When Kasey Shakespear broke his leg as a teenager, it took eight hours to get the care he needed. <\/p>\n
For 35 minutes, he rode an ambulance from his hometown of Tropic, past Bryce Canyon\u2019s red rock cliffs, to Garfield Memorial Hospital. X-rays confirmed the break, but doctors couldn\u2019t perform the surgery to fix the snapped bone. That meant another two-hour ambulance ride south to St. George \u2014 a journey familiar to many rural Utahns who face long waits and longer drives just to get basic medical care.<\/p>\n
\u201cAccessing care in rural Utah requires so much more effort than it does for other people,\u201d said Shakespear, who now serves as the director of the Rural Health Association of Utah. <\/p>\n
The long drives, limited services and other difficulties <\/b>may only get worse as changes to federal health programs in the One Big Beautiful Bill Act slash Medicaid funding and strip an estimated 77,000 Utahns of health insurance<\/a>, according to KFF, a health policy research group. Rural communities, where hospitals already operate on slim margins<\/a>, will be hit particularly hard.<\/p>\n (Rick Egan | The Salt Lake Tribune) Kasey Shakespear, the director of the Rural Health Association of Utah on the Utah Tech campus, on Thursday, August 14, 2025.
<\/p>\n Rural hospitals, on average, receive 13% of their revenue from Medicaid, according to Matthew McCullough, rural hospital improvement director for the Utah Hospital Association. That number is even higher for some, such as Blue Mountain Hospital in Blanding where over a third of the income comes from Medicaid. <\/p>\n The \u201cbig, beautiful bill\u201d may mark a breaking point for Utah\u2019s rural hospitals, which have broadened the care they provide over the past decade despite tight budgets. <\/p>\n \u201cMy fear is that all the progress we\u2019ve made in expanding services and keeping labor and delivery open are going to be cut,\u201d McCullough told The Tribune. <\/p>\n To prevent service cuts \u2014 or worse, closure \u2014 hospitals are looking closely at the spending bill and figuring out how to adapt to keep serving their communities. <\/p>\n \u201cIt\u2019s going to force us to reinvent how we offer health care in rural Utah,\u201d said Shakespear. <\/p>\n Last year, San Juan, Carbon, Duchesne, Uintah and Sevier Counties \u2014 all rural areas \u2014 had the highest percentage of county population enrolled in Medicaid, according to the Kem C. Gardner Policy Institute<\/a>. <\/p>\n (Christopher Cherrington | The Salt Lake Tribune)<\/p>\n \u201cRural areas usually have a higher proportion of population on Medicaid,\u201d said McCullough. \u201cSo when there\u2019s cuts to Medicaid, it\u2019s going to impact rural hospitals more.\u201d<\/p>\n Some rural areas have higher rates of disability<\/a> due to less preventative care, more elderly residents<\/a> and job types. Miners and farmers, for example, may be exposed to more environmental toxins or get injured at work. <\/p>\n Jobs are also more sparse, which may make rural community members particularly vulnerable to new work requirements for some federal health programs. <\/p>\n \u201cA lot of people will probably be dropped off of Medicaid, so they\u2019ll lose their insurance, and then what do they do?\u201d McCullough said. \u201cWe\u2019re talking about the impact to a rural hospital\u2019s revenue, but we\u2019re talking about people, real people.\u201d <\/p>\n Accessing care in rural Utah <\/p>\n Shakespear\u2019s long journey to get his broken leg fixed wasn\u2019t the only time he travelled far for care. Like many rural residents, he has had to wake up at 5 a.m. and drive four or five hours for a doctor\u2019s appointment in Salt Lake City. <\/p>\n Twenty-one hospitals<\/a>, <\/b>19 rural health clinics<\/a> and 53 federally qualified health center<\/a> sites serve rural communities across Utah\u2019s small towns, from Panguitch to Tremonton. But many lack specialty providers who perform complex surgery or treat rare diseases. <\/p>\n Even for primary care or routine exams, small town residents may drive 30 to 40 minutes to reach the nearest hospital or clinic. <\/p>\n \u201cOur health and our outcomes, our ability to be happy and healthy, shouldn\u2019t depend on where we live, but that\u2019s not the reality of how it works,\u201d Shakespear said.<\/p>\n Long travel means higher costs at the gas pump and lost wages. And many of Utah\u2019s rural communities already struggle with high unemployment and lower incomes<\/a>. Garfield, Piute, Wayne, San Juan and Emery counties had the five highest unemployment rates <\/a>in the state in July, according to the Department of Workforce Services. <\/p>\n (Christopher Cherrington | The Salt Lake Tribune)<\/p>\n With fewer jobs available, work requirements may have a \u201cdisproportionate impact\u201d on rural areas, said Rachel Craig, government affairs manager at the Association of Utah Community Health. <\/p>\n Starting January 1, 2027, adults ages 19-64 must work 80 hours per month<\/a> or attend school half time to qualify for Medicaid expansion or subsidized marketplace coverage. The bill included exemptions for parents with children ages 13 and under, those who are \u201cmedically frail\u201d and those who are in a substance use disorder treatment program.<\/p>\n Even rural residents with a job may face greater challenges in proving their employment. \u201cThere are folks that work 80 hours a week on their farms but don\u2019t collect a regular paycheck,\u201d Shakespear said.<\/p>\n Some rural areas also lack broadband access, making it difficult to submit required documents, which Medicaid recipients will have to do more frequently by the end of 2026<\/a>.<\/p>\n Rural community health centers have enrollment assistants, Craig said, but they\u2019re already overworked. \u201cTrying to get them to also help with the work requirement, they just won\u2019t have time to do that,\u201d she told The Tribune. <\/p>\n Hospitals brace for changes<\/p>\n Despite the challenges, Utah\u2019s small towns are faring better than some across the nation <\/p>\n \u201cWe\u2019re one of the only states in the country that hasn\u2019t had a rural hospital close in decades, and our workforce is very dedicated in rural Utah,\u201d Shakespear said. \u201cI\u2019ve yet to come across a physician or an administrator or anybody in health care in rural Utah that\u2019s not passionate about what they do \u2014 you have to be.\u201d<\/p>\n Castleview Hospital in Carbon County \u2014 where 22.5% of the county<\/a> is enrolled in Medicaid \u2014 told The Tribune it is \u201cstable and not currently at risk of closure or a reduction in services.\u201d <\/p>\n That stability will be tested, though, as Medicaid cuts lead to lower revenues for hospitals in the coming years. <\/p>\n Castleview said it\u2019s \u201cpremature to discuss any impact of the bill.\u201d The provisions that may hit hospitals\u2019 bank accounts hardest, including work requirements and limits on the provider tax that helps states reimburse hospitals, won\u2019t go into effect until 2027 or later. <\/p>\n (Trent Nelson | The Salt Lake Tribune) Danielle Pendergrass meets with a patient at Eastern Utah Women\u2019s Health in Price on Wednesday, March 13, 2024.<\/p>\n \u201cThere\u2019s also some hope and optimism that some things might change politically in the next two years that may challenge some of these provisions in the bill or make them not even actually happen,\u201d McCullough said. <\/p>\n If the changes do go forward, though, hospitals\u2019 budgets may end up in the red. <\/p>\n Moab Regional Hospital estimates it may lose $1.6 million to $2.3 million annually once the bill\u2019s provisions take effect. That would put them \u201csquarely into a negative margin,\u201d said Jen Sadoff, Moab Regional Hospital CEO. <\/p>\n Roughly 11% of Moab Regional\u2019s revenue comes from Medicaid, which covers about 15% of the patients who visit the hospital, according to Sadoff. <\/p>\n Fillmore Community Hospital and Beaver Valley Hospital, have been operating in the red for at least three years, according to a list <\/a>of threatened rural hospitals compiled by the office of U.S. Sen. Edward Markey, D-Mass.<\/p>\n Fillmore, though, is owned by Intermountain Health, which may use revenue from its more lucrative operations to keep Fillmore and the other eight rural Utah hospitals it owns afloat. <\/p>\n \u201c[Intermountain] is a very successful system, and it\u2019s very community minded, and I don\u2019t think if one of their hospitals was operating in the red that they would allow it to be closed,\u201d McCullough said. <\/p>\n Cuts to Medicaid will eat into <\/b>the company\u2019s bottom line, though. \u201cMedicaid enrollment and funding play a critical role in our ability to care for our growing communities, particularly those that are most vulnerable,\u201d a spokesperson for Intermountain said.<\/p>\n (Leah Hogsten | The Salt Lake Tribune) Navajo Mountain Health Clinic Manager Revina Talker talks with lab technician Roxanna Yazzie during the coronavirus pandemic in Monument Valley-Olahito in 2020.<\/p>\n Even if rural hospitals keep their doors open, some may have to cut services. Maternity care, which all of Utah\u2019s rural hospitals currently offer, may be the first to go because it doesn\u2019t generate revenue, McCullough said. <\/p>\n In recent weeks, though, McCullough has heard promising talks from rural hospitals. Some are exploring offering new services, such as surgery and oncology, that could bring in revenue and help compensate for the losses. <\/p>\n \u201cI applaud them for thinking this way and trying to increase revenue and services rather than cut services and close their doors,\u201d he said. <\/p>\n Cautious optimism <\/p>\n Last month, Shakespear visited hospitals and clinics across rural Utah, and he heard less \u201cdoom and gloom\u201d and more \u201ccautious optimism,\u201d he said. <\/p>\n (Kasey Shakespear) Kasey Shakespear stands outside Blue Mountain Hospital in Blanding on July 29, 2025. Throughout the summer, he visited rural hospitals and clinics across Utah.<\/p>\n That\u2019s in part because of the Rural Health Transformation Program \u2014 a $50 billion fund<\/a> that Congress added into the \u201cbig, beautiful bill\u201d in the final hours of negotiations. <\/p>\n Funds may go towards improving how rural Utah hospitals and clinics provide care, including recruiting and retaining clinical workforce and upgrading electronic health records and billing systems. <\/p>\n However, it won\u2019t make up for gaps in insurance coverage or lost hospital revenue. \u201cIt doesn\u2019t even replace half of what was cut,\u201d Shakespear said. <\/p>\n McCullough told The Tribune he\u2019s heard the fund called \u201ca Band-Aid on a dismembered arm.\u201d <\/p>\n Utah\u2019s Department of Health and Human Services will lead out on the state\u2019s application for the fund. It estimates Utah will receive<\/a> $100 million annually over the next five years. <\/p>\n