 Beset by chronically low inpatient censuses in recent years, declining reimbursement from Medicaid and Medicare, and facing rising costs, many rural hospitals, not just NARH, struggled to stay alive.Some turned to larger health systems for financial backing, partnership, or mergers.NARH went through Chapter 11 bankruptcy reorganization in 2011 and built an affiliation with Berkshire Medical Center (BMC) in Pittsfield, MA.