Your analysis is self serving and and the decline rural hospitals has nothing to do with the ACA. If we were to go to a single payer system which progressives seem to favor, the government would control all reimbursements to hospitals and Docs. And the reimbursements to these hospitals would go down further. Remember of all reimbursements in the healthcare system, the ones from the government are the lowest, which is why the cost of private healthcare and the requisite insurance most of us pay is so high so as to make up for the loss and lack of profit on the government reimbursed patients in addition to all the regulations and insurance the medical profession pays due to lack of self policing to protect their own. In addition the very upsidedown business model of the healthcare industry where the CASH CUSTOMER PAYS THE MOST and the THIRD PARTY PAYER CUSTOMER (government or insurance company) pays the least is just plain wrong. It should be against the law to charge differentail rates to customers so the medical profession can make up for what the government will not pay them…once this government intervention started with mandated low rates in the healthcare system over the last 50 years in Medicaid and Medicare is what has driven private health care costs so high to begin with to make up for the short fall in fees.