Jar of IOUs According to the nonprofit National Rural Health Association, bad debt for rural hospitals has gone up about 50 percent since the passage of the Affordable Care Act in 2010. (Photo: Shutterstock)

Kristie Flowers had been sick with the flu for four or five days in July before the 52-year-old registered nurse from Genoa, Colorado, acknowledged she needed to go to the ER.

At Lincoln Community Hospital, about 10 miles from her home on the Eastern Plains of Colorado, doctors quickly diagnosed her with pneumonia and sepsis. Her right lung had completely filled with fluid, and Flowers needed much more intensive care than the 15-bed hospital could provide.

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