Date of Award

3-27-2026

Embargo Period

4-18-2026

Document Type

Dissertation

Degree Name

Doctor of Health Administration

College

College of Health Professions

First Advisor

Dunc Williams

Second Advisor

Kevin Wiley

Third Advisor

Aaron Winn

Abstract

Rural hospitals operate on thin margins, have limited access to capital, and face a heightened risk of closure. During the COVID-19 pandemic, the Provider Relief Fund (PRF) distributed more than $170 billion to health care providers to offset revenue losses and preserve access to care. Most evaluations of PRF have focused on profitability, which may overstate financial resilience by overlooking liquidity. Using Hospital Cost Reports for hospitals from 2014-2023, we examined trends in Days Cash on Hand (DCOH), operating margin, total margin, and PRF funding intensity by rurality and ownership. Liquidity rose sharply during 2020-2021, coinciding with the peak of PRF disbursements, and then moderated as relief waned. Rural and government non-federal hospitals were disproportionately represented in higher PRF intensity categories relative to revenue and net income. Although the observed gains were temporary and structural disparities remained, policymakers and hospital executives should note that findings are consistent with PRF functioning as an effective short-term stabilization mechanism. By supporting the financial position of vulnerable hospitals, the program helped preserve access in rural areas while reducing the strain on urban systems. Incorporating liquidity into future relief

design may strengthen both equity and regional system resilience. Rural hospitals play a crucial role in the U.S. healthcare system, serving approximately 20 percent of the population in the United States (Audi et al., 2025). Despite their importance, rural communities have experienced a steady decline in access to hospital-based services. Since 2005, 195 rural hospitals have closed inpatient services. These closures highlight the persistent financial fragility of rural hospitals, which struggle to maintain operations, invest in quality improvements, and retain clinical staff.

Forty percent of rural hospitals operate at a loss, reflecting structural financial pressures that threaten sustainability (Carroll et al., 2024; Karim et al., 2025).

Rights

Copyright is held by the author. All rights reserved.

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