Minnesota
Considering a ‘Donut Theory’ of Development in Minnesota
In my former line of work (helping to support local public health departments from the position of a cubicle in the Capitol complex in St. Paul), much hay was made out of a notion of bridging a “rural-metro divide” between the Twin Cities and its surrounding suburbs and the rest of Minnesota. Indeed, overall, the arc of demography in Minnesota in the past half-century has been away from Greater Minnesota and toward the seven-county metro, including the Twin Cities and the surrounding areas.
It could be said that this sort of framing constitutes a “mental model” of geography and development in Minnesota — a set of “deeply held beliefs and assumptions and taken-for-granted ways of operating that influence how we think, what we do and how we talk,” as defined by John Kania and colleagues in their 2018 report on systems change. However, once I began living in the economically and culturally diverse Midway neighborhood of St. Paul, this model struck me as somewhat inaccurate.
Walking around, I saw many issues similar to ones raised in rural areas:
Jokes aside about how much nicer the Roseville Target is relative to the one in the Midway, while just a few miles apart, such sights have made me question whether the binary between the “metro” and “Greater Minnesota” was entirely accurate.
Indeed:
I have taken to refer to these visuals, where certain indicators for the metro suburbs stand in contrast to both Greater Minnesota and the cities of Minneapolis and St. Paul, as “donut theory,” or the notion that the true geographic divide in Minnesota is not between “Greater Minnesota” and the “metro,” but rather between the metro suburbs and everyone else.
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The monster that will come for us all, soon enough — suburban sprawl?For further, quasi-quasi scientific study of “donut theory,” I now turn my attention to the siting of hospitals in and around St. Paul.
Why Hospitals?
I selected hospitals as the focus of study because they are a salient example of public infrastructure, whose whole purpose is to serve people — and therefore, the location of hospitals ought to follow the location of people. Rural hospital closures are also known as an established issue, making it more practicable to draw comparisons between urban and rural issues on a common topic.
As the sole researcher on this study, my capacity constraints limited me to studying the fairer of the Twin Cities. Extensions of the analysis below to Minneapolis, as well as to the historic siting of public schools in both cities, are potential avenues for further study.
To the best of my abilities, I sought to locate every hospital within St. Paul’s city limits that was operational during a few select dates:
Date
Reason for inclusion
Hospitals operational within city limits
1960
The peak of the city’s population (pop. 313,411)
12
1980
The “trough” of the city’s population loss (pop. 270,230)
7, plus 2 children’s hospitals attached to a larger facility
2020
Peak contemporary population recovery, post-1960 (pop. 311,527)
4, plus 2 children’s hospitals attached to a larger facility
2025
The present day (pop. ~307,465)
3, plus 2 children’s hospitals attached to a larger facility, plus 1 behavioural health facility under construction
A map of identified hospitals, with sources, is below:
A table of all hospitals included in the study is also as follows:
Name
Location
Years active
Fate
Ancker
West Seventh
1874-1965
Replaced by St. Paul Ramsey (now Regions) Hospital
Bethesda
Frogtown
1883/1932-present
Moved to former site of St. Joseph’s
Charles T. Miller
Downtown
1920-1972
Merged to become part of United Hospital
Children’s
West Seventh
1928-present
Operational at United Hospital site
Divine Redeemer
South Saint Paul
1960-1994
Converted to a nursing home; demolished 2016
Gillette Children’s
Payne-Phalen
1908-present
Relocated to site at Regions Hospital in 1977
Midway
Union Park
~1927-1997
Closed
Mounds Park
Dayton’s Bluff
1906- ~1970s?
Converted into a senior living center
Regions
Downtown
1965-present
Operational
Riverview Memorial
West Side
1905-1980
Merged to become part of United Hospital
Samaritan
Hamline Midway
~1922-1987
Closed
St. John’s
Dayton’s Bluff/Maplewood
1915-present
Operational; relocated to Maplewood in 1987
St. Joseph’s
Downtown
1853-2020
Closed
St. Luke’s
West Seventh
1882-1972
Merged to become part of United Hospital
TBD Behavioural Health hospital
Frogtown
TBD
Under construction
United
West Seventh
1972-present
Operational
Woodwinds
Woodbury
2000-present
Operational
I welcome any corrections to the map and/or the tables. Send your corrections and ideas to [email protected].
Results and Discussion
A few trends immediately presented themselves:
- The consolidation of a larger number of dispersed facilities in town, to a smaller number of larger medical facilities in downtown.
- Relocation of hospitals to the suburbs.
- Loss of hospitals in many St. Paul neighborhoods, including the Midway, West Side and East St. Paul generally.
In the context of “donut theory,” this mapping exercise shows that St. Paul, too, has suffered from the loss of infrastructure (hospitals) within its boundaries, not unlike rural areas. For both, the driver for these closures is population decline, given that the demographics of Minnesota have shifted to the suburbs since the 1950s.
Below is a map showing the growth of the “donut” over the years. Courtesy of Todd Graham on Bluesky (@metrogram.bsky.social)
Although the changes in hospital location are, in large part, due to changing medical technology, patient needs and cost considerations, rather than an anti-urbanist conspiracy, the net result of these closures is to make it more difficult for people to reach medical facilities by foot, bicycle or transit. Interestingly, a study from 1974, commissioned by the Minnesota Department of Transportation’s (MnDOT) predecessor, the Department of Highways, found that the conversion of Highway 12 to I-94 in east St. Paul would have “the net effect of reducing accessibility to [Mounds Park Hospital].” Although an alternative solution was found to the point at issue (the loss of a nearby on-ramp), Mounds Park Hospital was closed later that decade, in spite of the study commenting that the hospital “could play a yet greater role in the delivery of healthcare in the future.”
In aggregate, the loss of urban facilities in St. Paul like Midway Hospital has also meant the loss of jobs to the suburbs, from custodians to surgeons.
On the public transit blog S(ubstack)-Bahn, author S.Y. Lee identified a “crisis of mobility” on multiple fronts in the United States:
Americans are getting squeezed on mobility, on all fronts
Americans are sleepwalking into a crisis of mobility — as a practice and as a right, both for self-interest and national health. Consider the following statistics:
- Most of the largest U.S. public transit agencies face a fiscal cliff, as aforementioned
- U.S. pedestrian fatality rates in 2023 by drivers were the highest since 1981
- U.S. car crash fatality rates (per 100k population) in 2023 rose back to 2007-levels after decade-long decline in the 2010s
- Americans spent nearly $50,000 on a new car in December 2024, the second highest month on record
- More than 80% of new car sales in the U.S. are trucks or SUVs, which are getting bigger and thus more likely to kill pedestrians or other drivers in crashes
- Car repair and maintenance costs have risen by nearly 40% since 2020
- Delinquencies on U.S. auto loans in 2024 hit highest levels since 2010
- National gas prices have stayed above $3 per gallon since 2021, the longest stretch since 2011-2014. (It is much higher in select regions, such as the West Coast.)
- All fifteen cities which recorded the largest population adds between 2022-2023 are in the South, per the U.S. Census. The top three cities — San Antonio, Fort Worth, and Charlotte — recorded, in sum, a daily ridership of ~145,000 in 2024. (Their total population: 3.5 million)
- Licensed drivers over the age of 65 has grown from 27.6 million in 2001 to 49.6 million in 2021, per NHTSA. Traffic deaths in 2022 involving drivers over the age of 65 was the highest since 1975.
S.Y. Lee End of the line: Transit thoughts in an uncertain America
The ability to access healthcare is essential for a fully realized life. But, within this contemporary crisis of American mobility, the trend of hospitals moving away from the urban core means that it is more difficult today for people to access medical facilities without a car, a public health risk in its own right.
Why Does Any of This Matter?
I explore “donut theory” vis-à-vis the extent to which mental models — which do not align with material reality as it exists — can cloud one’s judgement. At their worst, inaccurate mental models within the minds of policymakers can create poor public policy that fails to address its intended purpose, or even further worsen quality of life in society.
In urbanism, the prototypical inaccurate mental model, with disastrous consequences, is to view the city as a machine to be rationalized and planned meticulously, as in Le Courbusier’s concept for “La Ville radieuse” (The Radiant City) rather than as a vibrant ecosystem of people and place, as described by Jane Jacobs in “The Death and Life of Great American Cities.” The consequences of such mechanical thinking were the (mostly) failed schemes of urban renewal and slum clearance — in St. Paul, resulting in the construction of I-94 through the middle of the city, the demolition of neighborhoods such as Rondo and the sterile streetscape of downtown; in Minneapolis, much the same happened in the construction of urban highways, the demolition of neighborhoods like the Gateway District and vast, yet eerily quiet streetscapes in the center of the city.
The challenges Minnesota faces, now and tomorrow, are vast. Inequality is slowly but surely rising. In St. Paul, in particular, municipal finances are in disarray — a consequence of decades of stagnant population growth.
(Note: As an aside, for this reason I am sympathetic to Ward 4 City Council candidate Molly Coleman’s ideas for spurring development in St. Paul to increase the local tax base, including through upzoning, pre-approved plans and state action to legalize a land value tax, which all could incentivize and reduce regulatory barriers to expanded development in St. Paul.)
Climate change continues to be an increasingly salient issue, both in its impacts to land and people, as well as to the role that Minnesota plays in advancing or arresting the pace of climate change. The land of Minnesota also exists, like all of the other pieces of our country, subordinate to a federal government to whom the people of Minnesota pay taxes, and in return now receive harm and hostility.
At each of these junctures, the patterns of development and land use for nearly 80 years — suburban growth in exchange for both urban and rural stagnation or decline — exists as a culprit in these challenges:
- In relocating wealth and population away from the Twin Cities and rural areas alike.
- In the higher carbon footprint of suburban living.
- In the financial costs of sprawl, and the loss of farmland from sprawl, rather than investment in areas already developed.
Crucially, even with recent growth in housing and population, both Minneapolis and St. Paul have yet to recover their peak populations from 1950 and 1960, respectively.
It stands to reason as well that addressing any of these challenges will also entail policies and actions to redress the distribution of resources in Minnesota from out of the suburban “donut,” and back into the Twin Cities and rural areas alike.
It is my intention, and hope, that a carefully considered notion of “donut theory” better identifies sources and implications of geographic division and inequality in Minnesota, rather than the binary “Greater Minnesota/metro” dichotomy alone.
Related
MINNEAPOLIS (FOX 9) – Gas prices are climbing again in the Twin Cities, with experts warning drivers to brace for more increases if oil prices keep rising.
Twin Cities gas prices see sharp increase
What we know:
According to GasBuddy’s survey of 1,106 stations, the average price for regular gasoline in the Twin Cities jumped 10.9 cents per gallon in the last week, now sitting at $4.18 per gallon. That’s 38.6 cents higher than a month ago, and $1.28 more than this time last year.
The national average price for gasoline also rose, hitting $4.48 per gallon after a 5.1-cent increase over the past week. Diesel prices are up too, with the national average at $5.62 per gallon, a 0.2-cent increase.
The cheapest gas in the Twin Cities was $3.70 per gallon Sunday, while the most expensive was $4.63 — a difference of 93 cents per gallon. Across Minnesota, prices ranged from $3.70 to $5.01 per gallon.
Patrick De Haan, head of petroleum analysis at GasBuddy, said, “Average gasoline prices declined in just six states over the last week, led by the Great Lakes region, where motorists in states like Michigan and Ohio saw prices fall sharply, while Indiana experienced even steeper relief after the state temporarily waived both its excise and use taxes on gasoline.”
GasBuddy’s data shows that while some states saw relief, most drivers are paying more at the pump.
Gas prices in neighboring states
By the numbers:
Gas prices in neighboring states and cities are also fluctuating. Wisconsin drivers are paying $4.37 per gallon, almost unchanged from last week. Sioux Falls saw a significant jump, with prices rising 17.3 cents to $4.13 per gallon. Minnesota’s statewide average is now $4.16, up 11.1 cents from last week.
Looking at the last five years, Twin Cities prices have varied: $2.90 per gallon in May 2025, $3.25 in 2024, $3.47 in 2023, $4.11 in 2022 and $2.76 in 2021. GasBuddy compiles these numbers from more than 11 million weekly price reports across over 150,000 gas stations nationwide.
How much more you’re paying at the pump
Dig deeper:
In the scenario that your vehicle has a 15-gallon tank that you fill up about every 10 days, here is a look at how much more it’s costing you in May versus April, and in 2026 versus last year.
Now: At an average price of $4.18/gallon at three times per month at $62.70 per trip, that comes out to $188.10
One month ago: An average price of $3.79/gallon at $56.85 per trip, that’s $170.55 per month.
One year ago: An average price of $2.90/gallon at $43.50 per trip, that’s $130.50 per month.
Drivers face more uncertainty ahead
What’s next:
De Haan said, “Those declines helped pull the national average lower by roughly eight cents over the last several days after oil prices eased mid-week on optimism that the U.S. and Iran could reach a deal. However, that optimism has since largely unraveled, with talks appearing to stall and President Trump signaling the latest proposal is unacceptable, helping push oil prices higher again in Sunday electronic trade.”
He warned that if oil prices continue to climb, the national average could approach $4.65 per gallon. Ongoing refinery issues are also affecting diesel production, especially in the Great Lakes region, where prices are nearing record highs.
Should geopolitical tensions escalate further, fuel prices could rise even more sharply in the weeks ahead, De Haan said. Many drivers are watching prices closely and hoping for relief, but experts say the outlook remains uncertain for now.
What we don’t know:
It’s unclear how long prices will continue to rise or when drivers might see relief at the pump. Future changes will depend on oil markets, refinery operations and global events.
The Source: This story uses information from GasBuddy.
Cori Roberts of St. Cloud, Minnesota, incurred more than $8,000 in medical bills after she was diagnosed at CentraCare with early-stage cervical cancer. She says the health system told her she made too much — about $41,000 a year — to qualify for financial aid.
Anthony Souffle/The Minnesota Star Tribune
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Anthony Souffle/The Minnesota Star Tribune
ST. CLOUD, Minn. — Cori Roberts was living in a rented basement four years ago when she was diagnosed with early-stage cervical cancer.
Recently divorced, the former stay-at-home mother had returned to work in her mid-40s, taking a human resources job that paid $41,000 a year. Then, despite having insurance, she was hit with more than $8,000 in medical bills.
“I had my car and a basket of clothes,” Roberts recalled. “Medical bills were not something I could have afforded.”
Roberts sought financial assistance from CentraCare, the St. Cloud-based health system that treated her. It’s a nonprofit charity that receives millions of dollars in federal, state, and local tax breaks. In exchange, it’s obliged to offer charity care to patients who can’t afford their medical bills.
But Roberts said CentraCare told her she made too much to qualify.
Roberts instead scrimped on groceries and Christmas gifts for her kids and paid off more than $6,000 over two years. Then CentraCare sued her last year because she hadn’t paid off all the debt.
“They’re supposed to be a nonprofit,” Roberts said. “It’s like, ‘Come on!’”
This story was a collaboration between KFF Health News and the Minnesota Star Tribune.
A sliver of financial aid
CentraCare earmarks just a tiny fraction of its budget for helping patients with medical bills they can’t pay, but it’s not alone in that, a Minnesota Star Tribune-KFF Health News investigation found.
Minnesota’s hospitals and health systems are among the least charitable in the country, the investigation found, providing less financial aid as a percentage of their operating budgets on average than hospitals in almost every other state.
The investigation drew on a detailed review of every hospital charity care program in the state, an analysis of five years of hospital financial data, and dozens of interviews with patients, hospital executives and state officials.
Nationally, hospitals spend an average of about 2.4% of their operating budgets on charity care, according to federal hospital data compiled by Hossein Zare, a researcher at Johns Hopkins University. Minnesota hospitals spend about a third of that, on average.
CentraCare’s flagship hospital in St. Cloud, Minnesota, earmarks only a fraction of its budget for helping patients who can’t pay their medical bills.
Anthony Souffle/The Minnesota Star Tribune
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Anthony Souffle/The Minnesota Star Tribune
Some spend considerably less. Of Minnesota’s 123 general hospitals, 62 devoted less than 0.5% of their operating budgets to charity care from 2020 through 2024, the Star Tribune-KFF Health News investigation found.
“The system is not working,” said Erin Hartung, director of legal services at Cancer Legal Care, a Minnesota nonprofit that helps patients with medical debt and other financial challenges. “And the burden is falling hardest on the people who are least able to bear it.”
CentraCare’s flagship St. Cloud Hospital spent less than 0.25% on charity care, according to the analysis. That works out to $25 in patient aid for every $10,000 spent on hospital operations.
A growing burden
Charity care will become even more vital in coming years as Americans lose health coverage or can’t afford rising copays and deductibles. The nation’s uninsured rate has been ticking up and is expected to increase further as budget cuts pushed by President Trump force states to pare back Medicaid and other safety net programs.
Nationwide, healthcare debt — much of it from hospitals — burdens an estimated 100 million people. And charity care, which was historically aimed at the uninsured, is now critical to many people with health insurance who can’t afford their bills.
Hospital officials say it’s unfair to expect them to solve this affordability problem when many of their facilities are financially strained. “No amount of charity care from hospitals will ever fully meet the needs of uninsured or underinsured Minnesotans. The need is simply too great,” Minnesota Hospital Association spokesperson Tim Nelson said in a statement.
But Minnesota Attorney General Keith Ellison said hospitals have a duty to increase charitable help for all needy patients in exchange for the tax breaks they receive.
“There is a benefit you get from being a nonprofit hospital in the state of Minnesota,” he said. “But do the people get the benefit?”
Several factors help explain why Minnesota hospitals provide so little financial aid. For one, job-based insurance and an expanded Medicaid program offer broad coverage. Hospitals in states with less government assistance and more uninsured people typically spend more on charity care.
Eligibility standards vary
But patients also face significant barriers accessing financial aid at many hospitals, including inconsistent eligibility standards and extensive applications, the Star Tribune-KFF Health News investigation found.
To qualify at many hospitals, patients must submit detailed personal information, including bank statements, retirement accounts, mortgage documents and estimates of other assets such as cars, homes or livestock.
Cori Roberts, who was sued by her healthcare provider after she was unable to make full payments for her treatment, thumbs through copies of her payment records at her home in St. Cloud, Minnesota.
Anthony Souffle/The Minnesota Star Tribune
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Anthony Souffle/The Minnesota Star Tribune
And because Minnesota has not standardized the criteria for charity care, patients might receive aid at one hospital but not another. The investigation found that some hospitals give free care to patients with an annual household income of $47,000, while others cap it at about $15,000.
There are similar variations in charity care standards at hospitals nationwide, KFF Health News and other researchers have found. A recent analysis by the nonprofit Lown Institute found that one hospital in Boston set the limit for free care at less than half the level as another hospital just a few block away.
In Minnesota, had Roberts driven 30 miles east or 35 miles north, she would have found medical providers with more generous financial aid policies than CentraCare. But she didn’t know to look.
Roberts, now 49, has remarried and lives in a split-level home in St. Cloud decorated with inspirational plaques such as “Faith, Family, Friends.” CentraCare recently dropped the lawsuit against her, but only after she took out a loan against her retirement plan to pay off the medical debt. “It just feels very unfair,” she said.
CentraCare spokesperson Karna Fronden said medical privacy laws prevented her from discussing Roberts’ case. She also declined interview requests about the health system’s charity care spending.
In a statement, Fronden said CentraCare provides assistance in addition to charity care, such as helping enroll patients in insurance. “This helps provide broader, longer-term protection for patients,” she said.
Other hospital leaders said they serve their communities in ways besides forgiving medical bills, including training doctors and nurses and preserving money-losing services such as obstetrics and mental health care.
Hospitals in rural communities specifically also play an important role as employers, said Robert Pastor, chief executive of Rainy Lake Medical Center in International Falls, Minn.
“We are the second- or third-largest employer in town, running on razor-thin margins while navigating escalating labor and supply costs and routine underpayment by public programs,” Pastor said. “Meanwhile, many health insurers post billions in profits.”
“Rural hospitals like ours are often portrayed as though we are sitting on piles of cash and simply choosing not to spend it on charity care. That is far from the reality,” he said.
Hospital executives say they have a responsibility to ensure that limited resources for charity care go to patients who need them, said Travis Olsen, chief executive of Hendricks Community Hospital, near the South Dakota border.
Burdensome application process
To determine eligibility, some Minnesota hospitals consider only income, the Star Tribune-KFF Health News investigation found. But most demand information about patients’ bank accounts as well. More than two-thirds require even more information, including the value of retirement accounts, life insurance policies, property and vehicles.
In addition to copies of tax returns, W-2 forms, pay stubs and bank statements, Hendricks asks aid applicants 53 questions about their finances. These include questions about the make, model and value of vehicles; the current market value of farm equipment, livestock and land; and the purchase price and square footage of homes.
Other hospital applications ask patients to detail their monthly spending on food, utilities and other medical bills.
All these questions discourage patients from seeking assistance, said Jared Walker, founder of Dollar For, a nonprofit that helps people apply for charity care.
“The drop-off rates are much higher the more questions you ask and the more documentation you have to provide,” he said.
By contrast, most hospitals make it very easy for patients to click a button on the hospital website to pay their bills, Walker said. “Hospitals have optimized to get payment,” he said. “If you want to get on a payment plan, if you want to get on a credit card, it’s so easy.”
Back in St. Cloud, Roberts said that when she drives past CentraCare’s $200 million expansion at its Plaza campus in St. Cloud, she wonders why Minnesota hospitals don’t live up to higher standards.
“They have all the money,” she said. “But they can’t grant a good person some grace?”
This story was produced by KFF Health News and the Minnesota Star Tribune.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF.
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