Rural Health
Research Gateway

Research Alert: February 18, 2026

A Comparison of Independent and System-Affiliated Rural Hospitals

Rural hospitals play a critical role in ensuring that people living in small towns and remote areas can access essential health care. However, many rural hospitals face ongoing financial pressures, staffing shortages, and declining patient volumes, all of which increase the risk of service cuts or closure. This brief examines how independent and system affiliated rural hospitals differ across organizational structure, financial performance, community context, and financial distress risk, using the most recent national data to inform policymakers, researchers, and rural health stakeholders.

Key Findings:

In this study, system-affiliated hospitals are defined as those that are part of a chain organization (as reported in the Medicare Hospital Cost Report), and independent hospitals are those that are not part of a chain organization. Considering organizational characteristics, financial performance, and county characteristics, this study found that, compared to system-affiliated rural hospitals, independent rural hospitals:

  • Had fewer acute beds.
  • Had a higher proportion that were Critical Access Hospitals, did not receive a low volume adjustment, did not participate in the Medicare Shared Savings Program, were government-owned, operated Rural Health Clinics, provided long-term care, used swing beds, and were located in areas with Rural-Urban Commuting Area Codes 7-10 (small towns and rural areas).
  • Were substantially less profitable, had lower net patient revenue and acute average daily census, and had higher long-term debt and Medicare inpatient payer mix.
  • Were in counties with a smaller population, a higher percentage of residents in rural areas, and higher uninsured rates.
Contact Information:

George H. Pink, PhD
North Carolina Rural Health Research and Policy Analysis Center
Phone: 919.966.5011
gpink@email.unc.edu

Additional Resources of Interest: