Several rural communities across North Dakota are strategizing how to slow the pace of local grocery stores shutting down.

Some are making use of state grant money to aid their efforts, but challenges remain.

In North Dakota's Walsh County, the Rural Access Distribution Cooperative has been on the leading edge of establishing local grocery store co-ops, where a handful of smaller shops buy items in bulk together.

The initiative was eventually awarded a state grant to buy a bigger truck and van, making supply deliveries more manageable.

Cooperative President Alexander Bata said they continue to see progress with increased sales, and better options for area residents.

"So, there's less waste, less cost," said Bata, "and we've significantly improved the quality of food."

However, other elements of the initiative still face hurdles.

That includes utilizing food lockers, where customers can buy their food online and pick it up when they choose. But Bata said they haven't been able to make the technology work.

In 2023, the Legislature approved $1 million for interested communities to sustain grocery service in smaller towns with limited access.

The town of Milnor, with a population of around 600, was one of the early grantees - and used its money for a feasibility study.

Milnor's Community Economic Development Coordinator Carol Peterson said those findings were clear - their lone grocery store needs more storage space to stay afloat.

"It makes it very hard," said Peterson, "to order in enough product to service the community."

That limits the store from keeping prices lower.

Peterson said she worries more customers will then look at far away options, taking their tax dollars with them. While local leaders did get a read on what's needed, they haven't been able to secure additional funding for the next phase.

A key legislative sponsor of the pilot grant program says there's interest in extending it next session, but she's still gathering feedback.


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By Liz Carey for The Daily Yonder.
Broadcast version by Mark Richardson for Minnesota News Connection for the Public News Service/Daily Yonder Collaboration

When rural patients incur medical bills they can’t pay, the impact of the debt reaches far beyond their own personal pocketbooks, a new study has found.

Medical debt also impacts the hospitals that can’t collect on the debt and the communities they serve, according to a research brief from the Rural Health Research Center at the University of Minnesota. Although medical debt is something all communities have, it hits rural communities harder, Carrie Henning-Smith, co-director for the center, said.

Researchers interviewed rural hospital administrators in seven states – Arkansas, California, Illinois, Texas, Vermont, Washington and West Virginia – to look at the implications of medical debt on rural communities at large.

“We know how widespread medical debt is,” Henning-Smith said in an interview with the Daily Yonder. “We weren’t particularly surprised by anything we heard, but I think one thing that stands out to me is that this is not just an issue of healthcare facilities passing on big bills to patients and then patients shouldering that burden.” 

“This is really an issue that impacts individual patients, whole communities, and healthcare facilities, and I think smaller rural facilities that have a more tenuous bottom line are some of the most impacted,” she said.

Research indicates that about 44% of all U.S. adults are affected by medical debt, and that $88 billion in outstanding medical bills is currently in collections across the country. Researchers found the debts impact a rural hospital’s ability to continue paying their employees. With fragile bottom lines, rural hospitals are less likely to absorb the debt, respondents said.

A respondent from a Midwestern state said to the researchers, “One of the statistics that I think is really relevant is that we are about a $150 million organization… and 65% of those dollars go back in the form of compensation and benefits to our employees. So when we have medical debt that becomes excessive and we’re struggling to collect on the work that we do, it impacts our ability to employ [providers] and to serve our patients.”

With less revenue coming in, most respondents said, they are less likely to invest in equipment upgrades and their facilities, as well as less likely to hire more staff. Additionally, respondents said it’s harder to collect on that debt. 

“It’s a non-recourse issue. We can’t go back and take back what we’ve done,” a Southern state administrator told researchers. “You can’t repossess anything medical like you can with a car or a home or anything like that when there’s financial troubles. We end up really just getting unpaid, mostly.”

Researchers found that much of the blame for the debt issue is not solely because of patients who are underinsured. In many cases, insurance companies and other payers – including Medicare, Medicaid and Medicare Advantage – are not covering the cost of care that the hospitals provide.

“They need to have their cost recouped for the care that they provide,” Henning-Smith said, “and when they have patients who are uninsured or underinsured or when they are dealing with insurance companies and payers that are not providing a sufficient amount to pay for the cost of the care, then the facility suffers and the patients and community suffer too.” 

“It’s clear that our payer system is broken and that we have people whose care is not compensated at all or not at the rate that it needs to be to keep these facilities financially thriving,” she said.

Even if a patient is insured, some hospital administrators surveyed pointed out that underinsurance can create problems for patients and hospitals as well. High deductibles and plans with limited coverage options shift the responsibility for payment from the insurance company to the patient.

An administrator from the Midwest told the researchers, “Even the people who have the ability to pay, when you have more things like a high deductible health plan, no matter what your income is, it’s not easy for very many people if you have a $5,000 deductible. When that bill comes, that’s a difficult thing.”

Alan Morgan, CEO of the National Rural Health Association, said when rural hospitals don’t get paid, the impact is far reaching. Hospitals are typically among the largest employers in rural communities, and if a hospital fails because it can’t pay its bills, the whole community suffers.

“We’re in the midst of a hospital closure crisis and declining points of access to care in rural communities and it is because of bad debt, period,” Morgan said in an interview with the Daily Yonder. “When a hospital has to find ways to write off bad debt… for a lot of these rural hospitals, they’re operating on the margin and carrying large amounts of debt and uncompensated care that sometimes drives them to closure.”

When hospitals close due to financial problems, the economic hit on the community is multi-faceted, he said. The lost jobs not only reduce tax revenue coming into the community, but also impact the amount of consumer dollars being spent in the community. It means less income for businesses indirectly linked to the hospital, like flower shops, he said. And once the hospital closes, getting new families and businesses to move there becomes more difficult.

Fixing the issue will mean reforming how rural hospitals are reimbursed, Henning-Smith said.

“The message needs to continue to be about payment reform and understanding that medical debt is a widespread issue that’s not going away, but it’s not an individual issue and it’s not a matter of personal and individual responsibility,” she said. “It’s a community and a collective and a societal issue that if we don’t address, it’s not going to only impact the health and access to care of individuals, but it’s also going to impact availability of care in rural communities and places that need that care the most.”


Liz Carey wrote this article for The Daily Yonder.


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Rural West Virginia counties are already facing shortages of home health care services and nursing home workers. Now, they are facing accusations of alleged misconduct by contract workers in state nursing homes.

A new lawsuit cited a "systems failure" from top to bottom, where officials have allowed front line workers to act in ways that harm patients.

Michael Folio, legal director for the nonprofit Disability Rights of West Virginia, the group behind the lawsuit, outlined its goals.

"What we've identified is even the regulatory bodies in West Virginia that are charged with overseeing these facilities are so understaffed, so underfunded, that we oftentimes are reporting incidents to them, even though it's their job to actually uncover these incidents and take appropriate action," Folio explained.

The lawsuit alleged state officials knew about abuse, harassment, and retaliation of fellow employees and patients. According to the health care advocacy group KFF, there were more than 9,400 people living in certified nursing home facilities in West Virginia in 2024.

Folio pointed to documented incidents of abuse and neglect over the past year in state long-term care facilities. One case is now under criminal investigation, where hot water temperatures were said to reach between 134 and 140 degrees.

"What did they do? They ignored it for five months," Folio contended. "They placed an elderly gentleman who had dementia and he was nonverbal in this water and left him there."

According to the National Rural Healthcare Association, rural health facilities still have severe staffing shortages with fewer clinicians per capita, and sicker and older patients on average compared to urban areas.


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A new report highlighted how regional commissions are helping improve infrastructure in rural America.

According to the Brookings Institution, the Appalachian Regional Commission has directed nearly 70% of its infrastructure funding to distressed rural areas, addressing gaps left by traditional federal programs. The report said in Alabama and surrounding states, the commission has been a vital resource since 1965, completing 91% of its goal to build highways through the Appalachian Mountains.

Now, the commission said it is shifting its focus to modern priorities like broadband.

Gayle Manchin, federal co-chair of the commission, called broadband the "second highway," underscoring its role in expanding education, health care, and economic opportunities in rural communities.

"When our children were sent home to go to school virtually, they had no internet in which to do that," Manchin recounted. "Parents could not go home and work. There was no telehealth and so that has become obviously the second highway system that we are building."

Manchin explained the goal is to reduce the number of distressed counties and poverty rates. Since its creation, she said the commission has decreased the number of distressed counties by 60% and halved poverty rates. Manchin added there is still much more to do.

Manchin stressed collaboration is key to securing infrastructure funding for rural Alabama but matching requirements for federal grants remain a significant hurdle for many distressed communities. She noted commission grants, unlike federal loans, are designed to be more accessible for small towns with limited budgets.

The Brookings report highlighted how partnerships between commissions, nonprofits, and local organizations play a vital role in helping communities overcome obstacles and access critical resources.

"It's about the federal agencies working together," Manchin emphasized. "How they can help be a bridge to these communities by sharing their knowledge and their funding."

Manchin underscored the importance of building technical expertise in rural areas, acknowledging many communities lack the staff or resources to navigate complex grant applications without outside support.