America’s Rural Hospital Crisis Has Been Looming For Decades

Most Americans consider access to medical care a necessity, not a luxury.

Yet, in rural regions, such access has become increasingly sparse. Between 2010 and 2021, the American Hospital Association reported that there were 136 rural hospital closures around the country. This year, nearly one-third of the remaining rural hospitals could shutter their doors and services. And there is no sign that closures will slow down so long as rural poverty persists and rural populations continue to shrink.

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In rural Alabama, the closures are already having a significant impact. Women lack easy access to quality labor and delivery services, which necessitates driving long distances to deliver their babies. Those who experience medical emergencies often struggle to find doctors and nurses or necessary diagnostic services. Even routine check-ups are difficult to come by. 

This problem isn’t new. In fact, for Black Alabamians, they date back to segregation, when few facilities were open to them. In 1965, in Selma, Ala., for instance, there were two prominent segregated hospitals. One admitted no Black people, and the other only had “13 beds reserved for Negroes.” 

These conditions prompted a congressional investigation, after which Connecticut Senator Thomas J. Dodd concluded that “the fact that a man can be denied the care of a doctor or the services of a hospital on the basis of his race” was perhaps the most significant civil rights issue. 

Yet, there remained a beacon of hope—what the Atlanta Daily World called “a symbol of love and devotion to mankind”: Good Samaritan Hospital. Its history, however, spotlights the value of rural medical facilities, the struggle to keep them open, and the consequences when they close.

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In 1944, the Fathers of St. Edmund and the Sisters of St. Joseph purchased Good Samaritan in Dallas County, Ala., and made care available to everyone. The Catholic organizations understood health care provision as a Christian duty and cited Matthew 25’s call to serve the least of these as inspiration for their work.

While there were few Catholics in Dallas County, most Black residents in the area, as well as those in surrounding counties — and sometimes beyond — depended on Good Samaritan when health crises arose.

With a 60-bed capacity and two pieces of x-ray equipment purchased from the all-white Selma Baptist Hospital, Good Samaritan’s facility was equipped to serve patients from across the region. Good Samaritan’s leaders also established a nursing home for elderly Black people who lacked access to care due to segregation. 

In addition to providing integrated medical care with a staff of Black and white doctors, Good Samaritan set up a training school for Black nurses, the first of its kind in Alabama. After graduating from the program, nurses could attain a sufficient wage by working for the hospital. By 1964, 350 students had graduated. For them, Good Samaritan offered “a way out of what otherwise might be a hopeless economic mire.” 

Although the hospital focused on serving locals, Good Samaritan garnered national attention following the Selma to Montgomery March in March 1965. Civil rights organizers depended on the hospital after police attacked them as they marched over Edmund Pettus Bridge. Over 100 men, women, and children, most of whom were tear gas victims, received treatment at Good Samaritan. Doctors and nurses believed that “Divine Providence had planned for them [to provide] care during [those] trying days.” President Lyndon B. Johnson publicly commended their efforts.

Yet, for all of the good the hospital did, its finances were always precarious. Nighty-eight percent of Good Samaritan’s patients were Black, and most were poor — which meant they couldn’t pay their bills. Of 2,300 patients treated in 1964, only 70 had insurance. 

Good Samaritan sustained itself thanks to a Hill-Burton grant from the federal government, supplied to hospitals that provided medical care to the poor, and support from the Catholic Diocese of Mobile. Still, funds to improve facilities remained scarce.

The hospital’s leaders regularly called upon the public to contribute to hospital improvements that would enable them to remodel, add additional beds, and offer care to more patients. Good Samaritan’s Black supporters reminded residents that there was no “mysterious ‘pot of gold’” to fund the hospital. While some local white individuals offered donations and professed pride in the care Good Samaritan provided, the hospital received dismal assistance from local white organizations. Without sufficient local or state support, hospital leaders urged northern Catholics to donate. One newspaper advertisement reminded readers that “people are actually dying for want of hospital care!”

These campaigns and the federal money allowed Good Samaritan to expand its services at points. Beginning in 1965, Good Samaritan opened additional clinics across Alabama’s agricultural “Black Belt” that offered access to medical care for those in rural communities who could not get to the hospital. Good Samaritan’s leaders continuously advocated for opening such facilities throughout the rural South, where there was desperate need for hospitals with “services available to all citizens.” One Good Samaritan doctor believed that the persistent lack of medical access in rural communities was the most distressing thing he had witnessed in public health work. 

Nonetheless, Good Samaritan struggled to keep up with demand and to obtain money to sustain its work.

By 1980, the financial tightrope that it had always walked began to fray. Difficulty in obtaining sufficient Medicaid payments from the state of Alabama left the hospital’s finances in a bleak position. While one Good Samaritan administrator emphasized that they would not turn people away, the hospital was starting to run out of money at the beginning of each fiscal year. 

Despite these financial challenges, patient dependence on the hospital increased by 50% in 1981 as Good Samaritan expanded its emphasis on preventative care and health education, particularly for children.

Yet, the additional patients did nothing for the bottom line. In 1983, hospital leader Father Roger LaCharite reported that over 80% of Good Samaritan patients depended on Medicaid and Medicare, and the government programs only paid 85% of the costs per patient. By that point, Good Samaritan was losing $100,000 each month and around $1 million a year.

To curtail fiscal losses, administrators laid off longtime employees, going from a staff of 120-plus to fewer than 12. For financial assistance, they appealed to the Selma City Council to no avail. To survive, hospital leaders knew they needed the impossible: hundreds of thousands in government subsidies or a new federal program to support charity hospitals. No such support ever arrived.

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By summer of 1983, Good Samaritan had exhausted all resources and shut its doors for good.

Some Catholic leaders and locals believed that its demise signaled the successful integration of medical facilities. They saw Good Samaritan, which was conceived to address segregated care, as no longer necessary. Still, at the time of its closing, the hospital regularly served the region’s uninsured patients who could not pay off their medical debts. Plus, the hospital’s closure placed extreme pressures on other medical facilities to expand their capacities, but those hospitals also lacked financial resources. 

After Good Samaritan’s closing, leaders from other hospitals in Dallas County, including New Vaughan Hospital, were unsure how they could extend care to the poor while remaining financially stable. One New Vaughan administrator concluded that it would be impossible to provide care to those who could not afford their medical bills and stay open.

Without Good Samaritan, then, many impoverished Alabamians were left struggling to find access to medical care, and other rural hospitals languished under additional financial strain. After Good Samaritan’s closing, 10% of New Vaughan’s gross income went to caring for the poor, and they continued to operate in the red. The result was a “void in acute health care facilities” in the Alabama Black Belt.

And it’s only gotten worse. Mostly because of financial strain, rural hospital closures in the Black Belt have continued, leaving residents without access to medical care. By 2020, in Lowndes County, there was only one physician per every 9,641 residents. Additionally, a report that year found four rural counties in the Alabama Black Belt had no hospital at all and most rural Alabamians lacked ready access to medical care. 

Some hold politicians culpable for the grim financial conditions rural hospitals face, especially those in states like Alabama who refused to expand Medicaid under the Affordable Care Act. Doing so would’ve unlocked additional funding for rural hospitals.

Yet, whatever the cause, one thing is certain: public officials have not responded with sufficient action to keep rural hospitals open, not just in Alabama, but across the country. 

Without additional action rural Americans will be left with few options for health care, not unlike many across the rural South in the mid-late 20th century, with potentially catastrophic consequences. It will mean less access to preventative care, and for the many who can’t afford to travel long distances for medical treatment, worse health outcomes and higher morality rates. Some may have to leave their homes to seek care. It will be a heath care crisis — one that can only be solved with more resources.

Allie R. Lopez is Ph.D candidate in history at Baylor University, writing a dissertation on the freedom struggle in rural Alabama.

Made by History takes readers beyond the headlines with articles written and edited by professional historians. Learn more about Made by History at TIME here. Opinions expressed do not necessarily reflect the views of TIME editors.