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Nearly 60 million people live in a rural area across the United States. Since 2005, 162 rural hospitals have closed, and the rate of rural hospital closures seems to be accelerating. Major drivers of rural hospital closures are poor financial health, aging facilities, and low occupancy rates. Rural hospitals are particularly vulnerable to policy and market changes, and even small changes can have a disproportionate effect on rural hospital financial viability. Surgery can be safely performed in rural hospitals; however, hospital closures may be putting the rural population at increased risk of morbidity and mortality from surgical disease., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The chief of surgery of a 264-bed acute care facility and clinic system in Topeka, KS, USA, gives a chronology that illustrates the rapid and profound clinical, economic, and emotional impact of the SARS-CoV-2 outbreak on his hospital and community. In his view, the pandemic has laid bare the weaknesses of several factors basic to the modern US health care system and the resulting economic crisis: just-in-time supply chain technology; foreign sourcing of masks, gowns, and critical equipment, all at critical shortages during the crisis; rural hospital closings; lack of excess capacity through maximization of utilization for efficiency; and an overreliance on high revenue elective procedures and tests. His team was tested by an emergency operation for bowel obstruction that put all the isolation protocols into action. Despite their readiness and the success of the operation and the potential for telemedicine as an alternative to in-person evaluations and outpatient visits, the forced cancellation of all elective operations have led to the loss of revenue for both hospital system and providers, furlough and termination of workers, and financial hardship and uncertainty.

Background: In 2011, inclusion of injectable medications into an expanded ESKD payment bundle prompted concerns that dialysis facilities facing higher costs might close, disrupting care delivery and access to care. Whether this policy change influenced dialysis facility closures is unknown., Methods: To examine whether facility closures increased after 2011 and whether factors influencing closures changed, we analyzed US Renal Data System registry data to identify all patients receiving in-center hemodialysis from 2006 through 2015 and to track dialysis facility closures. We used interrupted time series logistic regression models and estimated marginal effects to examine immediate and longer-term changes in the likelihood of being affected by facility closures following payment reform. We also examined whether associations between selected predictors of closures indicating populations at "high risk" of closure (patient characteristics, facility characteristics, and geography-related characteristics) and closures changed after payment reform., Results: Dialysis facility closures were uncommon over the study period. In adjusted models, the relative odds of experiencing a closure declined by 37% (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.59 to 0.67) immediately after payment reform and declined by an additional 6% (OR, 0.94; 95% CI, 0.91 to 0.97) annually thereafter, corresponding to a 0.3% lower absolute probability of closure in 2015 in association with payment reform. Patients who were black and who dialyzed at small, hospital-based facilities experienced slight increases in closures following payment reform, whereas Hispanic and Medicare/Medicaid dual-eligible patients experienced slight decreases in closures., Conclusions: Expansion of the ESKD payment bundle was not associated with increased closure of dialysis facilities, although the likelihood of closures changed slightly for some higher-risk populations., (Copyright © 2020 by the American Society of Nephrology.)

Problem: Despite clinical guidelines and policy promoting choice of place of birth, 14 Freestanding Midwifery Units were closed between 2008 and 2015, closures reported in the media as justified by low use and financial constraints., Background: The Birthplace in England Programme found that freestanding midwifery units provided the most cost-effective birthplace for women at low risk of complications. Women planning birth in a freestanding unit were less likely to experience interventions and serious morbidity than those planning obstetric unit birth, with no difference in outcomes for babies., Methods: This paper uses an interpretative technique developed for policy analysis to explore the representation of these closures in 191 news articles, to explore the public climate in which they occurred., Findings and Discussion: The articles focussed on underuse by women and financial constraints on services. Despite the inclusion of service user voices, the power of framing was held by service managers and commissioners. The analysis exposed how neoliberalist and austerity policies have privileged representation of individual consumer choice and market-driven provision as drivers of changes in health services. This normative framing presents the reasons given for closure as hard to refute and cultural norms persist that birth is safest in an obstetric setting, despite evidence to the contrary., Conclusion: The rise of neoliberalism and austerity in contemporary Britain has influenced the reform of maternity services, in particular the closure of midwifery units. Justifications given for closure silence other narratives, predominantly from service users, that attempt to present women's choice in terms of rights and a social model of care., (Copyright © 2018. Published by Elsevier Ltd.)

Importance: Hospital financial distress (HFD) is a state in which a hospital is at risk of closure because of its financial condition. Hospital financial distress may reduce the services a hospital can offer, particularly unprofitable ones. Few studies have assessed the association of HFD with quality of care., Objective: To examine the association between HFD and receipt of immediate breast reconstruction surgery after mastectomy among women diagnosed with ductal carcinoma in situ (DCIS)., Design, Setting, and Participants: This retrospective cohort study assessed data from the Nationwide Inpatient Sample of 5760 women older than 18 years (mean [SD] age: 57.5 [13.2]) with DCIS who underwent mastectomy in 2008-2012 at hospitals categorized by financial distress. Women treated at 1156 hospitals located in 538 different counties across Arkansas, Arizona, California, Colorado, Connecticut, Florida, Iowa, Kentucky, Massachusetts, Maryland, Missouri, North Carolina, New Hampshire, New Jersey, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Utah, Virginia, Vermont, Washington, Wisconsin, West Virginia, and Wyoming were included. Of these, 2385 women (41.4%) underwent immediate breast reconstruction surgery. Women with invasive cancer were excluded. The database included unique hospital identification variables, and participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Data were analyzed from January 1, 2012, to February 28, 2014., Main Outcomes and Measures: The primary outcome was the adjusted association between HFD and receipt of immediate breast reconstruction surgery after mastectomy., Results: In this analysis of database information, 2385 of 5760 women (41.4%) received immediate breast reconstruction surgery. Of these, 693 (36.7%) were treated at a hospital under high HFD and received immediate breast reconstruction surgery compared with 863 (44.0%) treated at a hospital under low HFD (P < .001). Reconstruction surgery was associated with younger age, white race, private insurance, treatment at a teaching and cancer hospital, private hospital ownership, and the percentage of individuals in the county with insurance. After adjustment, women treated at hospitals under high HFD (OR, 0.79; 95% CI, 0.62-0.99) and medium HFD (OR, 0.76; 95% CI, 0.61-0.94) were significantly less likely to receive reconstruction than women treated at hospitals with low to no HFD., Conclusions and Relevance: The financial strength of the hospital where a patient receives treatment is associated with receipt of immediate breast reconstruction surgery. In addition to focusing on patient-related factors, efforts to improve quality should also focus on hospital-related factors.

Decisions by states about whether to expand Medicaid under the Affordable Care Act (ACA) have implications for hospitals' financial health. We hypothesized that Medicaid expansion of eligibility for childless adults prevents hospital closures because increased Medicaid coverage for previously uninsured people reduces uncompensated care expenditures and strengthens hospitals' financial position. We tested this hypothesis using data for the period 2008-16 on hospital closures and financial performance. We found that the ACA's Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion. Future congressional efforts to reform Medicaid policy should consider the strong relationship between Medicaid coverage levels and the financial viability of hospitals. Our results imply that reverting to pre-ACA eligibility levels would lead to particularly large increases in rural hospital closures. Such closures could lead to reduced access to care and a loss of highly skilled jobs, which could have detrimental impacts on local economies.

Background: Bed closures due to acute gastroenteritis put hospitals under pressure each winter. In England, the National Health Service (NHS) has monitored the winter situation for all acute trusts since 2010/11., Aim: To estimate the burden, duration and costs of hospital bed closures due to acute gastroenteritis in winter., Methods: A retrospective analysis of routinely collected time-series data of bed closures due to diarrhoea and vomiting was conducted for the winters 2010/11 to 2015/16. Two key issues were addressed by imputing non-randomly missing values at provider level, and filtering observations to a range of dates recorded in all six winters. The lowest and highest values imputed were taken to represent the best- and worst-case scenarios. Bed-days were costed using NHS reference costs, and potential staff absence costs were based on previous studies., Findings: In the best-to-worst case, a median of 88,000-113,000 beds were closed due to gastroenteritis each winter. Of these, 19.6-20.4% were unoccupied. On average, 80% of providers were affected, and had closed beds for a median of 15-21 days each winter. Hospital costs of closed beds were £5.7-£7.5 million, which increased to £6.9-£10.0 million when including staff absence costs due to illness., Conclusions: The median number of hospital beds closed due to acute gastroenteritis per winter was equivalent to all general and acute hospital beds in England being unavailable for a median of 0.88-1.12 days. Costs for hospitals are high but vary with closures each winter., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

(1) Over 50 percent of primary care health professional shortage areas (HPSAs) were in rural areas in November 2016, according to the Health Resources and Services Administration. (2) Rural areas face a higher uninsured rate than metropolitan areas. (3) Rural hospitals tend to have low patient volume, a high portion of patients on Medicare and Medicaid, and a high number of uninsured patients.

Purpose: Annual rates of rural hospital closure have been increasing since 2010, and hospitals that close have poor financial performance relative to those that remain open. This study develops and validates a latent index of financial distress to forecast the probability of financial distress and closure within 2 years for rural hospitals., Methods: Hospital and community characteristics are used to predict the risk of financial distress 2 years in the future. Financial and community data were drawn for 2,466 rural hospitals from 2000 through 2013. We tested and validated a model predicting a latent index of financial distress (FDI), measured by unprofitability, equity decline, insolvency, and closure. Using the predicted FDI score, hospitals are assigned to high, medium-high, medium-low, and low risk of financial distress for use by practitioners., Findings: The FDI forecasts 8.01% of rural hospitals to be at high risk of financial distress in 2015, 16.3% as mid-high, 46.8% as mid-low, and 28.9% as low risk. The rate of closure for hospitals in the high-risk category is 4 times the rate in the mid-high category and 28 times that in the mid-low category. The ability of the FDI to discriminate hospitals experiencing financial distress is supported by a c-statistic of .74 in a validation sample., Conclusion: This methodology offers improved specificity and predictive power relative to existing measures of financial distress applied to rural hospitals. This risk assessment tool may inform programs at the federal, state, and local levels that provide funding or support to rural hospitals., (© 2016 National Rural Health Association.)

Purpose: Since 2010, the rate of rural hospital closures has increased significantly. This study is a preliminary look at recent closures and a formative step in research to understand the causes and the impact on rural communities., Methods: The 2009 financial performance and market characteristics of rural hospitals that closed from 2010 through 2014 were compared to rural hospitals that remained open during the same period, stratified by critical access hospitals (CAHs) and other rural hospitals (ORHs). Differences were tested using Pearson's chi-square (categorical variables) and Wilcoxon rank test of medians. The relationships between negative operating margin and (1) market factors and (2) utilization/staffing factors were explored using logistic regression., Findings: In 2009, CAHs that subsequently closed from 2010 through 2014 had, in general, lower levels of profitability, liquidity, equity, patient volume, and staffing. In addition, ORHs that closed had smaller market shares and operated in markets with smaller populations compared to ORHs that remained open. Odds of unprofitability were associated with both market and utilization factors. Although half of the closed hospitals ceased providing health services altogether, the remainder have since converted to an alternative health care delivery model., Conclusions: Financial and market characteristics appear to be associated with closure of rural hospitals from 2010 through 2014, suggesting that it is possible to identify hospitals at risk of closure. As closure rates show no sign of abating, it is important to study the drivers of distress in rural hospitals, as well as the potential for alternative health care delivery models., (© 2015 National Rural Health Association.)

Hospital closures occur from time to time. These closures affect not only the patients that depend on the hospitals but also the economy in many rural areas. Many factors come into play when a hospital decides to shut off services. Although influencing reasons may vary, hospital closures are likely to be caused by financial shortfalls. In the USA recently, several rural hospitals have closed and many are on the verge of closing. The recent changes in the healthcare industry due to the new reforms are believed to have impacted certain small community and rural hospitals by putting them at risk of closure. In this article, we will discuss some of the highlights of the healthcare reforms and the events that followed, to relate how they may have affected the hospitals. We will also discuss what the future of these hospitals may look like and the necessary steps that the hospitals need to adopt to sustain themselves.

Background: Norovirus is the most common cause of outbreaks of acute gastroenteritis in National Health Service hospitals in the United Kingdom. Wards (units) are often closed to new admissions to stop the spread of the virus, but there is limited evidence describing the cost-effectiveness of ward closure., Methods: An economic analysis based on the results from a large, prospective, active-surveillance study of gastroenteritis outbreaks in hospitals and from an epidemic simulation study compared alternative ward closure options evaluated at different time points since first infection, assuming different efficacies of ward closure., Results: A total of 232 gastroenteritis outbreaks occurring in 14 hospitals over a 1-year period were analyzed. The risk of a new outbreak in a hospital is significantly associated with the number of admission, general medical, and long-stay wards that are concurrently affected but is less affected by the level of community transmission. Ward closure leads to higher costs but reduces the number of new outbreaks by 6%-56% and the number of clinical cases by 1%-55%, depending on the efficacy of the intervention. The incremental cost per outbreak averted varies from £10 000 ($14 000) to £306 000 ($428 000), and the cost per case averted varies from £500 ($700) to £61 000 ($85 000). The cost-effectiveness of ward closure decreases as the efficacy of the intervention increases, and the cost-effectiveness increases with the timing of the intervention. The efficacy of ward closure is critical from a cost-effectiveness perspective., Conclusions: Ward closure may be cost-effective, particularly if targeted to high-throughput units., (Published by Oxford University Press for the Infectious Diseases Society of America 2016. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

The Affordable Care Act (ACA) set in motion payment changes that could put pressure on hospital finances and lead some hospitals to close. Understanding the impact of closures on patient care and outcomes is critically important. We identified 195 hospital closures in the United States between 2003 and 2011. We found no significant difference between the change in annual mortality rates for patients living in hospital service areas (HSAs) that experienced one or more closures and the change in rates in matched HSAs without a closure (5.5 percent to 5.2 percent versus 5.4 percent to 5.4 percent, respectively). Nor was there a significant difference in the change in all-cause mortality rates following hospitalization (9.1 percent to 8.2 percent in HSAs with a closure versus 9.0 percent to 8.4 percent in those without a closure). HSAs with a closure had a drop in readmission rates compared to controls (19.4 percent to 18.2 percent versus 18.8 percent to 18.3 percent). Overall, we found no evidence that hospital closures were associated with worse outcomes for patients living in those communities. These findings may offer reassurance to policy makers and clinical leaders concerned about the potential acceleration of hospital closures as a result of health care reform., (Project HOPE—The People-to-People Health Foundation, Inc.)

Unanticipated situations can arise in biobanking. This paper empirically documents unexpected situations at the anonymous biobank 'Xbank'. Firstly, Xbank received an unexpected and significant quantity of tissue from the historical archive of a hospital network. Secondly, Xbank had its funding withdrawn before the designated end date for the grant, meaning the bank needed to either re-house or destroy its holdings. This paper articulates and uses the theoretical frameworks of bio-objectification and tissue economies to analyse the experiences of Xbank and draw out further implications of the potential precariousness of biobanking practice. The case study allows an inspection of how the value of tissue is configured and reconfigured as institutional contexts shift. We introduce the notion of momentariness as a way of grappling with the related temporariness and perpetualness of biobanking practice in both a theoretical and practical policy context.

Rural hospitals serve as major sources of health care and employment for their communities, but recently they have been under increased financial stress. What are the causes of this stress, and how have hospitals and their communities responded?

Key Findings. Twenty-five counties lost their sole community pharmacy between May 2006 and December 2010. Among these: (1) The average population density is 10.4 persons per square mile, compared to 87.4 for the United States. (2) The average population decreased by 1.6% between 2000 and 2010. Excluding the largest county, the average decrease was 2.4%. (3) The population age 65 years and older increased 5.4% between 2000 and 2010. Excluding the largest county, the 65-and-older population increased 2.1%. (4) The average change in the percentage of persons in poverty increased by 0.6 points between 2000 and 2010, from 15.5% to 16.1%, compared to a 4.0 point increase (11.3% to 15.3%) for the United States. (5) The average percentage of people younger than 65 years without health insurance was 24.6% in 2010, compared to 16.2% for the United States. (6) Nineteen of the 25 counties were designated "whole county" Health Professional Shortage Areas (HPSAs), meaning there was a shortage of primary medical care physicians across the entire county. (7) The average number of active doctors per 1,000 persons was 0.44, compared to 2.86 for the United States. Six of the 25 counties (24%) had no active MDs or DOs in 2010.

Local rural pharmacies provide essential pharmacy and clinical services to their communities. Pharmacists play a critical role in the continuum of care for rural residents, and the loss of a local pharmacy may impact access to prescription drugs and clinical care. This policy brief identifies factors that contributed to the closing of six pharmacies and describes how the affected communities adapted to losing locally based services. Key Findings. (1) Five out of the six pharmacies studied closed due to retirement and/or difficulties in recruiting a successor. (2) In five of the six communities, residents now either drive to the nearest pharmacy or use mail-order to receive their prescriptions and, in some instances, receive their prescriptions through a courier service from a pharmacy in a nearby town. (3) Access to pharmacy services in these communities is of most concern for individuals with limited mobility and those who lack a support system that can pick up and deliver their prescriptions (e.g., the elderly and people with acute conditions).

Healthcare financing and insurance is changing everywhere. We want to understand the impact that financial pressures can have for the uninsured in advanced economies. To do so we focus on analyzing the effect of the introduction in the US of managed care and the big rise in financial pressures that it implied. Traditionally, in the US safety net hospitals have financed their provision of unfunded care through a complex system of cross-subsidies. Our hypothesis is that financial pressures undermine the ability of a hospital to cross-subsidize and challenges their survival. We focus on the impact of price pressures and cost-controlling mechanisms imposed by managed care. We find that financial pressures imposed by managed care disproportionately affect the closure of safety net hospitals. Moreover, amongst those hospitals that remain open, in areas where managed care penetration increases the most, they react by closing the health services most commonly used by the uninsured.

From January to May 2006, a nosocomial outbreak caused by a multi-drug-resistant strain of Acinetobacter baumannii (MDRAB) occurred in a multi-specialty surgical ICU (SICU). During this episode, 20 patients were colonized by an identical MDRAB strain. Despite introduction of control measures, the outbreak was only stopped after complete closure of the unit. When a second MDRAB outbreak was confirmed in the same unit in January 2009, the SICU was closed as soon as possible. This measure allowed faster control of the outbreak, which only involved seven patients and lasted for 25 days. The economic impact of the outbreak was also considerably lower; estimated costs were €202,214 in 2009 compared with €539,325 in 2006. This study found that rapid closure of the SICU, with patients cohorted elsewhere, was a cost-effective way of controlling an MDRAB outbreak., (Copyright © 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

The closure of rural independently owned pharmacies, including pharmacies that are the sole source of access to local pharmacy services, from 2003 through 2011 coincides with the implementation of two major policies related to payment for prescription medications: (1) Medicare prescription drug discount cards were introduced on January 1, 2004; and (2) the Medicare prescription drug benefit (Part D) began on January 1, 2006. In this brief, we focus on rural pharmacy closure because of the potential threat such closures present to access to any local pharmacy services in a community. Services include providing medications from local stock without delay or travel, overseeing administration of medications to nursing homes and hospitals, and patient consultation.

Context: Between 1998 and 2008, the number of hospital-based emergency departments (EDs) in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures. Federal law requiring EDs to treat all in need regardless of a patient's ability to pay may make EDs more vulnerable to the market forces that govern US health care., Objective: To determine hospital, community, and market factors associated with ED closures., Design: Emergency department and hospital organizational information from 1990 through 2009 was acquired from the American Hospital Association (AHA) Annual Surveys (annual response rates ranging from 84%-92%) and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports. We evaluated 3 sets of risk factors: hospital characteristics (safety net [as defined by hospitals caring for more than double their Medicaid share of discharges compared with other hospitals within a 15-mile radius], ownership, teaching status, system membership, ED size, case mix), county population demographics (race, poverty, uninsurance, elderly), and market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs)., Setting: All general, acute, nonrural, short-stay hospitals in the United States with an operating ED anytime from 1990-2009., Main Outcome Measure: Closure of an ED during the study period., Results: From 1990 to 2009, the number of hospitals with EDs in nonrural areas declined from 2446 to 1779, with 1041 EDs closing and 374 hospitals opening EDs. Based on analysis of 2814 urban acute-care hospitals, constituting 36,335 hospital-year observations over an 18-year study interval (1990-2007), for-profit hospitals and those with low profit margins were more likely to close than their counterparts (cumulative hazard rate based on bivariate model, 26% vs 16%; hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.5-2.1, and 36% vs 18%; HR, 1.9; 95% CI, 1.6-2.3, respectively). Hospitals in more competitive markets had a significantly higher risk of closing their EDs (34% vs 17%; HR, 1.3; 95% CI, 1.1-1.6), as did safety-net hospitals (10% vs 6%; HR, 1.4; 95% CI, 1.1-1.7) and those serving a higher share of populations in poverty (37% vs 31%; HR, 1.4; 95% CI, 1.1-1.7)., Conclusion: From 1990 to 2009, the number of hospital EDs in nonrural areas declined by 27%, with for-profit ownership, location in a competitive market, safety-net status, and low profit margin associated with increased risk of ED closure.

Never is the fraught relationship between the state-run custodial mental hospital and its host community clearer than during the period of rapid deinstitutionalization, when communities, facing the closure of their mental health facilities, inserted themselves into debates about the proper configuration of the mental health care system. Using the case of Weyburn, Saskatchewan, site in the 1960s of one of Canada's earliest and most radical experiments in rapid institutional depopulation, this article explores the government of Saskatchewan's management of the conflict between the latent functions of the old-line mental hospital as a community institution, an employer, and a generator of economic activity with its manifest function as a site of care made obsolete by the shift to community models of care.

The objective of this study was to determine the costs and benefits of the MRSA Search and Destroy policy in a Dutch hospital during 2001 through 2006. Variable costs included costs for isolation, contact tracing, treatment of carriers and closure of wards. Fixed costs were the costs for the building of isolation rooms and the salary of one full-time infection control practitioner. To determine the benefits of the Search and Destroy policy, the transmission rate during the study period was calculated. Furthermore, the number of cases of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia prevented was estimated, as well as its associated prevented costs and patient lives. The costs of the MRSA policy were estimated to be euro 215,559 a year, which equals euro 5.54 per admission. The daily isolation costs for MRSA-suspected and -positive hospitalised patients were euro 95.59 and euro 436.62, respectively. Application of the Search and Destroy policy resulted in a transmission rate of 0.30 and was estimated to prevent 36 cases of MRSA bacteraemia per year, resulting in annual savings of euro 427,356 for the hospital and ten lives per year (95% confidence interval [CI] 8-14). In conclusion, application of the MRSA Search and Destroy policy in a hospital in a country with a low endemic MRSA incidence saves money and lives.

A recent study has found that U.S. hospitals are apparently shifting the unreimbursed costs of caring for Medicare inpatients to other payers. So far, hospitals have found other sources of revenue to offset negative margins from patient care, but how much longer they can continue to do so is uncertain. The number of states in which hospitals were enjoying positive Medicare margins was found to have dropped from 44 to 13 during the study period.

Purpose: We determine the rate of nursing home closures for 7 years (1999-2005) and examine internal (e.g., quality), organizational (e.g., chain membership), and external (e.g., competition) factors associated with these closures., Design and Method: The names of the closed facilities and dates of closure from state regulators in all 50 states were obtained. This information was linked to the Online Survey, Certification, and Reporting data, which contains information on internal, organizational, and market factors for almost all nursing homes in the United States., Results: One thousand seven hundred and eighty-nine facilities closed over this time period (1999-2005). The average annual rate of closure was about 2 percent of facilities, but the rate of closure was found to be increasing. Nursing homes with higher rates of deficiency citations, hospital-based facilities, chain members, small bed size, and facilities located in markets with high levels of competition were more likely to close. High Medicaid occupancy rates were associated with a high likelihood of closure, especially for facilities with low Medicaid reimbursement rates., Implications: As states actively debate about how to redistribute long-term care services/dollars, our findings show that they should be cognizant of the potential these decisions have for facilitating nursing home closures.