Graduation Year

2026

Document Type

Open Access Senior Thesis

Degree Name

Bachelor of Arts

Department

Biology

Second Department

Public Policy

Reader 1

Dr. Jennifer Armstrong

Reader 2

Dr. Eric Helland

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Terms of Use for work posted in Scholarship@Claremont.

Rights Information

2026 Juliette Des Rosiers

Abstract

From 2005 to 2025, over 200 rural hospitals shut their doors, often citing increased operational costs, staffing shortages, low patient volume, regulatory barriers, financial challenges exacerbated by the COVID-19 pandemic, and uncompensated care as common contributors to the closures. Rural patients are often referred by their primary care physician to a hospital for regular immunizations, since smaller clinics have less capacity to provide immunizations due to a shortage of pediatricians and limited vaccine stock. A crucial vaccine that is not required by schools and underutilized in rural areas is that against human papillomavirus (HPV), a virus that infects cutaneous and mucosal epidermal surfaces and causes benign lesions and warts. Persistent infections of one of the 13 oncogenic types of HPV are associated with a higher risk for cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancer. Luckily, the HPV vaccine targets seven HPV types that contribute to 73% of HPV-associated cancer incidence and reduces the risk of HPV-related cancers by approximately 97% if administered before the first sexual contact. However, adolescents from rural small towns and poor communities are less likely to initiate or complete the HPV vaccine series. Furthermore, accelerating numbers of rural hospital closures presents a remarkable challenge to public health campaigns that educate and encourage HPV immunizations, especially in rural populations that remain uninsured.

Current literature observes Affordable Care Act expansion of Medicaid as an intervention against the fiscal precarity of hospitals but has not integrated how the Medicaid expansion interacts with the longevity of rural hospitals. This study characterizes the effect of Medicaid expansion on the relative risk of hospital closure to understand whether Medicaid coverage strengthens hospital survival odds. Furthermore, this study connects hospital closures to HPV immunization rates in rural areas through the lens of Medicaid expansion, observing whether the Medicaid expansion was associated with improved HPV immunization rates following a hospital closure. This study adopted a two-pronged approach: one, it used open-access data on hospital closures (n = 207) over the past 20 years to conclude how the relative risk of closure and survival odds change following Medicaid expansion in the state, and two, it used open-access county data (n = 34) from state public health departments on HPV immunizations to identify the impact of hospital closures in tandem with Medicaid expansion on the rate of HPV immunizations in rural counties. The data analysis found that the relative risk of a rural hospital closure is significantly reduced when a state has adopted the Affordable Care Act Medicaid expansion, highlighting the impact of reduced uncompensated care and increased healthcare utilization on the survival of rural hospitals. Additionally, analysis revealed that the Medicaid expansion was associated with a smaller decline in HPV immunization rates following a hospital closure. However, year-to-year analysis demonstrated that Medicaid expansion does not significantly impact HPV immunization rates following a hospital closure, leading to the conclusion that immunization is affected by factors other than insurance coverage, such as access to transportation, political and religious attitudes, and relationships with primary care physicians.

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