The sun was just warming the horizon as rancher Mark Pieper left his home near Hay Springs, Nebraska, for an early dialysis appointment. For 3½ years he’d driven about 30 minutes, three days a week, to Chadron Hospital for the treatment that keeps him alive after cancer damaged his kidneys. One February morning he was at one of his last sessions there. The hospital announced it would shut down dialysis at the end of March.
Pieper was stunned. “I guess I’ll just bloat up and die in a month,” he recalled thinking when he heard the news. He was one of 17 patients who depended on the Chadron unit, where each treatment lasts about four hours. For people in this sparsely populated region, the local dialysis unit was not just a medical service but a lifeline.
The closure is an example of the shrinking health services in rural America, where chronic illness rates are higher but access to care is poorer. The Trump administration’s Rural Health Transformation Program pledged $50 billion to help rural health, and Nebraska celebrated receiving $219 million in first-year funding, but that money is intended for experimenting with new models of care rather than sustaining existing services. States can use only up to 15% of the funds to pay providers for patient care, limiting immediate relief for struggling units.
Chadron Hospital’s CEO, Jon Reiners, said the dialysis program lost about $1 million a year because reimbursement didn’t cover operating costs. The hospital is a critical access facility, which boosts Medicare payments for some services, but that designation doesn’t increase outpatient dialysis payments. Reiners said the hospital spent more than a year seeking solutions, including asking private dialysis companies to take over the unit; each declined after seeing the likely losses.
Nephrologist Mark Unruh described the closure as part of a broader trend of staffing and funding challenges that displace rural patients. Rural Americans are more likely to develop end-stage kidney disease and face higher mortality rates after diagnosis, studies and national data show. Unruh said prevention is key, and pointed to tele-education programs such as Project ECHO that help rural primary care doctors manage and prevent kidney failure. He also urged expanding home dialysis training and increasing transplantation for rural patients, including testing “fast-track” evaluation approaches to reduce travel burdens.
Some patients are moving closer to care. Jim and Carol Wright now rent a small house near Rapid City, South Dakota, and live there on weekdays so Jim can get dialysis. They said they’ll eventually have to sell their home near Chadron and relocate to a larger city to stay near treatment. Others transferred to nursing homes nearer to centers, a choice that can separate patients from family.
Many are making long drives. Pieper found treatment in Scottsbluff, the largest town in the Panhandle, but the one-way trip takes about 90 minutes, making his weekly driving time more than nine hours. Linda Simonson drives her husband, Alan, over four hours round-trip for his dialysis in Scottsbluff. She said closer centers either lacked capacity or have routes that are unsafe or impractical in poor weather. The region’s rural transit system exists but its schedule doesn’t suit many dialysis patients who need reliable, timely transport and support during trips.
Home dialysis is more common among rural patients than urban ones—nearly 18% of rural patients used home dialysis in 2023 versus about 14% in urban areas, according to NIH data. But home dialysis requires substantial training: one form needs surgery to place an abdominal catheter and up to about two weeks of training; another type requires up to eight weeks of training. The nearest center offering training for peritoneal dialysis is in Scottsbluff; the center for training in the other modality is three hours away in Cheyenne, Wyoming. Pieper said doctors told him he’s not a candidate for home dialysis or transplant, leaving him little choice but to travel.
Patients and families have tried to persuade policymakers and hospital leaders to find a fix. The Wrights wrote letters proposing that federal rural health funds help keep the unit open. Simonson said she spoke with legislative aides but felt ignored. “It feels like they don’t know that we exist at this end of the state,” she said.
The closure underscores structural problems: low reimbursement for outpatient dialysis, thin patient volumes that make units financially fragile, difficulty recruiting staff who can provide and train for home dialysis, and long distances that make routine treatment onerous. For the affected patients, the change is immediate and severe—more driving, greater expense, disruption of routines, and, in some cases, moving away from homes and support networks.
Efforts to address rural kidney care include prevention programs, tele-education for primary care, expanding home dialysis training and access, creative state uses of rural health transformation funds (some states have proposed mobile dialysis units or support for in-home therapy), and faster transplant evaluations to reduce travel. But those strategies take time and resources; for patients facing the sudden loss of a nearby clinic, the gap is already personal and pressing.
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