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About This Series
Inside Rural Minnesota’s 96-Hour Trap continues an editorial journey through the state of rural health care in Minnesota. The 13-part series is called “Minnesota’s Rural Health Reckoning.” It looks beyond the headlines and into the exam rooms, the nurse stations, the broadband gaps and backroads where small-town medicine is quietly being rebuilt. Each installment examines one piece of the transformation — from how hospitals survive when the math stops working to how doctors, nurses, and patients are rewriting the rules of care from the inside out.
Essentia Health has spent the past decade turning words like “value-based care” into something that actually lives in rural communities. But this isn’t just a health system’s story — it’s ours. What happens to medicine in Minnesota’s small towns will define who we are, how we age, and whether we can still look after one another when it matters most.
No organization sponsored this reporting. No PR firm pitched it. It’s one veteran columnist watching Minnesota’s health-care revolution unfold from the inside out — and trying to make sense of what it means for all of us.
Under a federal rule written when pagers were still high-tech, Critical Access Hospitals — CAHs — must keep their acute inpatient stays to an annual average of 96 hours. Four days. Not five. Not “as long as necessary.”
The clock is written into law. Go over, and you risk your Medicare certification — the financial lifeline that keeps rural hospitals alive.
Dr. David Herman has spent his career trying to make sense of the gap between the policy world and the patient world. As CEO of Essentia Health — which operates 15 Critical Access Hospitals across Minnesota and North Dakota — he’s watched his clinicians treat stroke patients, ventilator cases, and long-COVID survivors in places that Washington still treats like glorified first-aid posts.
He told senators last year, in language as measured as it was urgent: “CAHs are faced with compliance risk of the 96-hour rule while continuing to provide services to patients that cannot be discharged in a timely manner. Continued flexibility and stability will allow hospitals to provide access for their patients closer to home.”
That’s doctor-speak for let us use our judgment.
The rule might have made sense in 1997, when Congress created the CAH designation to save rural hospitals from collapse. Most were caring for low-acuity patients: broken wrists, uncomplicated births, bouts of pneumonia.
Back then, four days felt generous.
Today, rural hospitals handle patients who would have been transferred instantly a generation ago. But when every tertiary hospital from Duluth to Fargo is full, those transfers can take 12 to 36 hours to even secure an ambulance. Sometimes the sickest patients stay in town for days because there’s simply nowhere else to go.
Herman’s clinicians face an impossible math problem. A heart-failure patient stabilizes on day five. A child with RSV needs one more night on oxygen. The rule says four. The conscience says stay.
“Of course they choose the patient,” Herman said. “But each one of those choices puts us technically out of compliance. The people doing the right thing are the ones at risk.”
Every CAH administrator in Minnesota knows the tension. Some pad the averages with short stays — swing-bed admissions, minor procedures — to keep the annual number under 96. Others roll the dice and pray the auditors see intent, not infraction. The bureaucracy doesn’t measure compassion; it measures decimals.
When COVID hit, the Centers for Medicare & Medicaid Services (CMS) waived the 96-hour limit. For three years, rural hospitals practiced medicine without the stopwatch.
“Nobody died because of that,” said Herman. “In fact, care improved. We focused on outcomes, not averages.”
The waiver ended in May 2023 when the Public Health Emergency expired. Within weeks, surveyors were again preparing to enforce the rule. CMS even issued a memo explaining how to exclude the waiver period from the annual calculation — as if rural hospitals had time to run two sets of books.
“They call it an average,” Herman said, “but when you’re the one being audited, it feels like an ultimatum.”
Drive two hours south to Sandstone and the story repeats itself. The emergency room doors are open 24/7, even when the town diner closes by 7 p.m. Ambulance crews double as maintenance staff. The charge nurse has been there 32 years.
These places run on commitment, not convenience. Their reward is a regulation that tells them when to stop caring.
According to the Minnesota Department of Health, the state’s 78 Critical Access Hospitals serve roughly 900,000 residents — about one-sixth of the population — across a landscape larger than most states. They deliver one-third of all rural births and handle nearly 40 percent of emergency transports outside the Twin Cities metro.
Yet many of them are operating on razor-thin margins. The 96-hour rule doesn’t just threaten their certification — it threatens their solvency.
Urban hospitals are packed. Skilled-nursing facilities are short-staffed. And ambulance transfers can take half a day. Rural hospitals have become, in Herman’s words, “the safety nets for the safety net.”
During the PHE, Essentia used its rural network as a flexible grid. Data show that mortality rates fell slightly in CAH communities, even as they rose in congested metros.
When the waiver ended, that flexibility evaporated overnight. Administrators were back to counting hours.
“It’s like watching a firefighter turn off the hose because they’re over the water limit,” Herman said.
A bipartisan fix — the Critical Access Hospital Relief Act of 2025 (H.R. 538) — is now stalled in committee. It would remove the 96-hour payment certification rule, allowing Medicare reimbursement even when doctors expect longer stays. But it leaves the Condition of Participation untouched, meaning the clock still ticks in regulatory time.
It’s a distinction only a lawyer could love. For doctors, it’s still the same question: are we serving the patient or the policy?
Across northern Minnesota, the stories pile up.
A pneumonia patient in Grand Marais stabilized but waited two days for an ICU bed in Duluth.
A stroke victim in Park Rapids spent five days in a CAH because no rehab unit had space.
A diabetic in Ada returned home on day four to keep the hospital in compliance — and was back in the ER three days later.
Each case is invisible in the data but vivid in memory. The 96-hour rule doesn’t capture suffering. It counts minutes.
And yet, the people who enforce the rule aren’t villains.
“They’re trying to protect Medicare from abuse,” Herman acknowledged. “But the unintended consequence is rationing care by the calendar.”
Ask Herman what keeps him up at night and he won’t say finances or workforce, though those matter. He’ll say time. “Every decision takes longer — transfers, discharges, documentation, approvals. What we’re short on isn’t staff. It’s permission.
“If you want to help rural America without spending a dime, start by giving us back that permission.”
The data backs him. A 2024 analysis by the Minnesota Hospital Association found that average CAH stays had lengthened to 4.9 days, driven largely by transfer delays. The same report showed rural readmissions falling during the waiver years — proof that keeping patients longer, when medically necessary, actually saved money.
In Deer River, the nurses still know each cough by sound. They don’t read the Federal Register. They read the faces of families trying to make sense of the wait.
On a recent afternoon, one patient’s daughter asked a nurse when her mother could go home. The nurse glanced at the clock and said softly, “Soon.” She wasn’t thinking about the patient’s lungs. She was thinking about the regulation.
Dr. Herman isn’t a man who grandstands. He doesn’t thunder or scold. But his argument, repeated in hearings and interviews, carries the quiet weight of truth: rural health care isn’t collapsing — it’s mutating. It’s adapting faster than the rulebook can keep up. And every time a bureaucratic timer restarts, it erases some of that hard-earned evolution.
“This is a rule out of alignment with modern care,” he said.
He’s right. It’s also a rule out of alignment with common sense.
Policy reform doesn’t have to cost billions. Sometimes it just requires the courage to admit that time has passed. The 96-hour rule may have once been a guardrail. Now it’s a barrier.
If Congress wants to help rural America without another task force or photo op, it can start with one simple act: stop the clock.
Because out here, where the lights never really go out and the next ambulance is an hour away, four days isn’t a benchmark. It’s a sentence.
Minnesota’s Rural Health Reckoning — A Special Report by Howie
How Minnesota is quietly rewriting the rules of rural health care
Dr. David Herman is trying to rebuild a model that never fully existed — one that honors the spirit of small-town care while surviving the economics of modern medicine.
Examines the rural-urban digital divide through the lens of telehealth. Nearly 20 percent of rural Minnesotans still lack reliable broadband — meaning no video visits, no remote monitoring, no equity. Puts faces to the stats: seniors, veterans, parents juggling three jobs.
The 96-Hour Rule That’s Breaking Rural Hospitals
Herman’s call to scrap the federal 96-hour limit on Critical Access Hospital stays. Show what happens when a pneumonia patient is too sick to discharge but too “long” to bill.
“The 340B Lifeline Under Attack
Big Pharma’s assault on the 340B discount program threatens small-town hospitals. Translated: a few cents in Washington could close pharmacies in Grand Marais or Park Rapids.
From Fee for Service to Fee for Results
A plain-spoken explainer of the national shift to value-based care — with Duluth as Exhibit A. Herman’s testimony and local clinicians.
Food, Heat, and Hope: The Social Side of Medicine
Essentia’s 144,000-patient social-needs screening exposes hidden poverty in the Northland. When 14 percent of patients report food, housing, or transport insecurity, the clinic becomes a front line against generational hardship.
The Color of Rural Health
Focus on racial disparities in northern clinics: why 22 percent of Native patients report food insecurity vs. 7 percent of whites. Brings in tribal health directors and shows how Herman’s data demands new partnerships between hospitals and reservations.
The Next Great Minnesota Export: Rural Health Innovation
Frames Duluth as a policy lab. How Essentia’s success in value-based care could serve as a model for the Dakotas, Iowa, and Wisconsin — the same way Mayo exported tele-stroke.
When Hospitals Become Economic Engines
Follows the dollars: rural hospitals like Deer River or Ashland are now the largest employers for 50 miles. Details Herman’s $430 million in community investment and how “healthcare capital” props up Main Street economies.
The Doctor Will Text You Now
Profiles Essentia’s embedded tech — patient portals, nurse hotlines, “Virtual Visits on Demand.” Asks whether tech can rebuild trust in small-town medicine or just widen the gap between those online and those left out.
Un-Burdening the Healers
Probes clinician burnout and the quiet hope behind Herman’s claim that value-based care restores purpose. Pairs physician interviews with workforce data — the new rural exodus of nurses, the pipeline from St. Scholastica and Itasca CC.
Policy from the North: How Duluth Is Whispering in Congress’s Ear
A reporter’s take on Herman’s Washington moment. Charts how Duluth’s CEO is lobbying for permanent telehealth, ACO bonuses, and parity between Medicare Advantage and alternative payment models — small-town voices shaping national reform.
Howie writes from Duluth, where he’s been poking the city’s sacred cows since before half the current council learned to parallel park. He runs HowieHanson.com, a one-man newsroom blogger powered by caffeine, sarcasm, and an allergy to PR spin. Part columnist, part historian, part irritant, he still believes in telling the truth—even when it makes the room uncomfortable.
