Access to care complex in urban medical centers often generates a patient perception that all hospital care in rural areas is of lower quality. Those with financial resources and capacity to move tend to use distant urban centres much less complex needs. The majority of patients admitted to rural hospitals are either too fragile to withstand long-distance travel or hospitals lack the means nor the trip or the cost of care in urban areas. None of these populations generates sufficient reimbursement to cover the costs of services.

Many rural hospitals and providers have diversified services to increase revenue. However, this strategy often fails to hospital and must close. Closing leave the very elderly, disabled and poor who lack access to hospital inpatient care, and the whole community is left without access to emergency or emergency care. In addition, the region suffers from significant loss of employment.