OSCEOLA, Mo. (AP) — A growing number of rural hospitals are closing their doors, forcing many Americans in small communities to travel much farther for medical care.

The hospitals cite changing demographics, medical practices and management decisions. They have also been affected by federal policies that have put more financial pressure on facilities that sometimes average only a few in-patients a day.

Chris Smiley is a former operating-room nurse who was the last chief executive of Sac-Osage Hospital in Osceola, Missouri. He says money “just kept drying up.”

The National Rural Health Association says a total of 50 hospitals in the rural U.S. have closed since 2010, and the pace has been accelerating. More hospitals have closed in the past two years than in the previous 10 years combined.