Rural Hospital Closures: Affected Residents Had Reduced Access to Health Care Services

What GAO Found

GAO found that when rural hospitals closed, residents living in the closed hospitals’ service areas would have to travel substantially farther to access certain health care services. Specifically, for residents living in these service areas, GAO’s analysis shows that the median distance to access some of the more common health care services increased about 20 miles from 2012 to 2018. For example, the median distance to access general inpatient services was 3.4 miles in 2012, compared to 23.9 miles in 2018—an increase of 20.5 miles. For some of the less common services that were offered by a few of the hospitals that closed, this median distance increased much more. For example, among residents in the service areas of the 11 closed hospitals that offered treatment services for alcohol or drug abuse, the median distance was 5.5 miles in 2012, compared to 44.6 miles in 2018—an increase of 39.1 miles to access these services (see figure).

Median Distance in Miles from Service Areas with Rural Hospital Closures to the Nearest Open Hospital that Offered Certain Health Care Services, 2012 and 2018

Notes: GAO focused its analysis on the health care services offered in 2012 by the 64 rural hospitals that closed during the years 2013 through 2017 and for which data were available. For example, in 2012, 64 closed hospitals offered general inpatient services, 62 offered emergency department services, 11 offered treatment services for alcohol or drug abuse, and 11 offered services in a coronary care unit. To examine distance, GAO calculated “crow-fly miles” (the distance measured in a straight line) from the geographic center of each closed rural hospital’s service area to the geographic center of the ZIP Code with the nearest open rural or urban hospital that offered a given service.

GAO also found that the availability of health care providers in counties with rural hospital closures generally was lower and declined more over time, compared to those without closures. Specifically, counties with closures generally had fewer health care professionals per 100,000 residents in 2012 than did counties without closures. The disparities in the availability of health care professionals in these counties grew from 2012 to 2017. For example, over this time period, the availability of physicians declined more among counties with closures—dropping from a median of 71.2 to 59.7 per 100,000 residents—compared to counties without closures—which dropped from 87.5 to 86.3 per 100,000 residents.

Why GAO Did This Study

Rural hospitals face many challenges in providing essential access to health care services to rural communities. From January 2013 through February 2020, 101 rural hospitals closed.

GAO was asked to examine the effects of rural hospital closures on residents living in the areas of the hospitals that closed. This report examines, among other objectives, how closures affected the distance for residents to access health care services, as well as changes in the availability of health care providers in counties with and without closures.

GAO analyzed data from the Department of Health and Human Services (HHS) and the North Carolina Rural Health Research Program (NC RHRP) for rural hospitals (1) that closed and those that were open during the years 2013 through 2017, and (2) for which complete data generally were available at the time of GAO’s review. GAO also interviewed HHS and NC RHRP officials and reviewed relevant literature.

GAO defined hospitals as rural according to data from the Federal Office of Rural Health Policy. GAO defined hospital closure as a cessation of inpatient services, the same definition used by NC RHRP. GAO defined service areas with closures as the collection of ZIP Codes that were served by closed rural hospitals and service areas without closures as the collection of ZIP Codes served only by rural hospitals that were open.

GAO provided a draft of this report to HHS for comment. The Department provided technical comments, which GAO incorporated as appropriate.

For more information, contact James Cosgrove at (202) 512-7114 or cosgrovej@gao.gov.

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    The Department of Defense (DOD) is closer to being able to use military code (M-code)—a stronger, more secure signal for the Global Positioning System (GPS) designed to meet military needs. However, due to the complexity of the technology, M-code remains years away from being widely fielded across DOD. M-code-capable receiver equipment includes different components, and the development and manufacture of each is key to the modernization effort. These include: special M-code application-specific integrated circuit chips, special M-code receiver cards, being developed under the Air Force Military GPS User Equipment (MGUE) programs, and the next generation of GPS receivers capable of using M-code signals from GPS satellites. DOD will need to integrate all of these components into different types of weapon systems (see figure for notional depiction of integration for one system). Integration across DOD will be a considerable effort involving hundreds of different weapon systems, including some with complex and unique integration needs or configurations. Global Positioning System User Equipment Integration The Air Force is almost finished—approximately one year behind schedule—developing and testing one M-code card for testing on the Marine Corps Joint Light Tactical Vehicle and the Army Stryker vehicle. However, one card intended for use in aircraft and ships is significantly delayed and missed key program deadlines. The Air Force is revising its schedule for testing this card. The M-code card development delays have had ripple effects on GPS receiver modernization efforts and the weapon systems that intend to use them. For example, an Air Force receiver modernization effort that depends on the new technology will likely breach its schedule and incur additional costs because of the delay. In turn, DOD planned to incorporate that receiver into its F/A-18 fighter aircraft, AV-8B strike aircraft, and the MH-53E helicopter, but it no longer plans to do so because of the delay. DOD has not yet determined the full extent of the development effort to widely integrate and field M-code receivers across the department. The amount of additional development and integration work is expected to vary for each weapon system and could range from a few weeks to several years. DOD is taking steps to enable fielding modernized receivers that use M-code cards by working to identify integration and production challenges. DOD has been developing the capability to use its more jam-resistant military-specific GPS signal for 2 decades. The Air Force launched the first GPS satellite capable of broadcasting the M-code signal in 2005, but is only now completing development of the software and other equipment needed to use it. The GPS modernization effort spans DOD and the military services, but an Air Force program office is developing M-code cards for eventual production and integration into weapon systems. The National Defense Authorization Act for Fiscal Year 2016 included a provision that the Air Force provide quarterly reports to GAO on next-generation GPS acquisition programs, and that GAO brief congressional defense committees. Since 2016, GAO has provided briefings and reported on various aspects of GPS. This report discusses DOD's progress and challenges (1) developing M-code receiver cards, and (2) developing receivers and taking other steps to make M-code-capable receivers available for fielding. GAO reviewed schedules and cost estimates for the Air Force's MGUE programs; military service and DOD M-code implementation data; and test and integration plans for aircraft, ships, and ground vehicles. GAO also reviewed strategies for continued access to microelectronics and interviewed officials from the MGUE programs, military services, and DOD, and representatives from microelectronics developers. For more information, contact Jon Ludwigson at (202) 512-4841 or ludwigsonj@gao.gov.
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    The Department of Justice announced today that it has completed its investigation into whether Georgetown Day School, Holton-Arms School, Landon School, Maret School, National Cathedral School, The Potomac School, St. Albans School, and Sidwell Friends School (jointly, “the Schools”) collectively agreed to stop offering Advanced Placement (AP) courses by 2022 in violation of the Sherman Act.  The Schools announced in June 2018 that they would eliminate AP courses from their curricula by 2022. 
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  • Federal Telework: Key Practices That Can Help Ensure the Success of Telework Programs
    In U.S GAO News
    The Telework Enhancement Act of 2010 (the act) defines telework as a work flexibility arrangement under which an employee performs the duties and responsibilities of their position and other authorized activities from an approved worksite other than the location from which the employee would otherwise work. GAO previously identified key practices in telework-related literature and guidelines that federal agencies should implement in ensuring successful telework programs. These key practices may be grouped under seven categories. Program planning. Consistent with a key practice GAO identified, agencies are required to have a telework managing officer. Other key practices related to planning for a telework program include establishing measurable telework program goals, and providing funding to meet the needs of the telework program. Telework policies. Agencies can help ensure their workforces are telework ready by establishing telework policies and guidance. To ensure that teleworkers are approved on an equitable basis, agencies should establish eligibility criteria, such as suitability of tasks and employee performance. Agencies should also have telework agreements for use between teleworkers and their managers. Performance management. Agencies should ensure that the same performance standards are used to evaluate both teleworkers and nonteleworkers. Agencies should also establish guidelines to minimize adverse impacts that telework can have on nonteleworkers. Managerial support. For telework programs to be successful agencies need support from top management. They also need to address managerial resistance to telework. Training and publicizing. Telework training helps agencies ensure a common understanding of the program. The act requires agencies to provide telework training to employees eligible to telework and to managers of teleworkers. Keeping the workforce informed about the program also helps. Technology. Agencies need to make sure teleworkers have the right technology to successfully perform their duties. To that end, agencies should assess teleworker and organization technology needs, provide technical support to teleworkers, and address access and security issues. Program evaluation. Agencies should develop program evaluation tools and use such tools from the very inception of the program to identify problems or issues. Agencies can then use this information to make any needed adjustments to their programs. GAO has previously reported instances where selected agencies faced challenges implementing telework programs that aligned with key practices. For example, three of four selected agencies did not require review or document their review of ongoing telework agreements. These reviews are important to provide assurance that the agreements reflect and support their current business needs. GAO also previously reported that managers at three of four selected agencies were not required to complete telework training before approving staff's telework agreements. The training is important to ensure managers fully understood agency telework policy and goals before approving or denying requests to telework. Telework offers benefits to federal agencies as well as to the federal workforce. These include improving recruitment and retention of employees, reducing the need for costly office space, and an opportunity to better balance work and family demands. In addition, telework is a tool that agencies can use to help accomplish their missions during periods of disruption, including during the current COVID-19 pandemic. Congress has encouraged federal agencies to expand staff participation in telework, most recently by passing the Telework Enhancement Act of 2010 (the act). The act established requirements for executive agencies' telework policies and programs, among other things. This statement provides key practices to help ensure the success of telework programs. The statement is based on GAO's body of work on federal telework issued from July 2003 through February 2017. GAO has recently initiated two reviews related to federal telework. One is examining the extent to which agencies have used telework during the COVID-19 pandemic, including the successes and challenges agencies experienced. The second is reviewing agencies' telework information technology infrastructure. For more information, contact Michelle B. Rosenberg at (202) 512-6806 or rosenbergm@gao.gov.
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