Regional disparities in healthcare access and health outcomes are well-documented in the United States. Rural localities face worse health outcomes and greater challenges to accessing care than urban localities, particularly in the South. This study examines national and regional trends in hospital establishments (openings and closings), employment, size (employees per establishment), and regional concentration over three decades. We document an era of declining hospital counts and increasing employment within the industry, highlighting how the trends have differed across regions and rurality. Finally, we consider how these trends relate to the current policy environment in the United States.