Almost half of all incarcerated people are in rural jails and prisons and at risk of losing access to hospitals

Nearly a million incarcerated people depend on rural hospitals for routine off-site and emergency medical care.¹ Almost 60% of people in prisons and 25% of those in local jails are confined in rural counties, which are home to 3,000 of the nation’s correctional facilities. Following massive cuts to Medicaid passed by Congress this year, many rural hospitals will be forced to scale back operations or close entirely. As a result, critical, lifesaving healthcare will be further out of reach for huge swaths of the incarcerated population and those who live and work nearby, making an already bad situation far, far worse.

Rural and jail prison population estimates are based on an analysis of Vera’s Incarceration Trends jail data and the Bureau of Justice Statistics’ Census of State and Federal Correctional Facilities, 2019. The percentage of rural hospitals at risk of closure in each state as of August 2025 comes from the Center for Healthcare Quality and Payment Reform’s report, Rural Hospitals At Risk of Closing. See the methodology for more details.

The divisive “One Big Beautiful Bill Act” imposes significant cuts to Medicaid that slash funding for rural hospitals,² which are largely dependent on federal subsidies to stay afloat.³ Closing rural hospitals has disastrous consequences for entire communities, but especially for incarcerated people who have no choice about where they receive medical care. Rural communities can expect limited access to emergency care, higher costs for healthcare, and less-timely and more geographically distant medical treatment. The resulting loss of jobs and healthcare providers risks escalating poverty, unemployment, and disability rates, exacerbating an already dangerous cycle that often leads to incarceration.

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In this briefing, we present our estimates of the number of people in prisons and jails who are locked up in rural counties and explain how rural hospital closures would spike healthcare and incarceration costs while worsening public health. We are also making these state-by-state estimates available in an appendix. Additionally, we examine how a weakened rural hospital system can make healthcare delivery even worse than it already is for people on the inside. Finally, we highlight ways in which the consequences of rural hospital closures — unemployment, inadequate healthcare access, poverty — are felt across entire rural communities, not just behind bars.

The incarcerated population is disproportionately sick, aging, and locked up in rural areas

With more than half of prisons and around a quarter of local jails situated in rural counties, rural hospital closures pose real risks to incarcerated people’s health and wellbeing.⁴ Incarceration has a negative impact on the health of people behind bars and shortens life expectancies — a state of affairs that is especially worrisome given the increasingly elderly and sick incarcerated population.⁵ Researchers warn that closing rural hospitals “can increase the risk of bad outcomes for conditions requiring urgent care, including that for high-risk deliveries, trauma, and heart conditions.” These bad outcomes are particularly likely among the incarcerated population, where some of these conditions are common: for example, about 2% of women entering jail are pregnant and many jail births are high risk. Additionally, heart conditions are the second leading cause of death in prisons and jails. Many correctional facilities already struggle to provide basic healthcare to incarcerated people and have disturbingly high mortality rates. These issues will inevitably worsen with the loss of important medical infrastructure nearby.

The impact on state prison systems

In almost every state, thousands of people in prison who need emergency and routine off-site medical care (such as imaging and x-rays, surgeries, and specialist care) rely on nearby rural healthcare systems that are now threatened by Medicaid cuts. This is particularly alarming in states that almost exclusively hold incarcerated people in rural areas, like Idaho, where 91% of people in prison are in rural counties.⁶ But the scale of the problem is worse in states with some of the largest prison systems — like Texas, Florida, California, Georgia, Pennsylvania, Arizona, and New York — where between 30,000 and 117,000 people in rural prisons rely on those hospitals in each state. Nationally, more than 783,000 people are in prisons in rural counties.⁷

People in prison already have to contend with delayed referrals to medical specialists, which (along with understaffing) contribute to higher mortality (death) rates on the inside. The carceral system is notorious for denying and slow-walking medical care, and for the convoluted, lengthy process required to be seen by a healthcare provider — practices that undoubtedly contribute to higher mortality rates on the inside.⁸ In rural facilities, these conditions are often exceptionally bad.

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In Louisiana — where 42% of the state prison population is incarcerated in rural counties — the prison mortality rate is more than double the national rate in state prisons, according to the most recent national data. From 2001-2019, Louisiana had the highest prison mortality rate overall, as well as for deaths related to heart disease, cancer, AIDS-related illnesses, and respiratory disease. Such severe healthcare needs require ready access to emergency and specialist care at a nearby hospital, and yet the Center for Healthcare Quality and Payment Reform estimates that 46% of Louisiana’s rural hospitals are at risk of closure, with at least nine at immediate risk of closure due to federal funding cuts.

Impact on local jails

Nationally, almost 170,000 people are incarcerated in rural jails. In 19 states, more than one-third of the statewide jail population is confined in rural counties. Six of those states confine more than half of their entire jail population in rural counties.⁹ Even in states with large rural populations overall, the share of the jail population in rural counties still stands out: for example, in Mississippi, where about half of the statewide population lives in rural areas, almost 70% of people in jail are held in rural counties. In Kentucky, where around 40% of the state lives outside of metropolitan areas, a disproportionate 67% of the statewide jail population is confined in rural jails.

Each year, more than five million people are arrested and booked into jail and they are more likely to have serious health needs — including mental illness, substance use disorders, HIV, Hepatitis B or C, cirrhosis, and heart conditions — than people who are not jailed. Troublingly, small, predominantly rural jails consistently report the highest jail mortality (death) rates in the country.¹⁰

The medical care that people receive inside jails is terrible in most places, but it is particularly bad in states with mostly rural jails and prisons. These facilities compete with community healthcare systems for limited resources, including qualified staff, and their failure to provide adequate medical care on the inside puts additional strain on local hospitals. When patients arrive from the jail or prison, their care has often already been delayed, making their health issues more severe and likely to require emergency or specialized treatment.

For example, in Virginia, where about 40% of the state’s prison and jail facilities are in rural areas, there have been at least three civil rights cases related to healthcare in prisons and jails since 2010. In U.S. vs. Piedmont Regional Jail Authority (2013), the U.S. Department of Justice alleged that the rural regional jail in Prince Edward County was permitting unqualified staff to evaluate medical conditions, inadequately screening for medical issues on admission, and providing subpar mental healthcare. The lawsuit resulted in the appointment of a court monitor to oversee the jail’s efforts to address these issues, but subsequent jail deaths suggest problems persisted. Similarly, in West Virginia — where 53% of the jail population is in rural counties — formerly incarcerated people already report serious healthcare issues on the inside, including delays in cancer screenings, lack of access to insulin, and abrupt discontinuation of prescription medication. Accordingly, West Virginia also had the second highest jail mortality rate in the nation at last count in 2019.

Rural hospital closures are associated with rising healthcare and incarceration costs, and worse public health outcomes

In the past decade, more than 100 rural hospitals have closed and more are at risk: the Center for Healthcare Quality and Payment Reform reports that in most states, over 25% of rural hospitals are at risk of closing, and in 10 states, at least half are at risk as of August 2025. Aside from providing crucial emergency care, inpatient medical care, and laboratory testing and diagnostics, rural hospitals are often where the community receives routine primary care and inpatient rehabilitation services. These closures can “wreak irreparable havoc on rural communities” and will, in turn, make it harder to reverse local population declines, threatening to turn these communities into “ghost towns.”

Beyond the community-wide effects of hospital closures – including unemployment (including in non-healthcare industries), lower income levels, and slower economic growth – the tendency of police to target poor and chronically ill populations means that people who fall through the cracks as a result of these cuts to crucial federal subsidies risk being swept into the system. With evidence that high county jail incarceration rates are associated with a rise in county-wide deaths, Medicaid cuts risk accelerating a dangerous cycle of poverty, illness, incarceration, and death in rural communities.

Medicaid cuts also stand to make already-costly medical care for incarcerated people far more expensive by placing services further out of reach. People living in rural areas live an average of 10.5 miles from the nearest hospital (roughly twice the distance in other areas), and over one-third of rural hospitals that closed between 2013 and 2017 were more than 20 miles from the nearest hospital. States, counties, and municipalities are ultimately on the hook for the high and steadily rising costs associated with medical care for incarcerated people. In Cheshire County, New Hampshire, for example, the county jail already budgets $50,000 for healthcare outside of the facility, which is expected to cover medical care for 100 people in jail, including one person who requires dialysis to the tune of $6,000 every month. In Virginia, 27% of the prison healthcare budget in 2015 was spent on off-site hospital care.

In particular, the costs of transporting incarcerated people to hospitals for off-site or emergency care are already extreme. In Michigan, the cost for 224 ambulance trips to the rural Chippewa County Correctional Facility is upwards of $430,000.¹¹ Meanwhile, in New Hampshire, Department of Corrections expenditures on ambulances rose by 176% from 2022 to 2023. Requiring transport to hospitals that are further away will cause these costs to climb even higher, and will incentivize corrections departments to avoid doing so as much as possible.¹² Prisons and jails already engage in this practice because of untenably high transport and staffing expenses.¹³ In Allegheny County, Pennsylvania, (which is not even a rural county), medical transport from the jail “takes two correctional officers out of the jail for up to 10 hours.” In a survey of jail staff in southeastern states, one jail employee reported that they “try and get rid of dialysis patients as quickly as [they] can, too, because they don’t wanna have to transport them three days a week to dialysis.” In addition to delaying offsite transportation as much as possible, corrections authorities may also try to deflect rising costs onto their (typically poor) incarcerated patients. As the National Consumer Law Center notes, jails in at least 25 states already engage in such practices:

“When an incarcerated person suffers from an acute medical issue that requires care that the jail cannot provide in-house, some sheriffs will release the person on “medical bond” before transporting them to a hospital so that the jail will not have to pay the medical bills. Once the person receives treatment and recovers, the sheriffs then often quickly move to rearrest and book the person back into jail.”

The failure to address people’s health needs while incarcerated exerts pressure on the remaining healthcare infrastructure as sick people leave correctional facilities and return home. For example, people on probation and parole face higher rates of substance use disorders, mental health diagnoses, chronic conditions, and disabilities than the general population, and over a quarter of people on community supervision have no health insurance, further limiting their access to adequate healthcare in the community.

Conclusion

The latest cuts to Medicaid pose substantial risks to both rural communities and the people who are incarcerated within them. Healthcare for incarcerated people is already abysmal, and jails and prison systems have been complaining about the rising medical costs for years. Medicaid cuts will pour fuel on this fire by forcing many rural hospitals to close. Further restricting timely access to routine off-site and emergency medical care will stoke worse health outcomes and higher mortality rates for an aging confined population. Given that most incarcerated people will eventually return to the community, these problems will exacerbate larger public health issues, impact community-wide mortality, and further burden the existing, limited emergency medical services in rural communities. Taken together, these factors paint a grim picture of the future for all people in rural communities as the combination of poor health and poverty makes rural communities more of a target for policing and incarceration. The destruction of rural public health infrastructure is a policy choice that inevitably favors using jails and prisons to manage increasingly poor, sick, and neglected populations through punishment rather than care.