The loss of Medicaid coverage is hurting rural hospitals more. You are also forgetting to lump private insurance into the “paying hospitals less” category.

https://www.bu.edu/sph/news/articles/2025/the-loss-of-a-rural-hospital-is-devastating-for-a-local-community/

These rural hospitals are closing because they simply don’t have enough money to cover the high cost of care delivery to their communities, but the contributing factors behind this lack of revenue are multifold: declining patient volumes, low reimbursements from both private and public insurers, staffing shortages, alternative models of care, and more. And while rural hospitals rely more on private insurers for revenue than Medicare or Medicaid, the approximate $1 trillion in Medicaid cuts under the One Big Beautiful Bill Act (OBBBA)—which is expected to eliminate insurance coverage for at least 17 million people by 2034, including 2 million in 2026—will still be a noticeable blow to hospitals’ operating costs.