A federal economic relief package passed by Congress in March promised to provide a lifeline for hospitals, particularly those in rural communities where many facilities struggled to survive even before the coronavirus pandemic.

But over the past 10 months, the distribution of more than $100 billion in CARES Act funding for health care providers has been plagued by a dizzying rollout and, at times, contradictory guidelines for how to use the funding.The result has been a patchwork of problems for rural hospitals, which were already at far greater risk of closure than other health care facilities and in dire need of help, The Frontier and ProPublica found. The scope of those problems is clearly visible in Oklahoma, which tied for the third-highest number of hospital closures in the country in the nine years before the pandemic.

One hospital used more than $1 million in federal aid to pay off its years-old debt to a management company that left before Oklahoma’s first coronavirus case was diagnosed, a potential violation of federal guidelines that could require the hospital to return the money, according to experts.

Three Oklahoma hospitals that were purchased last year after filing for bankruptcy were unable to access more than $6 million in funds deposited by the Department of Health and Human Services, the agency in charge of the rollout for health care providers. The money was instead deposited into accounts tied to the previous owners, leaving the new owners with few options as they tried to keep the facilities from becoming insolvent.

And administrators at yet other hospitals have left millions in relief aid untouched, spiraling deeper into debt for fear that the wrong decision could force them to return money.

“Every day we have new rules, new guidelines, and it’s a struggle,” said Shelly Dunham, CEO of Okeene Municipal Hospital in western Oklahoma. Dunham said she used only $50,000 of the $3 million the hospital received in April and May because of concerns that the facility would have to return the money. “I can’t say we need more money right now. We just need to be able to keep what they’ve given us.”

Under the CARES Act, funding can be used to prevent, prepare for and respond to the coronavirus or to help with expenses or losses caused by COVID-19. The problem is in the details, which Congress left to HHS.

HHS has primarily managed concerns by publicly releasing responses to more than 100 frequently asked questions. Those responses have sometimes contradicted previous guidance from the agency, leaving health care providers confused about how money can be used and what the agency would seek to claw back. The whipsawing guidance has covered a range of topics, including how health care providers could calculate losses from the pandemic and whether they could use the money to pay for long-term capital improvement projects such as new heating, ventilating and air conditioning systems.

“Hospitals’ challenge right now is keeping their doors open and paying their debts,” said Carrie Cochran-McClain, vice president of government affairs and policy for the National Rural Health Association. “There is not enough flexibility to help providers really use the funds as Congress intended for the kinds of things that they need to address for COVID.”

Rural hospitals across Oklahoma and the country are disappearing at an alarming pace that could hasten without help from the federal government, Cochran-McClain said. In 2019, the year before the coronavirus pandemic, rural hospital closures reached a record high, with 18 nationwide. Texas led the country with three closures. Tennessee, Kansas and Oklahoma followed with two each.

Last year, despite the infusion of federal funding, another 17 rural hospitals shuttered, bringing the total number of closures since 2005 to 176.