Many hospital affiliations do lead to expanded services and even capital improvements. But relinquishing local control comes at a cost, and the dustup in Sandstone shows the difficulties that can arise when working out the details of these agreements. It's a pressing issue right now because increasingly, independent hospitals in rural Minnesota are joining bigger systems—Sanford Health, Essentia Health, Mayo Clinic Health System and others. According to the Minnesota Hospital Association, 16 hospitals have joined systems since 2005. Of 148 hospitals in the state, only 42 remain independent.