Hospital AI and Robotics Adoption, Access Inequality, and County Mortality: A National Study Across 3,143 U.S. Counties

Hospital artificial intelligence (AI) and robotics are spreading unevenly across the United States, yet national evidence on how these technologies are associated with hospital performance and population health remains limited. This observational study linked the 2024 American Hospital Association Annual Survey, capturing calendar-year 2023 adoption across 6,166 hospitals, to CMS, CDC, and County Health Rankings outcomes for 3,143 U.S. counties. Conditioning on 2019 baseline performance, hospitals using AI for staff scheduling had roughly 4% higher adherence to the SEP-1 sepsis bundle, and hospitals using AI for routine-task automation had approximately 5.1% lower 30-day pneumonia mortality. At the county level, the clearest timing-aligned outcome was contemporaneous hospital-setting mortality (2023): any access to workflow AI hospitals was associated with 25.5 fewer hospital deaths per 100,000 residents under cross-fitted doubly robust estimation (9.9% lower; non-cross-fitted estimate: 16.9 fewer per 100,000). A historical county benchmark (County Health Rankings premature mortality, 2020-2022) showed a concordant pattern, with the cross-fitted estimate corresponding to 975.8 fewer years of potential life lost per 100,000 before age 75 (p < 0.001), though this outcome predates the 2023 adoption measurement and should be interpreted as a lagged benchmark rather than a contemporaneous association. Workflow AI access was also associated with about 206 fewer preventable hospital stays per 100,000 residents (7.2% lower). Robotics showed narrower and more mixed associations. Yet access reflected a substantial digital divide: only 65.8% of Americans lived within 30 minutes of AI-enabled care, leaving about 114.6 million people outside that catchment (AI access Gini = 0.740), and despite a 56% increase in AI-enabled hospitals between 2022 and 2024, distributional inequality persisted. Overall, the evidence is consistent with adjusted associations between workflow AI access and better rescue outcomes where adoption occurs. Significance StatementIn this study of 6,166 hospitals and 3,143 U.S. counties, hospitals using AI for staff scheduling had roughly 4% higher adherence to the recommended sepsis care bundle, and cross-fitted doubly robust estimation associated workflow AI with 25.5 fewer contemporaneous hospital deaths per 100,000 residents (9.9% lower than comparable unexposed counties; non-cross-fitted baseline: 16.9 fewer per 100,000). A concordant historical benchmark (premature mortality, 2020-2022) and a 7.2% reduction in preventable hospital stays reinforce the pattern. Yet about 114.6 million Americans live beyond a 30-minute drive of any hospital using AI. Only 65.8% of Americans lived within 30 minutes of AI-enabled care (AI access Gini = 0.740), and despite a 56% increase in AI-enabled hospitals between 2022 and 2024, distributional inequality did not improve. The contribution is not a blanket claim that AI saves lives; it is a national estimate of health disparities created when hospital technologies diffuse unevenly, suggesting that extending AI-enabled care to underserved areas may represent a high-return intervention.