The main reason seems to be that it costs more for them to deliver services than they're getting paid by insurers (especially Medicaid). I'd love to see a fuller breakdown of how those costs compare to those for urban hospitals. How much is demographics, such as serving a generally older population more prone to "deaths of despair" because rural living is hard? How much is demand, because of different eating/exercise habits or the uneven distribution of addiction to different drugs? How much is logistics, delivering care over a wider area? How much is other factors I haven't even thought of? The question of why rural hospitals don't get paid as much as it costs them to provide care doesn't have to be a political one. It just has to be asked.