Nearly two-thirds of the lowest performing hospitals are in states that didn't expand Medicaid, according to a previous Chartis report.
One case-in-point: the state of Georgia, which did not expand Medicaid and where over half of the state's 73 rural hospitals are in danger of closing. Six have closed
Raju knew that Richland's Stewart-Webster Hospital was "financially strained." Even for those patients covered by Medicaid, low reimbursement rates did not make a big enough dent. But Raju did not turn away any patients, even if they couldn't pay, he said.
Rural hospitals take a financial hit when they provide care to uninsured patients who can't afford it, said Elehwany. By insuring poorer patients, the Affordable Care Act hoped to remedy that. Despite its positive impacts, she said, it wasn't the magic bullet rural communities had hoped for.
"We strongly support the goals of the ACA," Elehwany said. "Everybody admits there's a few problems with the ACA, and unfortunately ... they seem to be magnified in rural America."
Some of these problems, she said, stem from high-deductible plans with rising premiums, as well as few choices on the private exchanges. This may make insurance out of reach for an aging rural population, who are poorer and sicker on average
than their urban counterparts, and who bear the brunt of the opioid epidemic, according to experts.
Sen. Shelley Moore Capito, a Republican from West Virginia, came out against the Senate health care bill this week for these reasons.
"As drafted, this bill will not ensure access to affordable health care in West Virginia, does not do enough to combat the opioid epidemic that is devastating my state, cuts traditional Medicaid too deeply, and harms rural health care providers," Capito said in a statement.
Other Republican senators have argued that the health care bill could strengthen Medicaid, with Sen. Richard Burr, a Republican from North Carolina, saying in a statement last week
that the bill provides additional funding to community health centers "to ensure they can continue to provide access to care in rural and hard to reach places."
The Senate bill could cut revenues to rural providers by $1.3 billion each year, according to the Chartis Center and its partner iVantage Health Analytics. Roughly 34,000 jobs are also at risk, according to the analysis.
Raju, who sees 20 to 25 patients a day in his office, is not optimistic that hospital doors will reopen in Richland.
"I'm very doubtful it's going to happen, but we're not going to give up. We'll keep trying," he said.
That leaves his patients in what is known as a "medical desert." A long drive to the nearest hospital -- 45 minutes or more -- could be the difference between life and death, he said.
"Time is essential," he said. "We're going to lose some patients on the way because they cannot get the care in a reasonable amount of time."
But that doesn't deter Raju, who has been a staple in Richland for nearly four decades.
"I grew up in a rural area in India, and I always liked the small town," he said. "I've been here too long. I just can't go."