The sun was just warming the horizon when Mark Pieper left his home near his ranch on a crisp February morning.
It’s not unusual for ranchers to wake up early to take care of their livestock, but on this day, the cows weren’t there even at 5:45 a.m. For the past three and a half years, Pieper commuted early three days a week to receive dialysis at a nearby hospital.
Pieper lives in the suburb of Hay Springs, which has 599 residents, according to a sign on the outskirts of town. He makes sure to don his chocolate brown cowboy hat before starting up his pickup truck for the 30-minute drive to Chadron.
That February morning was one of the last dialysis sessions before the hospital ended its services at the end of March.
When Pieper learned the center would close, leaving her the only option near her home, she remembers thinking, “I’m just going to swell and die within a month.”
Cancer treatment damaged his kidneys, so he needs dialysis to live.
Pieper and 16 other patients relied on Chadron Hospital for life-sustaining treatment to filter waste and fluids from their blood, but their failing kidneys could no longer do so. Treatment takes approximately 4 hours.
The closures are just one example of a long-term decline in health care services in rural America, where people suffer from higher rates of many chronic conditions but have less access to health care than other regions.
The Trump administration promised to address the problem when it launched a $50 billion federal rural health transformation program in September. It may not be enough to stop this trend.
“(President Donald Trump) has said he’s going to support rural health care,” Pieper said. Dialysis “is one of the things we really need here.”
Some patients, including nursing home residents, have moved to live closer to care facilities. The new facility may be located far away from family members.
Some people drive long distances to dialysis centers. Pieper was eventually able to receive treatment in Scottsbluff, the largest city in Nebraska’s western Panhandle region with about 14,000 residents. The hour-and-a-half drive triples his travel time to more than nine hours each week.
Jim Wright and his wife have rented a small house near Rapid City, South Dakota, where they live during the week so he can receive dialysis, cutting down on driving time but increasing expenses. Wright said he understands that local hospitals are facing financial challenges.
“But we’re talking about saving lives. Getting treatment is not a matter of, ‘Oh, I want to go there,'” he said. “If you don’t do that, you’ll die.”
Influx of unaffordable funds
John Reiners, CEO of Chadron Hospital, an independent nonprofit organization, was struggling with the decision to end dialysis services. He and several patients said the closure was announced as Nebraska officials celebrated the $219 million the state will receive in first-year funding from the Rural Health Transformation Program.
However, the five-year program is not about helping existing services survive, but rather exploring new and creative ways to improve local health. Each state can only use up to 15% of the funds to pay providers for patient care.
At least 11 states (Nebraska is not among them) have mentioned using the funds for local dialysis programs, according to a KFF Health News review of the applications. Their ideas include starting a mobile dialysis unit to help people receive treatment at home or in a long-term care facility.
Reiners said Chadron Hospital loses $1 million a year in dialysis services due to low reimbursement rates that don’t cover operating costs.
The facility is a critical access hospital, a designation that allows certain small, mostly rural hospitals to receive increased reimbursement rates for Medicare patients. Reiners said most of the affected patients were on Medicare, but the Critical Access Program does not cover outpatient dialysis.
Reiners said the hospital worked for more than a year to find a solution, including approaching four private companies that could take over the center. But they all passed knowing they would lose money, he said.
Nephrologist Mark Unruh said the dialysis closure at Chadron reflects broader trends in staffing and funding challenges.
“We do find ourselves in a situation like this where we have displaced people, and it’s really sad,” said Unruh, chair of internal medicine at the University of New Mexico.
People living in rural America face significant disparities in kidney health and treatment, according to a 2024 study published in the American Journal of Nephrology. They are more likely to develop end-stage kidney disease and have higher mortality rates after diagnosis, according to data from the National Institutes of Health.
The best way to deal with this is to focus on prevention, Unruh said. She pointed to a distance education program that helps primary care physicians in rural and other underserved areas prevent end-stage renal disease.
Another idea, Unruh said, is to increase kidney transplant rates for patients in rural areas. He is participating in a study looking at whether scheduling all tests over several days to limit travel time could help patients “quickly” get the tests they need to get approved for a transplant.
Unruh said the U.S. health care system needs to hire more staff who can train patients and their caregivers to perform home dialysis.
Exploring the option of home dialysis
Dialysis patients in rural areas are more likely to receive home dialysis than those in urban areas, according to data from the National Institutes of Health. By 2023, this proportion will be approximately 18% for rural patients and 14% for urban patients.
One type of home dialysis requires surgery to place a catheter in the abdomen and up to 15 days of training. The other type requires up to eight weeks of training. The closest facility to Chadron offering training for the first option is in Scottsbluff. The closest facility offering the latter type of training is three hours away in Cheyenne, Wyoming.
Pieper said her doctor told her she was not a candidate for home dialysis or a transplant. The Panhandle has a non-profit regional transit system, but that schedule doesn’t apply to Pieper. So he has no choice but to seek treatment in Scottsbluff, a 200-mile round trip, he said.
Linda Simonson takes even longer to drive her husband, Alan, from the ranch to the treatment facility in Scottsbluff, making the round trip more than four hours.
During Alan’s final treatment at Chadron, Linda sat in the waiting room holding a yellow legal pad. Scribbled on the paper were politicians’ phone numbers and driving distances to local dialysis centers. She said facilities near the ranch don’t have room to accept new patients or there aren’t any good places along the route to take a break from driving during inclement weather.
“It’s just surreal,” she said.
She said that even if Alan took the bus, he would have to ride with him to support him during the journey and treatment.
Jim and Carol Wright, who stay near Rapid City during the week, said they can’t afford to rent a second home forever. Their weekly commute is already physically and mentally taxing. They said they would eventually have to give up their beloved home in the scenic Nebraska National Forest and move to a larger city.
Carroll said she finds the dialysis staff at Chadron to be wonderful.
“I don’t think it’s right to sacrifice one very important unit,” she said, standing next to a pile of moving boxes inside the rental room.
The Wrights wrote letters to politicians and hospital leaders sharing their concerns and ideas for keeping the hospital open, including leveraging federal local health funding.
Simonson said she spoke with aides to the governor and state representatives, but none of the leaders called her.
“I feel like they don’t know that we exist on this edge of the state,” she says.
