The sun was just warming the horizon as Mark Pieper left his house near his cattle ranch on a crisp February morning. It’s not unusual for the rancher to wake up early to tend to livestock, but at 5:45 a.m. this day, his cattle wouldn’t come first. For the past three and a half years, three days a week, Pieper has made an early-morning commute to get dialysis at the nearest hospital. Pieper lives outside Hay Springs, a small Nebraska town with a population of just 599 residents. He makes sure not to forget his chocolate-brown cowboy hat before starting up his pickup truck for the half-hour drive to Chadron.
That February morning was one of his last dialysis sessions at Chadron Hospital before the facility shuttered the service at the end of March, an abrupt decision that has sent ripples of anxiety and hardship through the already underserved rural community. "I guess I’ll just bloat up and die in a month," Pieper remembered thinking when he learned the center was closing, eliminating the only option within a reasonable distance from his home. He needs dialysis to survive after cancer treatment severely damaged his kidneys, a life-sustaining therapy that filters waste and fluid from the blood—a job his failing kidneys could no longer perform. Each treatment session lasts approximately four hours.
Pieper and 16 other patients relied on Chadron Hospital for this critical care. The closure of its dialysis unit is a stark illustration of the ongoing decline of healthcare services in rural America, a region grappling with higher rates of chronic conditions and significantly less access to care compared to urban areas. This trend is particularly concerning given the federal government’s stated commitment to addressing these disparities, such as the Trump administration’s launch of the $50 billion federal Rural Health Transformation Program in September. However, for communities like Chadron, the program’s design may not offer immediate relief for existing, vital services. "President Trump says he is going to help rural healthcare," Pieper remarked, emphasizing, "Dialysis is one thing that we really need here."
The Ripple Effect of Closure: Patient Hardships and Relocations
The closure has forced patients to make drastic, life-altering decisions. Some, particularly nursing home residents, have relocated to be closer to available dialysis facilities. These new arrangements, however, may distance them further from their families and established support networks. For others, the solution involves extensive and costly travel.
Mark Pieper eventually found a dialysis center in Scottsbluff, the largest city in the remote Panhandle region of western Nebraska, with a population of approximately 14,000. This new arrangement will triple his weekly travel time, extending his road time to over nine hours each week. The drive to Scottsbluff alone is an hour and a half each way.
Jim and Carol Wright represent another difficult situation. To reduce their commute time, they have resorted to renting a small home near Rapid City, South Dakota, and living there on weekdays. This allows Jim to receive his necessary dialysis treatments in town. While this arrangement shortens his travel, it significantly increases their financial burden. Jim Wright acknowledges the financial challenges faced by rural hospitals but stresses the life-or-death nature of dialysis. "But we’re talking about something that’s lifesaving. It’s not a matter of, ‘Oh, I would like to be there’ getting treatment," he stated emphatically. "It’s a case that if you don’t, you die."
An Influx of Funding, Out of Reach for Existing Services
The timing of the Chadron Hospital’s dialysis unit closure, at the end of March, coincided with a significant announcement regarding rural healthcare funding. Jon Reiners, CEO of the independent, nonprofit Chadron Hospital, expressed the difficulty of the decision to cease dialysis services. He and several patients noted the irony that the closure occurred as Nebraska officials celebrated the state’s allocation of $219 million in first-year funding from the Rural Health Transformation Program.
However, the nature of this program, designed to explore new and creative approaches to improving rural health over a five-year period, means that only a limited portion of the funds—up to 15%—can be used to directly support providers for patient care. This structure makes it challenging for facilities like Chadron Hospital, which were operating at a loss, to leverage the program for immediate operational support.
A review of state applications for the Rural Health Transformation Program by KFF Health News revealed that at least 11 states have indicated plans to use some of their funding for rural dialysis programs. Their proposed initiatives include the development of mobile dialysis units and support for at-home or long-term care facility treatments. Nebraska is not among the states that have explicitly mentioned using funds for rural dialysis programs in their initial applications.
Reiners detailed the financial strain that led to the closure, stating that Chadron Hospital lost approximately $1 million annually on its dialysis service. This deficit was primarily due to low reimbursement rates from Medicare that failed to cover the operational costs associated with providing the service. As a critical access hospital, Chadron Hospital receives increased reimbursement rates for Medicare patients, but this designation does not extend to outpatient dialysis services, Reiners explained.
The hospital made concerted efforts to find alternative solutions, including discussions with four private dialysis companies over more than a year. However, each company declined to take over the service, citing the projected financial losses.
Broader Trends in Rural Healthcare Access
The situation in Chadron is not an isolated incident but rather symptomatic of a larger, systemic issue facing rural healthcare across the United States. Nephrologist Mark Unruh, chair of the Internal Medicine Department at the University of New Mexico, described the closure as a reflection of widespread staffing and funding challenges. "You do end up in situations where you have people who are displaced like this, and it’s just sad," Unruh commented, highlighting the human toll of these service reductions.
Data underscores the significant disparities in kidney health and treatment faced by individuals in rural America. A 2024 study published in the American Journal of Nephrology revealed that rural populations are more likely to develop end-stage kidney disease and experience higher mortality rates after diagnosis, according to the National Institutes of Health’s U.S. Renal Data System.
Unruh emphasized that a primary strategy for addressing these disparities lies in prevention. He pointed to initiatives like Project ECHO, a tele-education program designed to empower primary care physicians in rural and underserved areas to prevent end-stage renal failure. Another promising avenue, Unruh suggested, is the acceleration of kidney transplantation rates for rural patients. He is involved in a study investigating the effectiveness of "fast-tracking" transplant evaluation tests, consolidating them over a few days to minimize travel burdens for patients. Furthermore, Unruh believes that strengthening the U.S. health system’s capacity to train staff who can then educate patients and their caregivers on administering dialysis at home is crucial.
Exploring Home Dialysis and Lingering Concerns
Home dialysis offers a potential alternative for rural patients, who are already more inclined to utilize this option compared to their urban counterparts. Data from the National Institutes of Health indicates that in 2023, nearly 18% of rural dialysis patients received home dialysis, compared to about 14% of urban patients.
However, the practicalities of home dialysis present their own set of challenges, particularly for those in remote areas. One form of home dialysis requires surgical placement of an abdominal catheter and up to 15 days of training. The nearest facility offering this training to Chadron residents is in Scottsbluff. The alternative, peritoneal dialysis, demands up to eight weeks of training, with the closest facility located three hours away in Cheyenne, Wyoming.
Mark Pieper has been informed by his doctors that he is not a candidate for either home dialysis or a kidney transplant. While a nonprofit rural transit system operates in the Panhandle, its schedule does not align with Pieper’s treatment needs. This leaves him with no viable option other than the extensive travel to Scottsbluff.
Linda Simonson faces an even more demanding journey for her husband, Alan. Their round trip to Scottsbluff for his treatments exceeds four hours. During one of Alan’s final sessions in Chadron, Linda sat in the waiting room, diligently filling a yellow legal pad with phone numbers of politicians and driving distances to various dialysis centers. She noted that facilities closer to their ranch either have no openings for new patients or lack convenient locations for necessary rest stops during the long drives, especially during inclement weather. "It’s just unreal," she expressed, highlighting the logistical nightmares faced by rural patients. Even if Alan were to take a bus, Linda feels she would need to accompany him to provide support during the lengthy travel and treatment.
The challenges extend beyond the immediate need for treatment. Jim and Carol Wright, who are currently renting a home near Rapid City, acknowledge that they cannot sustain this arrangement indefinitely. The weekly commute is taking a significant toll, both physically and emotionally. They anticipate eventually having to sell the home they cherish in the scenic Nebraska National Forest and relocate to a larger city to be closer to consistent medical care. Carol expressed her empathy for the dedicated dialysis staff in Chadron, describing them as "wonderful." "It just doesn’t seem right to sacrifice one unit that’s so vital," she lamented, surrounded by packed moving boxes in their temporary rental.
The Wrights have taken proactive steps, writing letters to politicians and hospital administrators to voice their concerns and propose solutions, including the utilization of federal rural health funding. Linda Simonson reported speaking with aides for the governor and her state representatives, but received no callbacks. "It feels like they don’t know that we exist at this end of the state," she said, a sentiment that likely resonates with many in isolated rural communities struggling to access essential healthcare services. The closure of the Chadron dialysis unit serves as a poignant reminder of the precarious state of rural healthcare and the profound impact its erosion has on the lives of its residents.