HAY SPRINGS, Neb. — On a cold February morning Mark Pieper left his ranch near Hay Springs for another dialysis trip to Chadron, a routine he had kept three days a week for 3½ years. That session would be one of his last: Chadron Hospital ended its dialysis service at the end of March, leaving Pieper and 16 other patients without their nearest lifesaving treatments.
Pieper, who needs dialysis after kidney damage from cancer treatment, recalled his first reaction when he heard the unit would close: he felt helpless and feared for his life. The therapy he and his neighbors relied on — outpatient treatments that filter waste and excess fluid and typically take about four hours each — was no longer available locally.
The shutdown underscores a broader decline in rural health care access. Rural Americans generally face higher rates of chronic illness while living farther from specialty services. Federal efforts to address the problem include the Rural Health Transformation Program, launched with $50 billion in pledged funding last year. But the program limits states to using no more than 15% of the money for direct payments to providers, meaning the initiative is aimed at new models of care rather than simply propping up loss-making services.
Chadron Hospital, an independent nonprofit and federally designated critical access hospital, had been operating the dialysis unit at a steep loss. CEO Jon Reiners said the unit lost roughly $1 million a year because reimbursements did not cover operating costs. While the critical access designation raises Medicare payments for some services, it does not increase payments for outpatient dialysis. Hospital leaders said they spent more than a year seeking alternatives and contacted four private dialysis providers; each declined after concluding the service would continue to lose money.
The fallout has forced patients and families to adjust in costly, disruptive ways. Pieper found a new treatment site in Scottsbluff, the region’s largest city, but the commute is long: about 1½ hours each way, tripling his weekly driving time to over nine hours. Jim and Carol Wright now rent a small house near Rapid City, South Dakota, and stay there during the week so Jim can get dialysis. They plan to sell their home near Chadron and move closer to care but said the rental costs aren’t sustainable indefinitely. Linda Simonson drives more than four hours round trip to take her husband, Alan, to sessions in Scottsbluff. Some nursing home residents have relocated to facilities nearer dialysis centers, increasing the physical distance between patients and their families.
Nephrologist Mark Unruh, chair of internal medicine at the University of New Mexico, said staffing shortages and financial pressure are prompting closures across the country, worsening kidney health disparities in rural areas. Studies and federal data show rural residents are more likely to develop end-stage kidney disease and face higher mortality after diagnosis. Unruh emphasized prevention and workforce training, pointing to tele-education models such as Project ECHO that teach primary care clinicians in rural communities how to manage patients to slow disease progression.
Home dialysis is an alternative for some patients, and rural patients are slightly more likely than urban patients to be using it — about 18% versus 14% in 2023. But home therapies require extensive training and sometimes surgery. One home technique needs a catheter and up to 15 days of training; the nearest training for that option from Chadron is in Scottsbluff. Another home modality can require up to eight weeks of instruction, with the closest program about three hours away in Cheyenne, Wyoming. Pieper’s doctors said he is not a candidate for home dialysis or a transplant.
Experts suggest several policy and operational fixes to ease rural patients’ access to dialysis: expanding transplant evaluations that can be completed in a few days to reduce travel, increasing staff who can train patients and caregivers for home dialysis, and deploying mobile dialysis units. Some states have proposed using their Rural Health Transformation Program awards to support such efforts: at least 11 states included dialysis-related proposals, including mobile units and support for home or long-term care dialysis programs. Nebraska’s first-year allocation was $219 million, but local hospital leaders and patients said program restrictions make it difficult to use that funding to sustain services that operate at a loss.
Inside Chadron’s former unit, staff who had built close relationships with patients were left without the service they provided. Local patients and families appealed to state and federal officials; some said their calls to aides and representatives went unanswered. “It feels like they don’t know that we exist at this end of the state,” Simonson said.
For now, families face longer drives, higher out-of-pocket costs and, in some cases, the need to relocate. Jim Wright acknowledged the financial realities hospitals contend with, but he stressed the life-or-death nature of dialysis: if patients miss treatments, the consequences can be fatal.
KFF Health News produced this reporting.