Why Scale Matters: WalMart Abandons Its Express Store Format While Mid-Size Rural Hospitals Fail Without Medicaid Expansion

It got kind of confusing for a while there with all the interchangeable monikers WalMart kept using for their relatively new small format stores: Express Stores, Neighborhood Markets, and not Super Centers. Here's what you really need to know: WalMart's much vaunted distribution and pricing genius stumbled and eventually failed in the small format stores it created for rural communities where the Dollar Store was king.  Oh, and re-naming the Express Stores, Neighborhood Markets did absolutely nothing to halt the debacle.  What ever you call them, WalMart stores with considerably less than 30,000 square feet had difficulty interoperating with WalMart's  Supercenter-focused acquisition and distribution systems.  Ever nimble, WalMart is closing its Express Stores, and some of its Neighborhood Markets with  almost of the closing facilities found in rural communities where retail choice may never have been large to begin with. 

What's all this got to do with a parallel story of small hospital closures also spreading across rural mid-America and the South? Some parts of the story will sound familiar: in acute care, scale matters as well. The very smallest most isolated rural hospitals are often propped up with Critical Access funds, however, so here the stories begin to diverge.  The mid-sized rural hospitals were supposed to find new lifeblood in an infusion of ACA expansion Medicaid dollars. With the now optional Medicaid expansion, that isn't happening everywhere. So, vulnerable rural mid-size hospitals are beginning to close, often under staggering unreimbursed care debt.  Many of these hospitals were troubled before the Medicaid expansion was optionalized, however, for the same reason those Express Store WalMarts struggled.  There is a price attached to the increased push for standardization in medicine and the rewards are to the technologically nimble, whether it is quality and performance data that must be quickly and efficiently gathered or hospital equipment and procedural expertise that must be accumulated.

I have been wanting to map WalMart closures on rural hospital closures in some kind of amazing "scale matters" and so does Medicaid expansion map. I just need to figure out how to map this onto this.  Of course, these two parallel tales may serve to undermine the happy narrative that rural hospital closures will be off-set by an increased number of  WalMart in-store care clinics in low income rural communities.  

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