Clinton Regional Hospital has over 100 years of history in its west Oklahoma community, which is currently home to a little over 8,000 people. Chasity Richardson, its co-administrator, is a part of its story.
She grew up running around its halls, volunteered there as a candy striper and has worked in various roles there since she graduated high school. Now, many of those halls are empty.
“It's quiet now, but when we were closed, it was a little eerie,” Richardson said.
The hospital closed at the end of 2022 after AllianceHealth, the private company managing it, decided not to renew its lease. Richardson found out in the newspaper. She said it was devastating, as regular patients who felt like family had to travel or be transported out of town.
Clinton Regional reopened after about 10 months with financial support from the city, new leadership under former CEO Len Lacefield and long nights spent working with the 17 staff members Lacefield inherited. But he said it couldn’t rely on the city forever.
“As any smaller community, they're not sitting on limitless funds,” Lacefield said. “It was getting down to a point where we were utilizing a lot of their public works.”
Clinton Regional decided to convert into a rural emergency hospital. The federal designation for rural hospitals became effective three years ago, allowing facilities to receive enhanced support for outpatient and emergency services if they gave up their more expensive inpatient care.
Small rural hospitals are facing significant challenges amid lower volume, aging populations and rising costs. As the designation gains traction in Oklahoma, providers said it's become a lifeline for their facilities, which would otherwise close. But critics argue there’s a need for other solutions that don’t require them to give up services.
What is a rural emergency hospital?
Congress established the rural emergency hospital designation through the Consolidated Appropriations Act, 2021. The goal was to offer financial stability to facilities to maintain local access to outpatient and emergency services amid growing concerns over closures.
Eligible hospitals include critical access, small rural acute care, tribally operated and Indian Health Service facilities with no more than 50 certified beds as of Dec. 27, 2020, that are enrolled in Medicare. Those who were enrolled but closed after that date can still qualify.
They must meet certain conditions to participate, including a transfer agreement with a Level I or II trauma center, 24/7 emergency department staffing and an average annual length of stay less than 24 hours. But observation care is still provided, and facilities have some flexibility because the length of stay is averaged.
Hospitals also must be located in a state that licenses them under state or local law. Oklahoma lawmakers defined the provider type through 2023 legislation. Clinton Regional was granted its license in November 2025.
It’s one of six licensed rural emergency hospitals in the state, compared to about 50 total nationwide.
Rural emergency hospitals receive a monthly payment, which is currently about $295,000. It doesn’t adjust by the facility's size or the amount of revenue it generates. And for rural emergency services provided to Medicare patients, they get paid an additional 5% over the Outpatient Prospective Payment System rate. That means $15,000 more a month in Clinton.
“That is pennies from heaven that takes the pressure off of CEOs like me, and boards like our authority board and the city from having to fund it,” Lacefield said.
In addition to required services, rural emergency hospitals can provide additional outpatient offerings. Clinton Regional, for example, used rural emergency dollars to start the Pritikin Intensive Cardiac Rehab program. The evidence-based offering is built on exercise and education that helps foster a healthy lifestyle.
Clinton Regional is the second entity in the state to provide the program, and it already has a waiting list. Richardson said they hope to expand it into some of their empty space.
“We have some finances that need to be taken care of, and so once we get a level out, then we can start bringing on more services,” Richardson said.
But the model does have caveats. Rural emergency hospitals can’t participate in the 340B program, which allows certain healthcare facilities to purchase prescription and non-prescription medications at reduced cost. And, they can no longer provide inpatient care.
Richardson said Clinton Regional had a small inpatient volume, and staff cuts were minimal, because it only had either two nurses or a nurse and a tech covering inpatient.
“When we closed that, yes, it's harder, because my family member will have to go somewhere else,” Richardson said. “But for the census that we had, it really didn't hurt us that bad.”
Is the rural emergency program the right fit?
Over 1,500 health care facilities are eligible to become rural emergency hospitals. So how do they decide if it’s the right avenue for them?
That’s where the Rural Health Redesign Center comes in. The nonprofit was chosen as the technical advisor for the rural emergency hospital program. It provides free support to interested or participating hospitals.
Ken Harman, a program director and regional liaison, said the center partners with an organization called Mathematica to provide hospitals with a financial model that compares their current finances and how they would change under conversion. From there, they decide if the conditions work for them.
“For probably about half the hospitals we do these assessments for, the answer is yes. For the other half of the hospitals, no is the answer,” Harman said.
Then, the center helps facilities through the licensure process. When they get approved, it provides in-depth assessments to help them improve their service to communities. That includes evaluating current practices and what they could add.
“To come back a year later and see a hospital that was wondering ‘Are we going to have enough money to meet payroll?’ to now be talking about ‘We have the chance to expand and add some services to this community, and we have a chance to partner to do some things to actually start drilling down and improving chronic conditions,’” Harman said. “That is tremendously rewarding.”
Challenges remain for rural hospitals
In 2023, Stillwater Medical Perry became the first hospital in the state to convert. Courtney Kozikuski, the president and chief financial officer for Perry and Stillwater Medical Blackwell, said it helped the town of over 4,000 people keep and build on its hospital.
“Before we even applied, we invited community members to come talk to us and tried to outline what this change would mean, and the feedback we mostly got in Perry was, 'We really need the ER to stay for stabilization,'” Kozikuski said.
But Kozikuski said the transition hasn’t come without challenges. Before, a low inpatient volume meant Perry was basically operating as a rural emergency hospital, she said. But the conversion did put some strain on local Emergency Medical Services providing patient transfers.
Kozikuski also said the transition worked for Perry because it was a prospective payment system hospital, meaning it received Medicare reimbursements based on predetermined, fixed amounts. But she said the conversion might not make sense for all critical access hospitals, which would lose out on being paid by Medicare based on cost.
“My concern is that it is being portrayed like we have the solution now. There's nothing more needed to do. We have the rural emergency hospital program – done, finished, solved the problem,” said Harold Miller, the president and CEO of the Center for Healthcare Quality and Payment Reform. “And that's not it.”
Miller said the rural emergency hospital program doesn’t spell out what should be done to support ambulance services.
He cited a case in Mississippi, where county officials demanded its ambulance service stop picking up patients from a hospital in Batesville, which became a rural emergency facility in 2023, to transfer them to higher-level care. They argued numerous transfers were leaving county ambulances unable to respond to emergencies.
Miller said there are some small hospitals where it isn’t cost-effective to deliver inpatient services, but there are many others where inpatient volume is higher, and services are needed.
The model also hasn’t worked for every hospital, Miller said. One facility in La Grange, Texas — St. Mark’s Medical Center — closed after converting, saying it “was not enough to keep them out of the red.”
“It's only a narrow range of hospitals that, financially, the idea works for, and it's even a smaller range of hospitals that might say, ‘It's a desirable thing for our community to be able to do this,’” Miller said.
The Center for Healthcare Quality and Payment Reform publishes a periodical brief showing how many rural hospitals are at risk of closing by state. It said the primary reason they’re at risk is because private insurance plans are paying them less than what it costs to deliver services to patients.
“The simple solution is that private payers need to pay more,” Miller said.
“Everybody's all focused on Medicaid right now, and even if you repealed the One Big Beautiful Bill, you would have rural hospitals closing, because the problems that they had preceded any discussion about that,” he added.
Researchers at the University of Texas at Arlington College of Nursing and Health Innovation, studying rural emergency hospitals, said it is too early to tell how the rural emergency hospital designation will impact availability and access to care, and the recruitment and retention of providers.
“I am really anxious to learn how creative the different local communities are in putting together the services,” said professor of nursing Beth Merwin.
“But I am very concerned about the impact on a community of not having inpatient beds, and that has in the past helped communities to recruit health providers,” she added.
Lacefield, the former Clinton Regional CEO, acknowledged the rural emergency hospital model isn’t a golden-egg solution.
“It is a solution for today's problem, and that's cash flow,” Lacefield said. “I think that's probably the best statement that I can make regarding ‘What does REH mean?’ REH is a today-solution for today's problem.”
“The rest of it’s still up to us, but that's a really good hand up.”
Looking toward the future
When operations at the hospital closed, Richardson transitioned to billing medical claims from home. The only thing she enjoyed about it was getting to work in her pajamas. She missed her home at Clinton Regional.
But when Richardson was asked to return, she wasn’t sure at first.
“There for a while I was like, ‘Was this a good choice?’” Richardson said. “I'm no spring chicken. Where am I going to go if it doesn't work? You constantly have those things in your mind.”
She said she doesn’t worry anymore because of the hospital’s conversion to rural emergency. Instead, she’s committed to the future.
“There's not much I feel like that they could throw at us anymore that I'd be like, 'OK, that's going to really worry me.’ We just roll with it and go,” Richardson said. “I’ve dedicated my whole life here, and I will ride her until she's done.”
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