Restructuring the Front Lines: How Outpatient and Community-Based Care is Reorganizing Rural Healthcare

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ID: 333680
2026
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Abstract
Abstract Introduction Over the past four decades, U.S. healthcare shifted from hospital-based to outpatient and community-based care, fundamentally changing frontline healthcare delivery. Methods Using establishment-level administrative data from the Longitudinal Business Database (1980–2023) and the American Community Survey, we examine long-run trends across nine healthcare industries in metro, metro-adjacent, and rural counties. We compare establishments per capita, employment location quotients, and consolidation, and estimate two-way fixed effects models relating provider presence to payer mix, shortage-area designations, and socioeconomic conditions. Results Hospitals and physician offices declined, while outpatient services expanded at different rates across industries and geography. Rural healthcare is not simply declining but is being reconfigured into a different mix of services, with greater reliance on outsourced care, especially for capital-intensive diagnostics. Despite outpatient growth, relative healthcare employment concentration remains lower across several frontline services in non-metro counties. Provider presence is closely tied to payer mix, though associations vary across metro and non-metro counties and service types. Conclusion These findings suggest the transition toward outpatient care has produced distinct patterns of frontline healthcare availability across rural and urban counties.
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Authors Anders T. Van Sandt, Anja F. Gruber, Craig Wesley Carpenter, Cristian L. Meier, Scott Loveridge
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Journal Health Affairs Scholar
Year 2026
DOI
10.1093/haschl/qxag297
URL
https://doi.org/10.1093/haschl/qxag297
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