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Rural hospital aren't eligible to receive the same pricing on drugs as large metropolitan hospitals bc they are unable to satisfy the indigent designation that falls under 340b. This gives large metropolitan hospitals an enormous advantage in "profit" off of steeply discounted drugs. Hence the reason why many of the small hospitals are assimilated by large hospital networks. Also the large hospital networks have a lot of buying power bc of their purchase power (volume) and can negotiate volume discounts with manufacturers furthering their advantage. The US uses a system called average sales price (ASP) by CMS (medicaid and medicare)to determine the amount the government will reimburse for any drug. As these enormous hospital entities negotiate steep discounts, this lowers the overall reimbursement price (ASP) for any drug which makes it almost impossible for the small hospitals to even make enough to pay for the drugs as reimbursement by CMS falls much less have enough to pay for administration ( IV infusion, nursing, pharmacy, overall care, etc). It is a very unfair system. The large hospital networks aren't incentivized to provide care to rural residents bc there is literally no money in it. So they force those residents to travel to larger hospitals to receive care. Its a tragedy that these small hospitals are dying. This limits healthcare access to people who live in these areas. many of whom cannot afford to live in large metropolitan areas due to the high cost of living. Small rural hospitals also have a very difficult time finding staff. Physicians, NPs, PAs, Nurses etc. The cards are stacked against them. This isn't a handout. This is a failure of a capitalistic system that is unfairly applied to the human right to receive healthcare. Large hospitals should be required to provide care to residents in these underserved areas. Particularly when their C suite administrators are taking in millions in bonuses every year.