HAY SPRINGS, Neb. — The sun was just warming the horizon as Mark Pieper left his ranch near Hay Springs on a crisp February morning. For the past 3½ years, three days a week, Pieper has driven to Chadron for dialysis. That morning was one of his last sessions before Chadron Hospital ended its dialysis service at the end of March.
“I guess I’ll just bloat up and die in a month,” Pieper remembered thinking when he heard the news. He needs dialysis after cancer treatment damaged his kidneys. Pieper and 16 other patients relied on Chadron Hospital for the life-sustaining therapy that filters waste and fluid from the blood. Treatments take about four hours each.
The closure is one example of a long decline in rural health care. People in rural areas have higher rates of many chronic conditions but less access to care. The federal Rural Health Transformation Program, launched with $50 billion in promised funding last year, aims to explore ways to improve rural health. But states can use only up to 15% of that money to pay providers for patient care, so the program is designed for new approaches rather than propping up existing services.
Jon Reiners, CEO of independent, nonprofit Chadron Hospital, said the dialysis unit lost about $1 million a year because reimbursements didn’t cover costs. The hospital is a critical access hospital, a designation that boosts Medicare reimbursement for some services, but that program doesn’t cover outpatient dialysis. Reiners said the hospital spent more than a year seeking solutions, contacting four private providers to run the unit; all declined after realizing they would lose money.
The closure forced patients to adapt. Pieper eventually found treatment in Scottsbluff, the largest city in the region, but the trip is long — a one-and-a-half-hour drive each way that triples his weekly driving time to more than nine hours. Jim and Carol Wright rented a small house near Rapid City, South Dakota, and live there on weekdays so Jim can get dialysis. They plan to sell their home near Chadron and move to be closer to care, but can’t afford the rental forever. Linda Simonson drives more than four hours round trip to take her husband, Alan, to treatments in Scottsbluff. Some nursing home residents have moved to facilities closer to dialysis, putting distance between patients and their families.
Nephrologist Mark Unruh, chair of internal medicine at the University of New Mexico, said staffing and funding challenges are driving closures nationwide. Rural residents face significant disparities in kidney health: they’re more likely to develop end-stage kidney disease and to have higher mortality after diagnosis, according to recent studies and federal data. Unruh said prevention is crucial and highlighted tele-education programs, such as Project ECHO, that train primary care clinicians in rural areas to prevent progression to renal failure.
Home dialysis is another option but isn’t always viable. Rural patients are slightly more likely than urban patients to use home dialysis — about 18% versus 14% in 2023 — but it requires substantial training and sometimes surgery. One type of home therapy needs a catheter implanted and up to 15 days of training; the nearest training for that option from Chadron is in Scottsbluff. Another home modality requires up to eight weeks of training, with the closest program three hours away in Cheyenne, Wyoming. Pieper’s doctors said he’s not a candidate for home dialysis or a transplant.
Unruh and others suggest boosting transplantation rates for rural patients — for example, fast-tracking required tests over a few days to limit travel — and expanding staff who can train patients and caregivers for home dialysis.
Patients and families appealed to local and state leaders and asked that federal rural health funding be used to shore up dialysis access. Nebraska officials celebrated receiving $219 million in first-year funding from the Rural Health Transformation Program, but Reiners and patients said the program’s restrictions make it insufficient to sustain loss-making services. At least 11 states have proposed using some of their rural health awards for dialysis programs, including ideas such as mobile dialysis units and support for home or long-term care dialysis; Nebraska was not among them.
Inside the Chadron unit, staff whose care patients praised were left without their dialysis service. Patients said they called aides for the governor and state representatives but heard no response. “It feels like they don’t know that we exist at this end of the state,” Simonson said.
For now, patients face longer drives, higher costs, or relocation. Jim Wright said he understands the financial pressures hospitals face, but emphasized the life-and-death nature of dialysis: “It’s not a matter of, ‘Oh, I would like to be there.’ It’s a case that if you don’t, you die.”
KFF Health News produced this reporting.