As Hurricane Helene battered Clinch Memorial Hospital last year, its chief executive was thinking about the storm shutters the hospital couldn’t afford.
Clinch Memorial had finished a years-in-the-making renovation weeks before the storm struck. As part of the construction process, Angela Handley, the CEO, had considered installing hurricane shutters on the foyer’s massive glass windows, but the rural southeast Georgia hospital couldn’t justify the $100,000 expense. It operates on a 1 percent profit margin.
“I could feel the roof pick up and drop with the wind, and we were just wishing we could have afforded those shutters,” she said in an interview, referring to the September 2024 storm. “We thought at any minute those front windows would come crashing through.”
The event illustrated how difficult it is for small, cash-strapped hospitals to prepare for natural disasters that are being turbocharged by climate change. A year later, Clinch Memorial is still rebuilding and is bracing for another storm: A slew of changes to federal health care policies that could add more financial stress.
Health care premiums under the Affordable Care Act are set to increase next year. The expiration of some subsidies that were keeping costs down for patients is now at the center of a battle over the government shutdown. It could mean small rural hospitals are faced with caring for more uninsured patients who can’t pay their medical bills.
The subsidy expiration follows changes to Medicaid and the Affordable Care Act included in President Donald Trump’s One Big Beautiful Bill Act passed earlier this year that some estimates say could force more than 300 rural hospitals to close.
The policy changes are coming as many rural hospitals are operating on shoestring budgets, and they could have less money to respond to disasters under Trump’s law. The chief executive of another storm-swamped hospital, in Tennessee, has blamed the new changes to Medicaid for making it financially unfeasible to rebuild the facility, which was surrounded by a raging river during Helene.
“We are on razor-thin margins, which will be going into the negative very soon,” Handley said. “There are so many things that can compound against our hospital’s survival, with the hurricane and the Medicaid cuts and the Affordable Care Act changes, it’s just one hit after another.”
Fewer resources
Small rural hospitals are often operating under financial strain because of their size, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, which advocates for affordable health care.
Emergency departments, and labor and delivery wards at rural hospitals tend to treat fewer patients than bustling urban facilities. That makes their costs to treat each patient higher than busier health centers. But most insurers pay rural hospitals the same amount per patient as bigger centers.
“They have these big, fixed costs, but they have a smaller number of patients and payments to compensate for it,” Miller said.
On average, 10 to 20 percent of rural patients rely on Medicaid, making hospitals that serve them sensitive to changes in the program. The Trump administration’s massive tax and spending law made changes to Medicaid and the Affordable Care Act that could push the number of uninsured U.S. residents to over 16 million people over the next decade, according to the Congressional Budget Office. The law also cuts Medicaid spending that is used by states to fund rural hospitals.
More than 700 rural hospitals nationwide are at risk of closing because of serious financial problems stemming from yearly losses and having low financial reserves, according to Miller’s group, which analyzed the financial data of hospitals. More than 300 are at “immediate” risk of closing.
Recent policy changes amplify that strain, he said, but the precise impact of Trump’s law is difficult to predict because states are still developing their responses.
“It’s really hard to say exactly what the impact is on rural hospitals, however most of them are already losing money and any hospital that is losing money is going to have fewer resources to deal with other problems that may come up,” Miller said.
White House spokesperson Kush Desai noted that the One Big Beautiful Bill Act includes $50 billion in grants for rural hospitals and rejected the idea that the legislation would increase the financial strain on those facilities.
“Rural hospital woes have nothing to do with the Trump administration’s policies and everything to do with the fact that rural hospitals in sparsely populated areas have chronically low utilization rates, with more empty beds than full ones,” he said.
Rural hospitals will face additional financial strain if the number of uninsured patients increases due to the expected expiration of Affordable Care Act subsidies.
Created by Congress in 2021 as part of the pandemic relief package, the subsidies helped people who did not qualify for Medicaid to obtain health insurance with no or very low premiums. Experts credited the subsidies with record-high Obamacare enrollment in 2025. But annual premiums could more than double in 2026 without the subsidies, according to the nonpartisan health research group KFF.
That could push 3.8 million people annually out of Obamacare, leaving them uninsured, according to the Congressional Budget Office.
“We will see sticker shock,” said Chiquita Brooks-LaSure who was the administrator for the Centers for Medicare and Medicaid Services during the Biden administration.
Rural hospitals could have to foot the bill when uninsured people need health care. That could lead to some of them closing.
“No one should have to forgo health care due to changes in coverage, and no one should have to drive hours more for care during or after a hurricane because their rural hospital shut down,” Brooks-LaSure said.
Climate change
In some states, hospitals at risk of closing are in areas that the Federal Emergency Management Agency has identified as being prone to disasters.
One analysis from the University of North Carolina’s Sheps Center for Health Services Research found that the One Big Beautiful Bill Act could force more than 300 rural hospitals to close. The analysis was done at the request of Senate Democrats. Thirty-three of those hospitals are in Louisiana, where 21 percent of Medicaid funding for rural hospitals is expected to be cut because of the legislation, according to a bipartisan resolution passed by the state Legislature this summer.
Of the 33 hospitals that could close, eight are in counties that FEMA says are at high risk for disasters, according to an analysis conducted by Sabotaging Our Safety. The advocacy group was formed by left-leaning emergency management and health care officials in the wake of the deadly Texas floods this summer.
Davante Lewis, who serves on the Louisiana Public Service Commission and sits on Sabotaging Our Safety’s advisory board, said the Medicaid cuts could “leave our disaster zones in danger without emergency care when hurricanes strike.”
Medicaid cuts would have less impact in Texas, which never expanded the program under the Affordable Care Act and has a number of state programs to help small rural hospitals cope with financial pressures. But those facilities are still bracing for the effects of people being pushed out of the insurance program, said Terry Scoggin, interim director of the Texas Organization of Rural & Community Hospitals.
“We already have a lot of uninsured patients, and we believe that our uninsured rate will increase between 2 and 3 percent across rural hospitals,” he said.
That could have a big impact during disasters in a state where a third of all hospitals have enough cash on hand to operate for less than 10 days.
“There is no rainy-day funds at these hospitals,” Scoggin said. “We are at the mercy of natural disasters, and unfortunately Texas experiences all of them, from floods to hurricanes to wildfires and tornadoes.”
Back in Georgia, Clinch Memorial Hospital is in a better financial situation than some other facilities.
Nine rural hospitals have closed in the state since 2005, while 23 have stopped offering chemotherapy over the last decade. More than a dozen rural hospitals have closed their obstetric and gynecology services within the last year.
Clinch Memorial doesn’t appear to be at risk of imminent closure, but the hospital currently faces $1.8 million in annual losses from treating patients who can’t pay their bills. Health insurance premiums for Clinch Memorial’s own staff are set to increase in 2026, and Handley said the hospital has chosen to absorb those costs rather than passing them on to employees, many of whom were personally affected by Hurricane Helene.
“It will be a lean year for us, but we just can’t pass those costs on to them so soon after the storm,” she said, adding that some are still living with “blue tarps for roofs.”
For 10 days after the storm, the hospital was one of the only places in Homerville with power, clean water and the ability to cook food — although its air conditioning stopped working and much of the new construction was destroyed.
The 25-bed hospital served more than 7,000 meals to the community before power was restored in the town of about 2,400 people. Handley herself worked 48 hours before she collapsed making peanut butter sandwiches in the kitchen and had to receive intravenous fluids for dehydration.
“People depend on us when no one else is open. When everyone else turns their backs, they come here because we are the safety net,” she said. “I want to be able to say that we will still be here doing that a year from now, but honestly I am very afraid we will not be.”
Correction: An earlier version of this article misstated the number of meals Clinch Memorial Hospital served following Hurricane Helene. It was 7,000.
