Early one morning, rancher Mark Pieper left his Hay Springs, Nebraska, home for a routine dialysis session — a trip he had taken three times a week for 3½ years. He had been driving roughly 30 minutes to Chadron Hospital, where each treatment lasted about four hours. Then the hospital announced it would close its dialysis unit at the end of March, leaving Pieper and 16 other regular patients scrambling for alternatives.
For many people in this sparsely populated corner of Nebraska, the local dialysis unit was not merely convenient medical care but a lifeline. The decision to shut the program exposed the fragile economics of rural health care: the program at Chadron lost roughly $1 million a year, hospital officials said, because reimbursements didn’t cover operating costs. Chadron Hospital is a critical access facility, a designation that helps certain Medicare payments, but it does not increase outpatient dialysis reimbursement. Hospital leaders spent more than a year seeking a solution and asked private dialysis providers to take over the unit; all declined after projecting continued losses.
The closure highlights a national pattern of shrinking rural services even as chronic illness burdens in small communities remain high. The federal Rural Health Transformation Program pledged $50 billion to support rural health innovation; Nebraska received $219 million in the first year. But those funds are meant primarily for experimenting with new approaches rather than propping up existing care, and states may use no more than 15% of the allocation to directly pay providers for patient care. That leaves limited immediate relief for units already operating in the red.
Local physicians and rural health advocates say the problem is structural: low outpatient dialysis reimbursement, small patient volumes that leave units financially vulnerable, difficulty recruiting and retaining trained staff, and long distances that make frequent, multi-hour treatments a major burden. Nephrologists note that rural Americans face higher rates of end-stage kidney disease and higher mortality after diagnosis. They argue the long-term response should include stronger prevention, better support for rural primary care clinicians, expanded home-dialysis training, and easier access to transplantation — measures that take time to implement.
Tele-education programs such as Project ECHO are examples doctors point to for helping rural primary care teams manage and prevent kidney disease. Home dialysis and increased transplantation are widely discussed as ways to reduce travel and improve outcomes, but both require investments: home therapies need surgery to place catheters and substantial patient training (a program can require roughly two weeks to eight weeks of instruction, depending on the modality), while transplant access depends on streamlined evaluation and donor pathways. In the Panhandle, the nearest center that trains patients for peritoneal dialysis is in Scottsbluff; training for the other common home modality is three hours away in Cheyenne, Wyoming — a practical barrier for many.
In the immediate term, patients have adopted a range of coping strategies, all of them disruptive. Some are moving closer to treatment centers. Jim and Carol Wright now rent a small house near Rapid City, South Dakota, and stay there during the week so Jim can receive dialysis; they expect they will eventually sell their home near Chadron and relocate permanently to a larger town. Others have transferred to nursing facilities near dialysis centers, a choice that can separate patients from family and community.
Many patients endure longer drives. Pieper found a new treatment location in Scottsbluff, but the one-way drive takes about 90 minutes, turning a thrice-weekly regimen into more than nine hours on the road each week. Linda Simonson drives her husband, Alan, to dialysis in Scottsbluff, a round-trip of more than four hours, because closer centers either lack capacity or have routes that are unsafe or impractical in severe weather. The region’s rural transit options exist but their schedules and services often do not meet the strict timing, reliability, and support needs dialysis patients require.
Home dialysis is actually somewhat more common in rural populations than in cities — federal data show about 18% of rural dialysis patients used home modalities in 2023 compared with roughly 14% in urban areas — but not everyone is a candidate. Pieper said clinicians told him he was not eligible for home therapy or transplant, leaving long-distance travel as his only realistic option.
Patients and families have appealed to hospital leaders and policymakers for assistance. The Wrights sent letters urging state and federal rural health funds be used to keep the Chadron unit open. Others spoke with legislative aides but say their pleas have not produced solutions. Residents express frustration that decision makers may not fully grasp the geographic isolation and daily burdens that make losing a local clinic devastating.
Policymakers and health systems have proposed a variety of remedies — from mobile dialysis vans and in-home therapy supports to expanded tele-education, boosted training for home programs, and fast-tracked transplant evaluations — and some states are experimenting with creative uses of federal rural health dollars. Yet implementing those changes requires time, staffing, and sustained funding. For the 17 patients displaced by Chadron’s closure, the effect is immediate: increased travel, higher out-of-pocket costs, disrupted routines, and in some cases the need to uproot lives to remain near life-sustaining care.
This episode is one local example of broader national tensions in rural health: communities with higher chronic-disease burdens and thin provider markets, hospitals struggling under narrow margins, and federal resources aimed at innovation but limited in their ability to fill urgent gaps. The result is that when a small, financially fragile service closes, patients face stark choices and urgent hardship.
KFF Health News produces in-depth reporting on health policy and health care issues as part of KFF’s national journalism program.