Closures of rural hospitals have had a disproportionate impact on residents in minority groups, a new study found.

Rural hospital closures were more likely to take place in counties with above-average populations of Black, Hispanic and American Indian residents, compared to typical rural counties.

The North Carolina Rural Health Research Program, which tracks the closure of rural hospitals, examined closures between 1990 and 2020 in its analysis.

Over that three-decade span, 334 rural hospitals across the country closed their doors for good, according to the program’s research.

Between 1990 and 2020, more than half of the rural hospitals that shut down (175 facilities) were in the south, according to the study. More than half of America’s Black residents live in the south, the study notes.

The disproportionate impact of rural hospital closures on Black residents appears to be growing, the study suggests. The median share of Black residents in counties with hospital closures between 2010 and 2020 was higher than in previous decades.

Many southern states opted not to expand Medicaid eligibility, and the south had the bulk of the nation’s rural hospital closures, the authors noted.

Rural counties with hospital closures were increasingly likely to be designated by the federal government as areas with a shortage of healthcare professionals. In the 2010s, 41% of the counties that lost a rural hospital were designated as areas with a shortage of healthcare professionals, up from 28% in the 1990s.

Only 10% of doctors practice in rural areas, and that’s a problem since about 20% of Americans live in rural communities.

Rural counties where hospitals shut down also endured more economic strife than other rural counties. Counties that lost hospitals had higher unemployment rates and lower income, the study found. Those counties also had greater income inequality.

More hospital closures in rural areas could be coming.

Diane Swonk, chief economist of Grant Thornton, projected that the country is on the precipice of seeing more hospital closures due to the financial impact of the COVID-19 pandemic. Rural hospitals have faced tough financial challenges, particularly in losing staff because they can’t match the compensation of competitors or staffing agencies, she said at the HIMSS 2020 Conference last week.

“We’re about to see a lot of hospitals close,” Swonk said.

“That means a loss of access of care in areas that are underserved,” she said.

More than 500 rural hospitals are at an immediate risk of closure due to financial losses, according to a report from the Center for Healthcare Quality and Payment Reform. Another 300 rural hospitals are at high risk of closure due to either low financial reserves or because they rely heavily on government aid or other sources of revenue beyond patient volume.

Altogether, nearly 900 rural hospitals – 40% of the nation’s rural hospitals – are facing a serious risk of closure, the group estimates. In 15 states, the majority of rural hospitals are at risk of closing.

The highest number of rural hospital closures (141) took place between 2010 and 2020. Seventy-four rural hospitals closed between 2000-2009, while 119 rural hospitals shut down between 1990 and 2000.

The rural health research program is based at the University of North Carolina at Chapel Hill. The research was funded by the U.S. Department of Health and Human Services.

The study did not include the states of Alaska and Hawaii, due to their isolated nature and the fact that they had few hospital closures, the authors said.