TRENTON (New Jersey) - HOSPITAL across the US are being squeezed by tight credit, higher borrowing costs, investment losses and a jump in patients - many recently unemployed or otherwise underinsured - not paying their bills.

All that has begun to trigger more hospital closings - from impoverished Newark, New Jersey, to wealthy Beverly Hills, California - as well as layoffs, other cost-cutting and scrapping or delaying building projects.

And industry consultants predict more closings and mergers are on the way.

'They'll get swallowed up by somebody else, if they need to exist, and if they don't, they'll just close,' said Mr Tuck Crocker, vice-president of the health care practice at management consultant BearingPoint.

Most endangered are rural hospitals and urban ones in areas with excess hospital beds and a lot of poor, uninsured patients.

Hospitals, which employ 5 million people, are reporting that donations and investment returns are down, patient visits are flat and profitable diagnostic procedures and elective surgeries are declining as people with inadequate insurance delay care.

But those patients are turning up later at ERs, seriously ill, making it tough for hospitals to lay off nurses and doctors.

All those problems are aggravating long-standing stresses: stingy reimbursements from commercial insurers, even-lower payments that generally don't cover costs for Medicare and Medicaid patients, and high labor and technology costs.

Hospital executives and consultants say the growing number of people with high-deductible health plans is boosting unpaid patient bills.

Many worry health reform efforts by the Obama administration could bring cuts in reimbursements from the federal government, and many cash-strapped states already have begun cutting payments for poor people.

In the past few months, patients and insurers have been paying hospital bills more slowly. As a result, some think hospitals will start demanding upfront payments for elective procedures.

In November, Moody's Investors Service changed its 12- to 18-month outlook from 'stable' to 'negative' for nonprofit and for-profit hospitals, citing 'prospects of a protracted recession', bad debt and the credit crunch.

'Looking forward, the cost of borrowing will likely be higher - and may be nonexistent for lower-rated hospitals,' Moody's noted, a problem because hospitals borrow for everything from expansions and equipment to payroll and supplies.

Since October, there's been 'a dramatic slowdown' in plans for new wings and building upgrades, with many delayed indefinitely, said Paul Keckley of the Deloitte Center for Health Solutions.

'It probably means we won't have as many new things in the hospital,' he predicted.

Mr Tim Goldfarb, CEO of Shands Healthcare, said his system, Florida's second-largest provider of charity care, this year has seen bad debt jump 20 per cent from patients with no insurance.

'We write them off,' Mr Goldfarb said. 'It's a burden that we cannot carry any longer.'

Florida started cutting Medicaid reimbursements two years ago, when its economy started to slow, Mr Goldfarb said. He fears another huge cut next year.

Around the country, while some hospitals still are doing well, closings and bankruptcies seem to be picking up.

In New Jersey, where 47 per cent of hospitals posted losses in 2007, five of the 79 acute-care hospitals closed this year, and a sixth may close soon. In Hawaii, nearly every hospital is in trouble, with two filing for bankruptcy and one nearly closing recently.

All over, hospitals are cutting costs by outsourcing services like housekeeping and security and trimming staff through layoffs, hiring freezes and attrition.

Most are trying not to touch patient care jobs - nurses, pharmacists, therapists and X-ray technicians - as those already have staff shortages.

'The last thing we can do is skinny down our staffing right where we need it the most,' said Mr Mike Killian, marketing vice-president for the three Beaumont Hospitals in Michigan state.

There, auto industry job losses and other factors now equal fewer patients with commercial insurance. The system expects a $22 million loss, its first in at least 40 years, Mr Killian said.

Mr Rich Umbdenstock, chief executive of the American Hospital Association, said some of the hardest-hit hospitals began reducing staffing and services as early as last spring and more will follow.

He expects some to eliminate services - money-losers such as behavioral health treatment, or those with high operating costs such as burn units - rather than weaken their entire operation. -- AP