cancer screenings, emergency care, or episodic care of chronic diseases.

While more research is needed to confirm the link between hospital closures and increased rural health disparities, the conceptual model suggests that the closure of these health care facilities will negatively impact mortality and morbidity. When a gap in access to necessary health care resources results, stakeholders and policymakers must come together to ethically address the issue (Fawcett & Russell, 2001). These solutions must be long-term, community-driven, and flexible enough to adapt to today’s rapidly changing health care environment (Mason, 2017).

While the current market-driven health care system may seem incongruent with the ethical imperatives outlined by the APHA (2019), Rambur (2015) suggests that economics and ethics are complementary forces in health reform and improve the quality, value, and outcomes of care. Rambur (2015) further indicates that this ethinomic undertaking requires a comprehensive approach, incorporating social determinants of health (which are often lacking in rural communities (Mason, 2017; Rural Health Information Hub, 2020)), health care financing, and innovative models of care delivery.

Our findings suggest that hospital closures indeed negatively impact rural communities. Themes that emerged from the focus group data indicated that the process of closing rural hospitals contradicts public health’s core values and points to concerns about transparency, trust, fairness and equity, accountability, safety, and well-being (both physical and economic). The data also indicate that policy actions are required to overcome the adverse effects of the closures.

Significance for Public Health

The data point to the reasons rural hospitals are financially at risk and closing, the effects of hospital closures on the communities (ranging from the economic impacts to the psychological implications on patients), and the policy changes that are needed to stabilize the health and care of Tennessee’s rural communities. In addressing this crisis in Tennessee, the research team framed its analysis and consequent recommendations upon public health’s core values, as defined in the Public Health Code of Ethics (APHA, 2019). These values align well with the themes that emerged from the data.

Broadly, the research team identified several ethical public health concerns, including the process of hospital closure decisions, which stakeholders are involved, and who justifies these decisions. It is essential to address these questions to fulfill the ethical responsibility of ensuring access to health care. Not unlike the ethical dilemma surrounding individual autonomy vs. the collective good afforded by public health (Kass, 2001), competing private investments (in the form of corporate-owned, for-profit hospitals) and public interests (in terms of access to quality care) affect the sustainability of rural hospitals (Topchik et al., 2020; Wishner et al., 2016). This tension has been apparent throughout the focus group discussions and may ultimately have a place in future policy deliberations regarding rural hospitals.

Policy Recommendations

This study gives voice to rural residents and is an initial step in addressing this health crisis affecting rural communities throughout Tennessee. These findings highlight the need to rethink rural hospitals’ structure in order to effectively and appropriately address rural health needs in the context of today’s healthcare environment, as noted by Greenwood-Ericksen et al. (2020) and Mason (2017). Policymakers must comprehensively approach the crisis and recognize the complexities of the shifting healthcare landscape. Solutions must not be temporary quick fixes. These policies should provide access to health care and reduce the need for resources in the first place, as framed by the Vulnerable Populations Conceptual Model (Flaskerud & Winslow, 1998).

Rural communities must be mindful of their risk level for hospital closures and the possibility of a rapid decline in health care resources. To assist communities in their risk assessment, the Rural Health Equity team members from THCC and the Vanderbilt researchers took the focus groups’ results and assembled a toolkit. This toolkit presents community strategies to prevent or mitigate the effects of hospital closures, as well as policy recommendations. The findings suggest that rural communities face unique challenges in providing adequate healthcare due to hospital closures in underfunded and high poverty rural regions. A new rural hospital and healthcare model must meet the needs of individual communities and provide equitable access to needed services.

Following the initial descriptive analysis, the study team identified policy-oriented themes. These emerged from the focus groups and interviews with rural hospital CEOs, consultations with statewide organizations interested in rural health care delivery, and debriefing discussions between THCC Rural Health Equity Committee members. Demonstrating the research’s participatory action component, the team engaged in iterative dialogues to transform these themes into recommendations for policymakers. Overall, the committee members intend to 1) Fill the gap between the current market-driven rural health care delivery system and the communities’ needs; 2) Illuminate the need for multilateral transparency and engagement between hospital operators, governments, and agencies through coordination of resources and effective communication; 3) Create novel health care delivery models to reach rural communities and effectively address the emergency, diagnostic, specialty, and rehabilitative needs of all rural residents, effectively creating comprehensive care networks for rural communities; and 4) Attract operational funding to support rural hospitals (THCC, 2020).

The functional domains of public health policies and actions vary and depend upon the core values under consideration and the public health service provided to society (APHA, 2019). The following functional public health domains are congruent with this research and the recommended policies and strategies: 1) Conduct research and communicate findings regarding population and community health problems; 2) Engage with the specific populations and communities to determine and productively deal with health problems; 3) Develop policies and solutions to address public health issues; and 4) Promote improved access to care and other needed social resources (APHA, 2019). Most importantly, the recommended policies and strategies are part of an overall focus on health equity and improved health outcomes for Tennessee’s rural populations.

The Rural Health Equity Committee categorized the policy recommendations by the level of governmental engagement that best fits the above-noted objectives. For example, at the federal level, policy change could address creating funding streams for rural hospitals based on the recognition that many serve low-income, uninsured, older, and chronically ill individuals. At the state level, the government should provide coverage to more low-income individuals and more oversight regarding hospital purchases and hospitals’ need to disclose financial information. Local policies could ensure more community representation in hospital boards and hospital decisions. Table 3 summarizes the recommendations for each level of policy engagement.

Table 3.

Strategies to ethically address Tennessee’s rural hospital closure crisis.

Federal Actions	Funding streams Enhance funding for rural hospitals through innovative reimbursement programs (such as global budgeting), grants for operational funding, funds for telemedicine, and tax relief for rural hospital operators. Affordable Care Act Expand/reform the Affordable Care Act (ACA) to allow families and individuals to purchase ACA plans regardless of employer-based offerings and to provide options for low-income individuals living in non-expansion states. Halt reductions in Disproportionate Share (DSH) payments (per the ACA) in states that have not expanded Medicaid. Grow the Rural Healthcare Workforce Expand efforts to retain and recruit health care providers in rural communities. Increase funding for student loan repayment programs for rural health care providers.
State (Tennessee) Actions	Executive and Legislative Branches of State Government Accept federal funds for Medicaid expansion or develop other equitable means of providing coverage for the state’s uninsured population. Help rural communities fill service gaps by identifying and funding alternative health care delivery systems, including wellness and preventive care programs. Department of Health Require hospitals to work with community leaders and to provide annual reports of current service offerings, general financial status, and how the community’s needs are being met. Certificate of Need Program Reform the Certificate of Need program to investigate hospital operators’ failures to provide promised services and encourage the use of mini-hospitals, stabilization sites, free-standing emergency rooms, innovative emergency transport services, and other creative responses to losses of hospital services. Economic and Community Development Agency Prioritize funding to improve roadways linking rural communities to hospitals through the Tennessee Department of Transportation. Insurance Commission Require insurers to streamline network licensing to prevent prolonged gaps in services in rural communities.
Community Actions	Immediate actions to support a hospital and prevent a closure Encourage local citizens and providers to support the hospital through the use of hospital services that are available locally and maximize the role of committed community leadership in supporting the local healthcare delivery system. Encourage the community to work with the local hospital to identify community health needs and best ways of implementing the programs. Steps to take when a hospital closure is anticipated or has occurred Collaborate with neighboring communities to identify health resources that could be shared and work collectively toward regional solutions. Consider a merger with another hospital or evaluate the possibility of the community taking hospital ownership. Legislative connections Encourage legislators to engage in systematic problem solving to equitably meet the health care needs of rural communities, and routinely inform legislators of evolving community health needs.

These recommended actions stem from focus groups, key informant interviews, and debriefing discussions, as outlined in THCC’s toolkit (THCC, 2020).

The research team recognizes the importance of examining each of these recommendations in light of ongoing policy changes, stakeholder engagement, economic trends, and the political environment through formal policy analyses (Teitelbaum & Wilensky, 2013). The researchers further recognize that most policy changes involve incremental steps, rather than sweeping changes, to allow economic and social systems room to adapt (Longest, 2016). Indeed, this research points to the need for meaningful changes, albeit incremental, for a positive and equitable transformation of the state’s rural health.

Limitations

The researchers aimed to create awareness of the hospital closure crisis and present possible solutions to legislators and policymakers. Thus, this study includes an element of participatory action research, which introduces a potential bias in its intention to exert power and create change (Polit & Beck, 2017). To address this bias, the researchers solicited feedback from study participants regarding their findings and policy recommendations. The study is further limited by possible selection bias, as it undertook discussions in a limited number of affected rural counties in Tennessee. However, focus group participants represented Tennessee’s three grand divisions (East, Middle, and West Tennessee), which reduced specific geographical and cultural effects. While there are racial and ethnic differences in the counties represented in this study, we found commonalities in the issues and impacts gleaned from the data across all counties included in this study, reducing the likelihood of racial bias in this context.

The researchers achieved data saturation during the final focus group and curtailed the sessions at this point. The Chartis Center for Rural Health recently defined more than 40% of Tennessee’s rural hospitals as either vulnerable or most vulnerable to closure (Topchik et al., 2020), pointing to the widespread nature of this crisis. However, there remains the possibility that new data can be gathered by engaging other groups, particularly those in the few rural counties with successful hospitals and healthcare delivery. For this reason, this data cannot be generalized to other rural populations, but may provide a foundation for additional research.

Conclusion

In conclusion, multiple public health ethical concerns were identified through the analysis, including how hospital closure decisions are made, which stakeholders are involved, and who justifies these decisions. Addressing these questions is critical in terms of the ethical responsibility of ensuring access to health care in rural communities with competing private and public interests. The current findings will be utilized to inform future policy recommendations at the federal, state, and local levels and to compile a toolkit with community strategies to prevent or mitigate the effects of a hospital closure.

Funding Statement

The research study was funded by the Meharry Vanderbilt Alliance Community Engaged Research Core and was approved through Vanderbilt University’s Human Research Protection Program, IRB #191052.