In the windswept prairie town of Bowman, North Dakota, with its population of just 1,400, healthcare has always been a pressing concern. For years, residents like Retta Jacobi have depended on Southwest Healthcare Services, the local hospital, for everything from emergency care to routine checkups. But as rural hospitals across the United States face mounting financial pressures and the threat of closure or consolidation, Bowman's lifeline has found a new way to keep its doors open and its services local.
Enter the Rough Rider Network, a coalition of 22 independent rural hospitals scattered across North Dakota. Launched in late 2023 with the help of Cibolo Health and a $3.5 million boost from the North Dakota Legislature, this network is part of a growing movement among small-town hospitals to band together, share resources, and negotiate better deals with healthcare vendors. According to KFF Health News, the network now serves about two-thirds of rural North Dakotans, offering a model that other states are eyeing closely.
For Jacobi, the benefits are tangible. Recently, she needed an MRI scan to pinpoint the cause of persistent pain in her shoulders. Thanks to the network, a mobile MRI unit now visits Southwest Healthcare Services every Wednesday, sparing her a 40-minute drive to the nearest imaging facility—a trip that would have been both time-consuming and costly. "Anytime we can maintain more local control, it's a good thing for our small towns," Jacobi said, echoing the sentiments of many rural residents who worry about losing their community hospitals to distant corporate systems.
The stakes are high. According to research from the Sheps Center for Health Services Research at the University of North Carolina, 153 rural hospitals in the U.S. have shuttered or ceased inpatient services since 2010. Meanwhile, a report commissioned by the Coalition to Strengthen America's Healthcare found that 441 rural hospitals merged with or were acquired by larger health systems between 2011 and 2021. These consolidations often lead to cuts in services and staff, leaving rural communities with fewer healthcare options and longer travel times for basic care.
The Rough Rider Network offers a different path—one that preserves local autonomy while reaping the benefits of collective bargaining. Dennis Goebel, CEO of Southwest Healthcare Services, explained, "Healthcare vendors probably wouldn't be talking to us if we're by ourselves. They're not looking for the little, tiny crumbs. They want a big contract, and they'll give you better pricing." By pooling their patient numbers, the network hospitals can negotiate better rates for essential services like mobile medical imaging, telehealth, prescription drug programs, and even employee health insurance plans.
But the collaboration goes beyond just cost savings. The network allows hospitals to share specialists who aren't needed full-time at any one location, making it possible to offer services that would otherwise be out of reach for small facilities. It also supports investments in community wellness, such as broadband expansion, housing, and preventive care outreach. These initiatives aim to address the broader social determinants of health, helping people stay healthy and access care more easily.
Cibolo Health, the company that helped launch the Rough Rider Network, has become a key player in this new era of rural healthcare. Nathan White, CEO of Cibolo Health, said he started the company after a rural North Dakota hospital leader approached him about collaborating with similar facilities. Since then, Cibolo has assisted in forming networks in Minnesota, Nebraska, Montana, and Ohio, with a sixth set to open in September 2025. Once operational, these Cibolo-affiliated networks will represent more than 120 hospitals and serve 4.7 million people.
White noted that the networks, which are nonprofit entities owned by the hospitals themselves, pay an annual fee to Cibolo for management services. Leaders from 10 other states are reportedly considering adopting this model, which has gained momentum since the passage of the Affordable Care Act in 2010 and the more recent Rural Health Transformation Program, part of President Trump's tax and spending reform. The latter provides funding opportunities for value-based care agreements, which reward providers for the quality of care they deliver rather than the sheer volume of services.
While the promise of clinically integrated networks is enticing, the evidence for their effectiveness is still emerging. A 2020 report by the Rand Corporation noted, "In theory, quality should improve with the alignment of healthcare organizations, but there is no evidence." The report also cautioned that such networks could inadvertently drive up prices, a risk traditionally associated with mergers and acquisitions. Nonetheless, supporters point to real-world successes. Marnell Bradfield, executive director of the Community Care Alliance in rural western Colorado, said her network has reduced insurance costs and improved patient outcomes, including a decreased need for inpatient and emergency care.
The Rough Rider Network is already piloting innovative programs to boost preventive care. At SMP Health-St. Kateri, one of the network's hospitals, a partnership with Caret Health focused on reaching patients overdue for annual physicals, cancer screenings, and vaccinations. Gabby Wilkie, finance director at St. Kateri, explained that Caret Health staff called and texted patients—sometimes as many as 11 times—before successfully scheduling appointments. "To be honest, we didn't have the resources to reach out," Wilkie said, adding that such outreach would have cost the hospital an estimated $300,000 for 1,000 patients. Instead, the hospital expects to earn more than $100,000 in revenue when those patients come in for their preventive care. The costs are shared by Cibolo Health and the Rough Rider Network, and the program is now rolling out to other member hospitals.
For patients like Jacobi, the benefits of these changes are immediate and profound. After her MRI, she's now on medication and undergoing physical therapy. If those treatments don't resolve her pain, she may need to make a five-hour round trip to Bismarck for further intervention. But for now, she's grateful that diagnosis and treatment advice are available close to home.
Goebel, the hospital CEO, underscored the broader impact of hospital independence on rural economies, noting that local hospitals are often major employers. "Anything that can help our rural hospitals and add services is awesome," Jacobi added, highlighting the sense of community pride and resilience that runs through Bowman and towns like it.
As rural hospitals across the country grapple with financial uncertainty and the threat of closure, the Rough Rider Network's approach offers a glimmer of hope. By joining forces without sacrificing their independence, these hospitals are charting a new course—one that aims to keep healthcare local, accessible, and sustainable for the communities that depend on it.
