WICHITA, Kan. (AP) — The closure beginning next month of the hospital in the southeast Kansas community of Independence is highlighting problems faced by rural health care providers in states that have refused to expand their Medicaid programs.

Mercy Hospital spokeswoman Joanne Smith says the climate of health care is very challenging. That is particularly true for small rural hospitals that are facing decreased reimbursements and declining populations. She says the state’s refusal to expand Medicaid was not the deciding factor in Mercy’s decision to close its Independence hospital, but it was certainly significant.

Medicaid expansion would have brought in $1.6 million annually to the Independence facility.

The National Rural Health Association estimates 55 rural hospitals across the nation have closed since 2010, and 283 more are at risk of closure.