Ru­ral hos­pi­tals un­sure on GOP health care bill

Austin American-Statesman - - BUSINESS - By Russ Bynum, Re­becca San­tana and Kath­leen Foody

Talmadge CLAX­TON, GA. — Yar­brough had just sat down at his desk and opened a box of pecans when he let out a gasp that could have been his last breath. He’d gone into car­diac ar­rest in his of­fice, a co-worker called 911, and an am­bu­lance drove him 2 miles to the small hospi­tal that serves this ru­ral com­mu­nity in south­east Ge­or­gia.

“I would have never lasted to get to Sa­van­nah or States­boro,” Yar­brough said of the big­gest cities near Clax­ton — each 30 to 60 miles away. “I firmly be­lieve if that hospi­tal wasn’t here, I wouldn’t be here.”

But like Yar­brough, the 10-bed Evans Memo­rial Hospi­tal has fought to sur­vive. That story is re­flected na­tion­wide — ru­ral hos­pi­tals have long strug­gled, with pa­tients who are older, suf­fer from chronic ill­nesses, and face few in­sur­ance op­tions, if they’re in­sured at all.

Most ru­ral hos­pi­tals have a higher-than-nor­mal per­cent­age of Med­i­caid pa­tients. Ex­pected cuts to the fed­eral pro­gram for low-income residents will af­fect fa­cil­i­ties ev­ery­where, but ex­perts and ad­min­is­tra­tors are par­tic­u­larly wor­ried about ru­ral ar­eas. Still more ru­ral pa­tients are on Medi­care, for those 65 and older, but both pro­grams’ re­im­burse­ments are lower than the cost of care.

Now, as Repub­li­cans in Washington put for­ward long-an­tic­i­pated plans to get rid of for­mer Pres­i­dent Barack Obama’s Af­ford­able Care Act, ru­ral hos­pi­tals and com­mu­ni­ties are watch­ing the de­bate closely. But if they didn’t fare too well un­der the ACA, many ques­tion whether they’d be bet­ter off un­der the plan backed by Pres­i­dent Don­ald Trump.

At Evans Memo­rial, many blue-col­lar work­ers are un­able to af­ford in­sur­ance but are too well-off for Med­i­caid, said chief fi­nan­cial of­fi­cer John Wig­gins. Such unin­sured pa­tients are per­haps the No. 1 prob­lem for ru­ral hos­pi­tals: Evans Memo­rial has been sad­dled with $3 mil­lion or more in un­paid med­i­cal bills in re­cent years.

But the hospi­tal can’t and won’t turn away the unin­sured — fed­eral law pro­hibits it in emer­gen­cies. Re­cently, Dr. Kyle Parks per­formed an ur­gent gall­blad­der op­er­a­tion on an unin­sured woman. “It is what we’ve al­ways done — we take care of peo­ple, payer or no payer,” Parks said. “But we’re fight­ing a struggle to keep our lit­tle hospi­tal open.”

Evans Memo­rial, which opened in 1968, has man­aged to keep op­er­at­ing by seek­ing new rev­enue — for ex­am­ple, a new wing for de­men­tia pa­tients sched­uled to open soon. But the hospi­tal was in the red for four years be­fore find­ing it­self $50,000 in the black this year.

“We do not have fear of the doors clos­ing, but we re­mem­ber those days and we never get com­fort­able,” said Nikki NeSmith, the CEO who dou­bles as chief nurs­ing of­fi­cer, in part to cut costs. “I don’t think we’ll be in that com­fort­able po­si­tion anytime soon.”

Mean­time, other ru­ral hos­pi­tals have shut­tered — 80 since 2010, mostly in the South and Mid­west, ac­cord­ing to the North Carolina Ru­ral Health Re­search Pro­gram. A wave of clo­sures also hit in the 1980s and early ’90s with changes in Medi­care re­im­burse­ment, though Congress even­tu­ally in­creased that.

At Evans Memo­rial, about half the pa­tients are cov­ered by Medi­care; 10 per­cent are on Med­i­caid. An un­even, state-by-state ex­pan­sion of Med­i­caid has been a prob­lem there and else­where. Ge­or­gia’s among 19 states that didn’t ex­pand the pro­gram un­der the ACA. It’s never been a pop­u­lar pro­posal in ru­ral Ge­or­gia, where Trump saw his strong­est sup­port in the state. But Evans CFO Wig­gins said many of his unin­sured pa­tients would have qual­i­fied un­der an ex­pan­sion.

The ACA was in­tended to slash the num­ber of unin­sured pa­tients seek­ing care they could never af­ford at hos­pi­tals. It suc­ceeded in ru­ral ar­eas, where over­all the rate of unin­sured peo­ple fell by 8 per­cent since full im­ple­men­ta­tion of the law in 2014, said Brock Slabach, of the Na­tional Ru­ral Health As­so­ci­a­tion. But it fell more in ur­ban ar­eas, in part be­cause of the dearth of choices in the ex­changes set up un­der the ACA. Thirty to 40 per­cent of ru­ral com­mu­ni­ties have only one com­pany from which to pick.

Be­yond the in­sur­ance, Medi­care and Med­i­caid prob­lems, ru­ral hos­pi­tals face death by a thou­sand pa­per cuts: a na­tion­wide trend to­ward out­pa­tient care, trou­ble re­cruit­ing staff, in­dus­try con­sol­i­da­tion, low-pa­tient vol­ume, and a pref­er­ence by pri­vate-in­sur­ance clients for newer hos­pi­tals.

When ru­ral hos­pi­tals are forced to close, the ef­fects re­ver­ber­ate, a 2016 Kaiser Fam­ily Foun­da­tion study shows. Such hos­pi­tals are of­ten the com­mu­nity’s largest em­ployer, lead­ing to job losses. Doc­tors and oth­ers leave the area. Clo­sures also make it hard to at­tract out­side em­ploy­ers or in­vestors who want quick ac­cess to emer­gency rooms.


Evans Memo­rial Hospi­tal has long fought to sur­vive in Clax­ton, Ga. Many blue-col­lar work­ers who use the hospi­tal can’t af­ford in­sur­ance but are too well-off for Med­i­caid, a hospi­tal of­fi­cial said.

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