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Abstract

Disparities in health care access have long affected both rural and urban communities across the United States. While much of the discourse has focused on rural hospital closures, inner-city hospitals—often safety-net institutions serving vulnerable populations—are increasingly shutting down due to financial instability, systemic underfunding, and policy changes. These closures have profound consequences for access to surgical care, exacerbating existing disparities and straining remaining health care infrastructure. Patients in affected urban areas face longer travel distances, increased wait times, and, in some cases, the inability to receive critical surgical interventions. This paper explores the impact of inner-city hospital closures on surgical care access, examining trends in urban hospital insolvency, disparities in surgical outcomes, and the financial and policy challenges that contribute to these closures. Through case studies of major hospital shutdowns, including Atlanta Medical Center and Hahnemann University Hospital, we highlight the real-world consequences of losing essential surgical services. We further analyze policy solutions such as Medicaid expansion, financial stabilization strategies, and community-driven health care initiatives that may mitigate these effects. Addressing urban hospital closures is imperative to ensuring equitable access to timely surgical care in underserved populations.

Keywords

inner-city hospital closures access to surgical care Medicaid expansion health care

Introduction

Disparities in health care have persisted for decades across the United States, disproportionately affecting both rural and urban populations. While much of the discourse around hospital closures has historically focused on rural areas, where geographical isolation poses substantial barriers to health care access, urban communities are increasingly experiencing their own health care crises. These crises emerge when essential inner-city hospitals, often serving as safety-net institutions, close their doors due to financial insolvency, systemic underfunding, or policy shifts.

Rural hospital closures create significant challenges for affected populations, forcing patients to travel considerable distances for medical services. The closure of a rural hospital is linked to increased Medicare-covered ambulance trips, highlighting the additional burden placed on emergency medical services.¹ Furthermore, the loss of rural health care facilities is perceived by many as an indication of economic neglect, social marginalization, and a declining commitment to public health investment. These concerns are exacerbated in low-income regions where access to transportation and medical specialists is already limited.

Similarly, inner-city hospitals in major metropolitan areas serve as critical health care providers for vulnerable populations. They not only offer routine and emergency care but also play an essential role in ensuring equitable access to surgical services. These hospitals often provide charity care and absorb a significant share of uninsured and underinsured patients who might otherwise struggle to obtain necessary medical treatments.²

The closure of an inner-city hospital has profound and long-lasting consequences for the communities it once served. Beyond eliminating access to immediate health care services, these closures create a ripple effect that exacerbates existing social and economic disparities. Many urban hospitals stabilize local economies by providing employment, fostering public health programs, and ensuring that underserved populations receive critical care. Urban hospital closures threaten health outcomes and disrupt the broader social infrastructure that supports these communities.

The impact of hospital closures on surgical care is particularly concerning. Surgical services, including trauma surgery, cancer treatments, orthopedic interventions, and other essential procedures, are often time-sensitive. The ability to access surgical care in a timely manner can mean the difference between life and death, between recovery and long-term disability. When hospitals close, surgical patients are forced to travel farther, endure longer wait times, or, in some cases, forgo surgery altogether due to financial or logistical barriers.

This paper aims to explore the full extent of how inner-city hospital closures affect access to surgical care in urban communities. It will examine the financial and systemic challenges that contribute to hospital insolvency, assess the disparities in surgical outcomes that result from hospital closures, and analyze potential policy solutions, such as Medicaid expansion, to mitigate these effects. Additionally, case studies of major hospital closures will provide concrete examples of the real-world implications of these trends, illustrating how the loss of surgical capacity affects patient outcomes and community well-being.

The need for policy interventions to stabilize urban hospitals and maintain access to surgical care is more urgent than ever. Without strategic investments in health care infrastructure, urban populations—particularly low-income and minority residents—will continue to experience worsening health disparities, delayed surgical interventions, and preventable complications. Addressing these issues through financial stabilization, health care policy reforms, and community-driven initiatives can help preserve access to life-saving surgical services for patients within the urban hospital catchment area.

Background

Trends in Inner-City Hospital Closures

The financial instability of inner-city hospitals is a long-standing issue that has worsened over the past several decades. Many of these hospitals operate with extremely tight financial margins, relying heavily on Medicaid and Medicare reimbursements. Unlike wealthier suburban hospitals that receive a mix of private insurance payments and supplemental funding, inner-city hospitals primarily serve low-income patients who are either uninsured or covered by government programs with low reimbursement rates.³

Economic pressures have led to a steady decline in urban hospital capacity. Between 1989 and 1998, nearly 290 urban short-term general hospitals closed, accounting for 40% of all hospital closures in the United States during that period.³ More recent trends indicate that financial distress has continued to drive closures, disproportionately affecting hospitals that serve minority and low-income communities.²

A major contributor to this crisis is the rise of managed care and hospital consolidation. As health care systems increasingly prioritize profitability, hospitals that fail to generate sufficient revenue—despite their essential role in community health—are either closed or absorbed into larger networks that may not prioritize local needs. Additionally, Medicaid reimbursement rates have remained stagnant or declined in many states, placing additional strain on hospitals that depend on these funds for financial viability.

Another critical factor in inner-city hospital closures is the demographic shift in urban populations. Gentrification and economic displacement have altered the patient mix for many hospitals, leading to changes in payer sources. As wealthier residents move into urban centers, they often seek care at private institutions, leaving safety-net hospitals with an increasingly vulnerable patient base that lacks the resources to sustain hospital operations. This shift has contributed to the closure of numerous inner-city facilities, even in areas experiencing overall economic growth.⁴

Trends in Rural Hospital Closures

While urban hospital closures present a unique set of challenges, rural hospital closures have also been a significant issue in recent years. As of November 2024, 192 rural hospitals have closed or been converted into facilities that no longer provide acute care services.^5-7 Since 2020 alone, 36 hospitals in rural areas have shut down, drastically reducing access to emergency, surgical, and critical care for residents in these communities.⁸

The closure of a rural hospital has widespread consequences beyond the loss of medical services. It results in job losses for health care professionals, reduces local economic activity, and forces residents to seek care at distant facilities. The impact of these closures extends to surgical care, as rural patients often have to travel considerable distances for procedures that were previously available in their own communities.

A study by the Society of Critical Care Medicine analyzed ICU admissions in rural hospitals between 2010 and 2019, revealing a significant increase in reliance on these facilities even as their numbers declined. The number of rural ICU admissions rose from 181.7 per 1000 admissions in 2010 to 188.8 per 1000 admissions in 2019, while urban ICU admissions declined. Additionally, rural hospitals saw higher transfer rates for critically ill patients, indicating that many facilities lacked the capacity to handle complex cases locally.⁴

Despite these differences, the fundamental issue underlying both rural and urban hospital closures remains the same: financial instability. Hospitals that serve predominantly uninsured or underinsured populations struggle to maintain operations without sufficient government support. As closures continue, vulnerable populations—whether in rural towns or inner-city neighborhoods—face increasing barriers to timely and appropriate surgical care.

Surgical Care in Urban Communities

Surgical services are a critical component of hospital care, particularly for trauma patients, cancer patients, and individuals with chronic conditions requiring surgical intervention. Inner-city hospitals serve as vital providers of both emergency and elective surgical care, offering procedures that range from appendectomies to complex orthopedic surgeries.^2,4

Safety-net hospitals bear the greatest burden of providing surgical care to low-income populations. These hospitals often operate under financial duress, absorbing large amounts of uncompensated care. Medicaid and Medicare reimbursement policies significantly influence the ability of these hospitals to maintain surgical services, as they account for a substantial portion of revenue.^3,9

However, when inner-city hospitals close, surgical patients are among the most directly affected. Patients requiring urgent procedures must seek treatment at the remaining hospitals, which often lack the capacity to accommodate increased demand. This results in delayed surgeries, longer wait times, and, in some cases, the complete inability to access necessary procedures.⁴

Effects of Hospital Closures on Surgical Access

The closure of inner-city hospitals significantly affects access to surgical care, creating immediate and long-term disruptions that impact patient outcomes and community well-being. These disruptions manifest in multiple ways, including a reduction in surgical capacity, widening disparities in health outcomes, and challenges in both emergency and elective surgical services. Given that surgical interventions are often time-sensitive, hospital closures can have life-threatening consequences, particularly for vulnerable populations who already face barriers to accessing care.

By examining how hospital closures affect surgical access, it becomes clear that these changes lead to increased mortality rates, longer wait times, and reduced availability of specialty surgical services. The consequences of these closures highlight systemic challenges within the U.S. health care system and underscore the need for policies aimed at preserving hospital infrastructure and ensuring equitable access to surgical care.

Reduction in Surgical Capacity

One of the most immediate consequences of hospital closures is the reduction in surgical capacity, as the total number of available operating rooms, surgical specialists, and acute care beds decreases. This reduction places immense strain on the remaining hospitals in a region, which are often already operating at or near capacity.

Research by Carson et al found that after a hospital closes, surrounding facilities experience a measurable increase in surgical caseloads, leading to extended wait times for elective procedures and potential delays in emergency surgeries.¹⁰ Patients who previously had access to timely surgical interventions must now compete for limited resources, exacerbating disparities in care.

Lindrooth et al further examined the effects of hospital closures on regional health care markets, finding that closures often force patients to travel greater distances for surgeries, leading to longer delays in critical interventions.³ Delayed surgeries can result in worsened outcomes, particularly for conditions such as appendicitis, trauma-related injuries, and cardiovascular emergencies. For example, a delay in performing an appendectomy can result in complications such as peritonitis, significantly increasing morbidity and health care costs.

The increased patient load at surviving hospitals also limits their ability to invest in advanced surgical technologies or expand specialized services. Hospitals that once provided niche surgical specialties, such as neurosurgery, cardiothoracic surgery, or pediatric surgery, may find themselves unable to sustain these services due to financial pressures. This forces patients in need of specialized care to seek treatment in other cities or states, introducing additional logistical and financial burdens.

Disparities in Surgical Outcomes

The effects of hospital closures are not evenly distributed across populations. Low-income and minority communities are disproportionately affected by reduced access to surgical care, further entrenching existing health care inequities.

Multiple studies have documented the disparities in surgical outcomes resulting from hospital closures.^10-13 The closure of safety-net hospitals, which primarily serve uninsured or underinsured patients, results in increased barriers to timely surgical interventions. Patients from these communities may be unable to travel long distances to access care, leading to preventable complications and increased mortality rates.

The Institute of Medicine reported in 2003 that hospital closures contribute to higher mortality rates among underserved populations by limiting access to time-sensitive surgical procedures.⁹ Patients with chronic conditions, such as diabetes or peripheral artery disease, require regular surgical interventions to prevent complications such as amputations. When surgical services become less accessible, these patients experience higher rates of limb loss, disability, and premature death.

Carroll and Kang et al have further highlighted how delays in surgical treatment caused by hospital closures increase mortality and complication rates.^14,15 Conditions that require urgent intervention, such as ruptured aneurysms or severe fractures, become life-threatening when care is delayed due to distance or lack of available surgical teams. These disparities also extend to postoperative care. Patients from low-income communities may struggle to access follow-up appointments, rehabilitation services, and physical therapy, all of which are critical to achieving positive surgical outcomes. The inability to obtain proper postoperative care increases the risk of readmission, complications, and long-term disability.

Emergency vs Elective Surgical Care

Emergency surgical care is among the most significantly impacted services following hospital closures. Overwhelmed emergency departments in remaining hospitals must accommodate increased patient volumes, leading to long wait times and potential delays in life-saving surgeries. The Institute of Medicine emphasized that emergency departments in urban areas often operate at or above capacity even before hospital closures occur.⁹ When additional patient load is introduced following a closure, the system becomes overwhelmed, resulting in increased transport times, longer waits for surgical interventions, and overall reduced quality of care.

In trauma cases, time is a critical factor in determining patient survival. The “golden hour” in trauma care refers to the crucial first hour after a severe injury, during which immediate surgical intervention can significantly improve survival rates. However, when hospitals close, trauma patients may need to be transported to distant facilities, increasing the likelihood of negative outcomes. While not as immediately life-threatening as emergency surgery, elective surgical care also suffers significantly from hospital closures. Many low-income and uninsured patients rely on public hospitals for procedures such as joint replacements, hernia repairs, and cancer-related surgeries. When these hospitals close, patients face financial and logistical challenges in accessing care at private facilities. These trends contribute to widening health disparities. Well-insured patients often have the financial means to seek care at alternative hospitals, while underserved populations are left with fewer options, leading to worsening health conditions over time.

Medicaid Expansion and Mitigation of Hospital Closures

Financial Stabilization Through Medicaid Expansion

One of the primary policy tools available to mitigate hospital closures is Medicaid expansion under the Affordable Care Act (ACA). Research has demonstrated that Medicaid expansion has significantly reduced hospital closure rates by improving financial margins and decreasing uncompensated care costs.¹⁶

Hospitals in states that expanded Medicaid have experienced fewer closures compared to those in non-expansion states.^3,17 Medicaid expansion has provided increased reimbursement for previously uninsured patients, ensuring that hospitals receive adequate funding to sustain their operations. This financial stabilization is particularly critical for safety-net hospitals that serve a disproportionately high number of Medicaid and uninsured patients.

By increasing insurance coverage among vulnerable populations, Medicaid expansion reduces the burden of uncompensated care, allowing hospitals to maintain surgical services and invest in infrastructure improvements. In states that opted not to expand Medicaid, hospital closure rates have remained high, underscoring the importance of government intervention in maintaining hospital viability.

Preservation of Surgical Services

Medicaid expansion has played a significant role in preserving access to surgical services by stabilizing hospital finances. Expansion states have demonstrated lower rates of hospital closures, helping to sustain access to surgical infrastructure, including operating rooms, surgical equipment, and specialized surgical teams.¹⁸ Expanding insurance coverage also reduces financial barriers that prevent patients from seeking timely surgical care. Patients in expansion states are more likely to undergo necessary surgical procedures without experiencing the delays associated with financial constraints. This has led to improved surgical outcomes and reduced disparities in access to care.³

However, while Medicaid expansion has contributed to the financial stabilization of hospitals, it is not a complete solution. The impact of expansion varies depending on locoregional factors, hospital-specific circumstances, and state policies. Some hospitals continue to face financial difficulties despite Medicaid expansion, particularly in regions with high rates of uncompensated care or declining patient volumes.

Equity in Surgical Care

Access to surgical care is a fundamental component of health equity, yet disparities persist due to socioeconomic status, racial and ethnic identity, and systemic barriers.^19,20 Medicaid expansion serves as an example of a structural intervention that mitigates these disparities by protecting access to surgical care for underserved populations. Nationally, insurance coverage gaps between African American, Hispanic/Latino, and white patients have narrowed, reflecting broader improvements in access to care. These gains in coverage under the Affordable Care Act (ACA) have had direct benefits for surgical patients, improving access to timely treatment and reducing delays in seeking care for acute conditions.^21,22

Without policies that prioritize health equity, disparities in surgical access will continue to worsen. Medicaid expansion has demonstrated its role in reducing health care disparities by sustaining hospital operations and significantly reducing the uninsured rate among surgical populations. In addition, expansion has led to improvements in surgical outcomes, lower hospital readmission rates, improved access to both emergent and elective surgical care, and minimized financial barriers for vulnerable populations.²²

Community-Level Impacts on Surgical Access

The closure of inner-city hospitals has far-reaching consequences for communities that rely on them for surgical care. These closures exacerbate existing health care disparities, leaving vulnerable populations with diminished access to timely surgical interventions. The systemic consequences extend beyond the immediate loss of hospital beds, affecting the entire health care infrastructure, surgical outcomes, and the overall well-being of affected urban populations. This section explores how hospital closures reshape the health care landscape, deepen disparities in surgical care, and illustrate these issues through real-world case studies.

Effects on Health care Infrastructure

Inner-city hospitals serve as critical pillars of health care infrastructure in urban communities, providing both routine and emergency surgical care to thousands of patients annually. When these hospitals close, they leave behind a void that is not easily filled, leading to systemic inequities in surgical care provision.

Carson et al highlight that hospital closures in urban settings disproportionately affect low-income communities, where alternative health care options are already limited.¹⁰ This effect is compounded when the remaining hospitals struggle to absorb the influx of displaced patients, leading to longer wait times for surgical procedures and reductions in overall surgical capacity.

In an interview with the CEO of Three Rivers Hospital, Freda Russell, in 2018, she emphasized that hospital closures result in severe systemic challenges, forcing remaining hospitals to operate at or above capacity.¹⁸ These hospitals face difficulties maintaining surgical care quality, as they contend with resource limitations, overcrowded emergency departments, and overburdened surgical teams. Lindrooth et al found that surviving hospitals in markets with closures experience a measurable increase in inpatient admissions and emergency room visits, which in turn strains their ability to provide efficient and effective surgical care.³

Additionally, closures lead to the loss of specialized surgical services. Many inner-city hospitals house trauma centers, burn units, and specialized surgical departments, which are not always available at alternative hospitals. As a result, critically ill or injured patients may need to travel significant distances for care, increasing the risk of complications or death. The lack of accessible surgical infrastructure also impacts elective surgical procedures, as patients often delay or forgo treatment due to the logistical and financial burdens of seeking care elsewhere.

Urban Disparities in Surgical Outcomes

The loss of inner-city hospitals exacerbates pre-existing disparities in surgical outcomes, disproportionately affecting minority and low-income populations. Communities with higher uninsured rates experience worse access to surgical care, leading to poorer health outcomes.^3,9,10 The concentration of hospital closures in economically disadvantaged areas means that residents must navigate significant barriers to receive care, including transportation challenges, financial constraints, and increased travel times to surgical facilities.

The Institute of Medicine underscores that urban communities with high uninsured rates have demonstrably worse access to surgical care.⁹ These communities often experience higher rates of preventable surgical complications due to delayed treatment. For example, conditions such as appendicitis, hernias, and gallbladder disease require timely surgical intervention to prevent severe complications. When hospital closures force delays in care, these routine conditions can escalate into life-threatening emergencies, disproportionately affecting patients who lack financial or logistical means to seek care elsewhere.

One potential mitigating factor in reducing these disparities is Medicaid expansion. Research by Lindrooth et al suggests that Medicaid expansion has played a crucial role in stabilizing hospital finances, reducing uncompensated care burdens, and decreasing hospital closure rates.³ In states that expanded Medicaid, hospital closures occurred at a lower rate, preserving access to essential surgical services for vulnerable populations.

However, the benefits of Medicaid expansion have not been uniformly realized across all urban communities, particularly in states that opted out of expansion, where closures continue to limit surgical access.

Case Studies

The closure of inner-city hospitals has a profound impact on the communities they once served, disrupting access to surgical care, displacing patients and health care providers, and straining the financial stability of remaining institutions. The following case studies examine the closure of Atlanta Medical Center (Atlanta, GA), Hahnemann University Hospital (Philadelphia, PA), and St. Vincent’s Catholic Medical Center (New York, NY), illustrating the systemic consequences of these shutdowns.

Case Study 1: The Closure of Atlanta Medical Center (Atlanta, GA)

Atlanta Medical Center (AMC) was a 466-bed acute care hospital that played a vital role in providing emergency and specialty surgical services to underserved communities in Atlanta. Before its closure in 2022, AMC was one of only two level 1 trauma centers in the city, ensuring access to life-saving surgical interventions for trauma victims.^23,24

AMC’s shutdown left Grady Memorial Hospital as the sole level 1 trauma center in the region, significantly increasing patient volumes at Grady and other Atlanta-area hospitals.²³ The hospital’s closure displaced thousands of patients, with an estimated 31% of the affected residents living in poverty and 42% identifying as Black.²⁴ These populations relied heavily on AMC for surgical services, and with its closure, they were forced to seek care at already-overburdened facilities like Emory University Hospital Midtown and Grady Memorial Hospital.

Financially, AMC’s closure was attributed to Wellstar Health System’s claims of over $100 million in losses in 2022 and the hospital’s inability to achieve financial sustainability. However, Wellstar reported over $150 million in net income and received $186 million in CARES Act funding during the same period, raising concerns about the motivations behind the closure.²⁴

The impact on physician trainees was also severe. The closure forced residents and fellows to transfer to other programs, disrupting their education and reducing the number of trained medical professionals available to serve Atlanta’s most vulnerable populations.

Case Study 2: The Closure of Hahnemann University Hospital (Philadelphia, PA)

Hahnemann University Hospital, a 496-bed safety-net hospital in Philadelphia, served as a major surgical and trauma center before its closure in 2019. Located in an area with a high proportion of uninsured and low-income patients, Hahnemann provided critical care to approximately 50 000 emergency department visitors per year, many of whom required surgical interventions.⁴

The hospital’s closure had immediate and devastating consequences for the community. Nearly 800 medical residents and fellows were forced to relocate to other institutions, causing a significant disruption in medical education and reducing the number of surgical providers available to treat patients in the region. Many patients who had relied on Hahnemann for surgery, including orthopedic procedures and cancer treatments, were left without accessible alternatives, leading to delays in care and worsened outcomes.

Financially, Hahnemann’s closure was driven by its for-profit ownership structure. Despite its role as a crucial safety-net hospital, the facility was sold to a private equity firm that ultimately determined it was financially unviable. The decision to close the hospital rather than seek alternative funding sources or partnerships sparked widespread criticism, particularly given the hospital’s role in training future surgeons and providing vital surgical services to Philadelphia’s most vulnerable residents.

The remaining hospitals in Philadelphia struggled to absorb the displaced patient population, particularly in surgical specialties such as trauma, neurosurgery, and cardiothoracic surgery. Nearby hospitals, including Temple University Hospital and Thomas Jefferson University Hospital, saw an increase in surgical caseloads, leading to longer wait times and increased pressure on already strained resources.

Case Study 3: The Closure of St. Vincent’s Catholic Medical Center (New York, NY)

The 2010 closure of St. Vincent’s Catholic Medical Center, a 160-year-old institution in Lower Manhattan, removed a crucial source of surgical care from the region. St. Vincent’s was a major hospital, a level 1 trauma center, and a key provider of specialized surgical services, including cancer treatment and transplant surgery.²⁵

The closure displaced tens of thousands of patients, forcing them to seek care at already-overburdened hospitals such as Bellevue Hospital, New York-Presbyterian/Weill Cornell Medical Center, and Mount Sinai Beth Israel. These hospitals reported a 10-30% increase in emergency department visits, placing immense strain on surgical departments and trauma services.²⁵ Patients requiring urgent surgeries, such as appendectomies or emergency orthopedic procedures, faced longer wait times due to the increased demand.

The financial impact of St. Vincent’s closure was severe. The hospital had accumulated over $1 billion in debt, leading to its eventual bankruptcy. However, critics argued that mismanagement and lack of state intervention contributed to the closure, which disproportionately affected uninsured and low-income patients.²⁵ Many of these patients relied on St. Vincent’s for charity surgical care, and with its closure, they were left with few alternatives.

Physician trainees, particularly those in surgical residency programs, were forced to relocate or seek new training opportunities, disrupting their education and reducing the number of available surgical providers in New York City. The loss of St. Vincent’s also impacted medical research and innovation, as it had been a hub for surgical advancements and training.

The long-term effects of St. Vincent’s closure have continued to shape health care access in Lower Manhattan. While new urgent care centers and outpatient surgical clinics have opened in the area, they do not provide the same level of complex surgical care that St. Vincent’s once did. As a result, patients requiring specialized procedures must travel farther, leading to delays in treatment and exacerbating health disparities.

Lessons from These Closures and the Role of Medicaid Expansion

The closures of Atlanta Medical Center, Hahnemann University Hospital, and St. Vincent’s Catholic Medical Center illustrate the devastating consequences that hospital shutdowns can have on surgical care access in urban communities. In each case, patient displacement, physician trainee disruptions, and financial instability have contributed to worsened health outcomes and deepened health care inequities.

One key policy intervention that could help mitigate these effects is Medicaid expansion. As Lindrooth et al demonstrated, states that expanded Medicaid saw lower hospital closure rates and improved financial stability for safety-net hospitals.³ The closure of hospitals in non-expansion states, such as Georgia, underscores the risks of inadequate health care funding and the importance of policies that support hospitals serving vulnerable populations.

Without sustained investment in inner-city hospitals, urban communities will continue to face significant barriers to surgical care, leading to preventable complications, increased mortality rates, and widening health disparities. Moving forward, policymakers must prioritize strategies to preserve hospital infrastructure, support surgical workforce development, and ensure equitable access to life-saving surgical interventions for all populations.

Policy and Practice Recommendations

Addressing the impact of inner-city hospital closures on surgical access requires a multifaceted approach that strengthens urban health care infrastructure, ensures financial sustainability, enhances emergency surgical services, and mitigates social determinants of health that contribute to disparities in surgical outcomes. The recommendations outlined in this section emphasize the need for strategic investments in hospital systems, Medicaid expansion, emergency care improvements, and policies that address underlying social and economic barriers to care.

Strengthening Urban Surgical Infrastructure

Health care infrastructure encompasses a vast network of systems, services, personnel, and facilities that facilitate patient care, including hospitals, surgical centers, medical staff, technology, and outpatient services. The accessibility and quality of this infrastructure are directly linked to patient outcomes, the overall efficiency of health care systems, and the availability of surgical services.²⁶ In many urban communities, particularly those with high rates of poverty and uninsured individuals, safety-net hospitals play a critical role in providing accessible surgical care. These institutions, including community health centers, hospital outpatient departments, and nonprofit hospitals, serve as essential providers for both emergency and elective surgical procedures.

However, safety-net hospitals are increasingly strained by high patient volumes, financial challenges, and difficulty retaining medical staff.²⁷ The combination of rising demand, declining reimbursement rates, and workforce shortages threatens the ability of these hospitals to maintain surgical services. Overburdened health care systems in these areas often experience declining care quality, increased patient morbidity, and worsening health outcomes.²⁸ Furthermore, studies have shown that shortages in hospital infrastructure—including reduced physician availability, long distances to specialty care, and limited surgical resources—result in significant delays in diagnosis and treatment, ultimately worsening surgical outcomes.²⁹

To strengthen health care infrastructure and sustain surgical capacity, policymakers must implement strategic investments in physician retention, advanced surgical technology, patient-centered care models, and community-based health initiatives.²⁷ Retaining skilled surgical professionals in urban hospitals is crucial to maintaining adequate surgical capacity. Providing loan repayment incentives for physicians who work in underserved communities, increasing funding for medical residency programs in urban hospitals, and establishing policies that support the recruitment and retention of experienced surgical teams are necessary steps to prevent workforce shortages.

Technological advancements can also enhance urban surgical infrastructure by improving efficiency and reducing barriers to care. The expansion of telemedicine and remote preoperative assessments can help improve access to surgical evaluations, especially for patients in areas with limited specialist availability. Additionally, investing in robotic-assisted surgical systems can enhance precision in procedures and increase the efficiency of surgical teams. The integration of electronic health record (EHR) interoperability is another critical component, allowing seamless communication between hospitals, outpatient clinics, and surgical specialists, ensuring continuity of care for patients undergoing surgical procedures.

Ultimately, investing in urban health care systems ensures that underserved and underinsured populations have access to surgical care while strengthening the resilience of hospitals and their ability to adapt to evolving community health needs.

The Role of Medicaid Expansion

Medicaid expansion under the Affordable Care Act (ACA) has played a vital role in improving the financial viability of hospitals, reducing the burden of uncompensated care, and decreasing hospital closure rates. Research has shown that the expansion of Medicaid to previously uninsured adults has resulted in a measurable reduction in hospital financial distress. States that expanded Medicaid experienced a 0.33 per 100 hospitals decline in closure rates, while non-expansion states saw a 0.43 per 100 hospitals increase in closures during the same period.³ This correlation highlights the significant impact of insurance expansion on hospital financial sustainability and operational stability. Medicaid expansion under the Affordable Care Act (ACA) has led to decreases in hospitals’ uncompensated care, increases in operating margins, and reductions in rural and urban hospital closures.¹⁶

The loss of urban hospitals in non-expansion states has resulted in diminished access to emergency and surgical care, creating severe consequences for communities that rely on safety-net hospitals for essential medical services.¹⁷ Hospitals that primarily serve Medicaid and uninsured patients are particularly vulnerable to financial instability. Without reimbursement for services provided to uninsured individuals, hospitals struggle to remain solvent, leading to the closure of emergency departments, trauma centers, and surgical units.

Ensuring the financial sustainability of hospitals in vulnerable urban areas requires a continued commitment to Medicaid expansion. Expanding Medicaid in non-expansion states would provide hospitals with additional financial support, allowing them to maintain their surgical services and prevent further closures. By reducing the financial barriers to care, Medicaid expansion helps ensure that patients who require surgical interventions—whether for chronic conditions, trauma, or cancer treatments—can access timely and necessary procedures.

Additionally, Medicaid expansion improves access to preventive surgical care by increasing the number of insured patients who can receive early screenings and interventions. For example, expanded Medicaid coverage has been associated with increased rates of preventive colonoscopies, hernia repairs, and orthopedic surgeries, reducing the need for costly emergency interventions.³ In states that have adopted Medicaid expansion, improved financial performance has allowed hospitals to reinvest in surgical infrastructure, sustain trauma centers, and enhance postoperative rehabilitation services.

Future policies should prioritize Medicaid expansion as a long-term strategy for hospital sustainability, particularly in urban areas where safety-net hospitals play an indispensable role in reducing health care disparities. By securing a stable financial foundation for hospitals, Medicaid expansion ensures that surgical and emergency services remain available for the populations that need them the most.

Enhancing Emergency Surgical Care

Emergency departments in urban hospitals face increasing pressures due to rising patient demand, hospital closures, and workforce shortages in emergency general surgery (EGS) services. These challenges are particularly concerning for low-income, African American, and Hispanic populations, who are disproportionately affected by emergency care shortages.³⁰ As hospital closures continue to shrink the availability of trauma and surgical services, strategies must be implemented to enhance emergency department efficiency and sustain high-quality surgical care.

One approach is to improve emergency triage systems by integrating evidence-based triage protocols that ensure rapid identification of surgical patients who require immediate intervention. Implementing optimized triage frameworks can reduce unnecessary emergency room admissions, allowing hospitals to prioritize resources for patients in critical need of surgical care.³¹

Another critical strategy is expanding regional surgical care networks, which facilitate collaboration between hospitals in metropolitan areas. Regional frameworks for surgical care allow hospitals to redistribute patient loads, share resources, and ensure that patients requiring urgent surgical interventions can be efficiently transferred to facilities with available capacity. These networks can also support rural-to-urban patient transfers for hospitals experiencing resource shortages.

To reduce strain on emergency surgical departments, telemedicine initiatives should be expanded to provide remote preoperative assessments and postoperative follow-ups, reducing the need for unnecessary emergency visits. In addition, expanding hospital capacity for emergency general surgery services by increasing funding for surgical staff recruitment and retention would help address growing demand in overburdened facilities.³¹ By adopting these strategies, urban hospitals can better manage emergency surgical cases, reduce patient wait times, and improve outcomes for individuals requiring trauma and emergency surgical interventions.

Addressing Social Determinants of Health

Health care access is not solely determined by hospital availability—it is also influenced by social determinants of health such as income level, geographic location, education, and transportation access.²⁰ Addressing these determinants is essential to improving surgical outcomes and ensuring that low-income urban populations receive timely medical interventions. Transportation barriers are among the most significant challenges preventing patients from obtaining necessary surgical care. Millions of Americans delay or miss medical appointments due to lack of reliable transportation.³² Patients who require preoperative evaluations, surgical procedures, and postoperative rehabilitation often face insurmountable logistical challenges in reaching their health care providers.³³ To bridge these gaps, policies should focus on expanding non-emergency medical transportation (NEMT) services, partnering with ride-sharing providers, and establishing hospital-funded patient shuttle programs to ensure that vulnerable populations can access surgical facilities.

Additionally, expanding community-based surgical outreach programs can help deliver essential care to underserved populations. Mobile surgical clinics and community health workers can play a role in providing preoperative education, postoperative monitoring, and assistance with medication adherence.³⁴ A comprehensive strategy that integrates insurance expansion, health care infrastructure investments, emergency surgical enhancements, and social support systems will be necessary to address the challenges posed by urban hospital closures. By implementing these policies, surgical disparities can be reduced, hospital sustainability can be preserved, and all patients—regardless of socioeconomic status—can access timely, high-quality surgical care.^8,35

Conclusion

The closure of inner-city hospitals has far-reaching and devastating consequences for access to surgical care in urban communities. These hospitals are often the backbone of health care systems for low-income, uninsured, and underinsured populations, providing critical trauma services, specialized surgical interventions, and essential emergency care. When these institutions shut down due to financial insolvency, systemic underfunding, or shifting health care policies, the immediate and long-term effects ripple across entire communities, disproportionately impacting marginalized populations. Patients who once had access to timely and necessary surgical procedures are now forced to navigate an increasingly fragmented and overburdened health care system, often resulting in delayed interventions, worsened medical outcomes, and increased mortality rates.^3,9,10

Beyond the direct medical consequences, inner-city hospital closures also exacerbate existing health disparities by reducing the availability of essential surgical services.³⁵ The loss of trauma centers and specialized surgical units forces patients to travel farther distances, endure longer wait times, or in some cases, forgo necessary surgical procedures altogether due to financial or logistical constraints.^4,15 These barriers disproportionately affect communities of color and low-income individuals, compounding systemic inequities in health care access. The disruption of surgical residency programs and the displacement of medical professionals further weaken urban health care infrastructure, making it even more difficult to maintain the surgical workforce needed to serve these communities.^24,25

The case studies of Atlanta Medical Center, Hahnemann University Hospital, and St. Vincent’s Catholic Medical Center illustrate the devastating real-world implications of these closures. In each case, thousands of patients lost access to surgical care, nearby hospitals became overwhelmed, and community health deteriorated. The economic motivations behind these closures underscore the need for stronger policy interventions, such as Medicaid expansion and increased federal and state funding for safety-net hospitals.^3,17 Medicaid expansion has proven to be a crucial tool in mitigating hospital closures and preserving surgical access by reducing uncompensated care and stabilizing hospital finances.¹⁶

Addressing this crisis requires a comprehensive, multi-pronged approach that strengthens urban health care infrastructure, expands Medicaid coverage, enhances emergency surgical networks, and addresses social determinants of health. Without targeted interventions, vulnerable populations will continue to bear the brunt of hospital closures, facing preventable surgical complications and avoidable deaths. Policymakers, health care leaders, and community stakeholders must take urgent action to safeguard access to surgical care in inner-city communities before these disparities become irreversible.^8,20

Footnotes

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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