The Commercial Appeal - - View­point -

About 60 miles south­east of Brownsville, Mc­Nairy Re­gional Hos­pi­tal in Selmer closed last May. Ves­tiges of its care a gur­ney, an IV pole, a crash cart - are strewn in the hall­way near what was the emergency room. And within an hour to the north, Hum­boldt Gen­eral Hos­pi­tal and Gib­son Gen­eral Hos­pi­tal also closed. Some out­pa­tient ser­vices have come back at both — but no hos­pi­tal beds.

Brownsville’s hos­pi­tal en­joyed a spe­cial legacy. When the orig­i­nal opened in 1935, a gift from a man who made his for­tune in Nashville to his home town, Hay­wood County be­came one of the first poor coun­ties in Ten­nessee with its own hos­pi­tal. To­day, the county re­mains so tied to its agri­cul­ture that family pic­tures are still taken in cot­ton fields. Its poverty also per­sists. More than 1 in 5 of the 18,000 peo­ple here live be­low the poverty line, with fa­mil­iar con­se­quences. Hay­wood ranks 90th out of Ten­nessee’s 95 coun­ties for health, with obe­sity and di­a­betes es­pe­cially com­mon.

To­gether with Franklin Smith, Hay­wood County’s mayor for most of the past three decades, Rawls is strug­gling to bring at least an emergency room back to Brownsville. In his of­fice in the small city hall ad­ja­cent to the fire de­part­ment, he has a let­ter from a woman whose 8-year-old nephew was play­ing in the family drive­way on a late win­ter morn­ing last year when their Dodge sedan rolled back­ward, pin­ning him un­der a tire.

With­out a hos­pi­tal in town, she ex­plained, “need­less to say he did not make it.”

It is not rare for peo­ple to tell the mayor such sto­ries, but this one came in writ­ing, and he keeps it on his desk within eye­sight. “What do you do about this?” Rawls asked. “It’s a heavy bur­den.”

Fate­ful call

On that spring day in 2014, Smith got a call from Hay­wood Park’s ad­min­is­tra­tor hours be­fore the of­fi­cial an­nounce­ment. The hos­pi­tal’s par­ent com­pany, Com­mu­nity Health Sys­tems of Franklin, Tenn., had filed pa­per­work with the state to shut it down in 90 days.

The news was stun­ning and abrupt but not a to­tal sur­prise. For years, Hay­wood Park had been hem­or­rhag­ing pa­tients and money. It had been years since an ob­ste­tri­cian was on staff, so ba­bies were no longer be­ing de­liv­ered. And as treat­ment for heart attacks, strokes and other life-threat­en­ing ail­ments had be­come more so­phis­ti­cated, the hos­pi­tal had be­come ac­cus­tomed to sta­bi­liz­ing pa­tients, then send­ing them by ambulance for more spe­cial­ized care at Jack­son-Madi­son County Gen­eral Hos­pi­tal, nearly 30 miles away. Even­tu­ally, more and more pa­tients de­cided to skip the first stop and head di­rectly to Jack­son.

The year be­fore it closed, 62-bed Hay­wood Park ad­mit­ted 245 pa­tients — down from 917 three years be­fore, ac­cord­ing to data filed with the state. Dwin­dling pop­u­lar­ity was not the only rea­son for the drop.

Fed­eral of­fi­cials who over­see Medi­care had started send­ing au­di­tors to make sure all hos­pi­tal ad­mis­sions were war­ranted, and hos­pi­tals did not want to risk ad­mit­ting pa­tients for whom they might not get paid. Then a new rule prompted hos­pi­tals to place more older pa­tients on “ob­ser­va­tion sta­tus” for brief stays — put in beds but not of­fi­cially ad­mit­ted, which meant lower gov­ern­ment re­im­burse­ment.

One other fi­nan­cial blow: The Af­ford­able Care Act cur­tailed hos­pi­tals’ Medi­care pay­ments on the the­ory that more pa­tients would be in­sured. Even if the law dis­ap­pears, predictions vary on whether Repub­li­can health-care pro­pos­als be­ing con­tem­plated in Washington would help or hurt.

The Af­ford­able Care Act has not gained much ground here. In 2016, just 664 Hay­wood County res­i­dents bought health plans through its mar­ket­place for peo­ple with­out cov­er­age through a job. By one es­ti­mate, 2,200 res­i­dents would qual­ify for Med­i­caid ben­e­fits if Ten­nessee ex­panded the pro­gram un­der the law; the Repub­li­can gover­nor tried but was re­buffed by the more con­ser­va­tive leg­is­la­ture.

Near the end, more than a quar­ter of Hay­wood Park’s charges were for “self­pay” pa­tients who lacked health in­sur­ance. Hay­wood Park losses grew from $4.2 mil­lion in 2010 to $6.6 mil­lion in 2013, the data show.

“They tried ev­ery­thing to keep it open,” said Clarey Dowl­ing, who ar­rived in Brownsville in 1980 as a fledg­ing family prac­ti­tioner and never left. Over the years, he was Hay­wood Park’s med­i­cal di­rec­tor and a mem­ber of its board, and the staff knew it was lunchtime when he walked across the park­ing lot from his of­fice to the hos­pi­tal each week­day to check on pa­tients.

When the hos­pi­tal closed, Com­mu­nity Health Sys­tems an­nounced it would keep an ur­gent care cen­ter there. Dowl­ing added Wed­nes­day af­ter­noon and Saturday morn­ing shifts to his work sched­ule to help out. Yet five months later, the com­pany an­nounced that the ur­gent care was not draw­ing enough pa­tients. By the end of Jan­uary 2015, it was gone, too.

Tod­dler saved

On the morn­ing of the hos­pi­tal’s last day, Natalie Pin­ner drove to its park­ing lot, turned off her car and prayed.

Ex­actly a year ear­lier, she had been with her par­ents, who live next door along a coun­try road that bears the family name. Her father and hus­band were grilling. She was in the kitchen with her mother, a sis­ter and her son, Clay­ton. It was 5 p.m., and the 15-month-old was hun­gry, so she gave him some peanut but­ter on a cracker. He touched it to his lips, not even tak­ing a bite, and red welts im­me­di­ately popped out on his face. He started gasp­ing for air.

Her sis­ter, a nurse, knew they needed to get the lit­tle boy to the hos­pi­tal, pronto. They piled in the car and, blar­ing the horn and flash­ing the lights as if it were an ambulance, raced the eight miles to Hay­wood Park in less than six min­utes. Clay­ton’s eyes were rolled back as Pin­ner ran in with his limp body. The ER doc­tor said his air­way was closed and his oxy­gen level so low that he might not sur­vive. But shots of ep­i­neph­rine gave the staff enough time to sum­mon a med­i­cal he­li­copter that flies the most des­per­ately ill or in­jured pa­tients to Mem­phis, about 60 miles away.

Pin­ner, a part-time teacher, be­lieves her son would have died if they’d had to drive to Jack­son. When she heard the news about Hay­wood Park, she sent let­ters that begged the staff to keep it open. And when that failed, she marked the an­niver­sary of Clay­ton’s emergency by pray­ing for the safety of her town.

Some ef­fects of the hos­pi­tal’s ab­sence are in­con­ve­niences that nonethe­less mat­ter. Crestview nurs­ing home in Brownsville of­ten has to scram­ble when frail res­i­dents must be taken to the dial­y­sis cen­ter down the street. The am­bu­lances are usu­ally too busy.

Other events are crises. Phyl­lis Cozart worked at Hay­wood Park for 21 years and was its hu­man re­sources man­ager when it closed. Last Au­gust, on a hu­mid, 100-de­gree morn­ing, she and her hus­band were work­ing in their gar­den when Charles col­lapsed. If the hos­pi­tal were still there, she thought, she could have forced him to go to the emergency room. But he re­fused to go to Jack­son and miss an af­ter­noon of golf. By lunch, he seemed to be OK. He headed out.

It would be his last golf game. At 8:30 p.m., he was sit­ting in his fa­vorite re­cliner when his wife looked over and no­ticed that his smile was crooked. Im­me­di­ately fear­ing a stroke, she asked her hus­band to raise his arms, right and then left. His left arm would not move.

By the time the ambulance an­swered the 911 call and got Charles Cozart to Jack­son Gen­eral, his carotid artery was 100 per­cent blocked. He was there for a week, then at two fa­cil­i­ties for re­ha­bil­i­ta­tion, be­fore fi­nally com­ing home in De­cem­ber.

“My left arm isn’t do­ing any­thing,” Cozart, 73, said late last month. “I can walk a lit­tle, but it’s kind of slow.”

He some­times vis­its the golf course, rid­ing in his cart to watch his friends play.

A place in his­tory

For such a small, ob­scure place, Hay­wood County has a rich her­itage. It stands out in civil rights his­tory as the place where the first NAACP mem­ber was found mur­dered. Dur­ing the 1960s, it was the site of “tent cities” erected by black ten­ant farm­ers evicted from their land by white own­ers for at­tempt­ing to vote.

In cul­tural his­tory, the area is the child­hood home of singer Tina Turner, au­thor Alex Ha­ley and blues pi­o­neers in­clud­ing “Sleepy” John Estes.

It was that same spirit — of man­ag­ing to make some­thing from noth­ing — that fu­eled the de­ter­mi­na­tion of Brownsville’s lead­ers to re­place the shut­tered hos­pi­tal or at least re­claim an emergency room. Smith, the county mayor, and Rawls, his city coun­ter­part, met with sev­eral health-care sys­tems in Mem­phis. They pointed out that Hay­wood County is the site of Ten­nessee’s largest “meg­a­site,” a 4,100-acre par­cel where the state has been try­ing to re­cruit an auto assem­bly plant or other ma­jor in­dus­try. If the site is filled, they said, the pop­u­la­tion will swell and there will be plenty of pa­tients. So far, they have been re­jected. Last fall, state of­fi­cials be­gan talk­ing of spread­ing $1 mil­lion in left­over dis­as­ter re­lief aid among four coun­ties that had lost their hos­pi­tals. Three were in west Ten­nessee: Hay­wood and the coun­ties just to the south. But last month, as Hay­wood was mak­ing plans to buy land for an emergency room, the state de­cided to send the money in­stead to help Gatlin­burg, at the edge of the Great Smoky Moun­tains, re­cover from deadly wild­fires.

“Ev­ery time we get two steps for­ward,” Rawls said, “we get knocked back.”

A year af­ter Hay­wood Park closed, Rawls started a pro­gram he dubbed “Healthy Moves.” It urges Wed­nes­day night Bi­ble study groups to do five laps around their churches, en­cour­ages baked chicken — not fried — at fu­ner­als and pro­motes morn­ing walks around the high school track with a lo­cal ra­dio DJ. If Brownsville can­not de­pend on a hos­pi­tal, the mayor fig­ures, its peo­ple have to be­come health­ier so they need less care.

And as it be­came clear that no big­ger hos­pi­tal sys­tem was in­ter­ested in the area, a county task force went to Nashville to meet with a lawyer spe­cial­iz­ing in health care. The only so­lu­tion, the lawyer ad­vised, was to ex­pand the ambulance ser­vice to help get pa­tients out of town.

De­spite their strapped bud­get, the county com­mis­sion­ers added seven paramedics and ad­vanced emergency med­i­cal tech­ni­cians. Hay­wood went from two am­bu­lances avail­able at any given mo­ment to three.

The typ­i­cal call, 30 min­utes when the hos­pi­tal was open, is now 2 1/2 hours. Even with the ex­tra ambulance, there are times when all are on runs out­side the county. A woman who fell and broke a hip not long ago waited in her drive­way for an hour.

David Smith, the ambulance au­thor­ity’s di­rec­tor, had ex­pected such com­pli­ca­tions. What he had not an­tic­i­pated was how many peo­ple would call an ambulance, be treated in their drive­ways and then refuse to be taken to Jack­son or Mem­phis. The ride is “a one-way ticket,” as one para­medic put it. That’s a de­ter­rent; pa­tients have to find their own way home.

But un­less a pa­tient is trans­ported, nei­ther Medi­care nor Med­i­caid will pay for the ambulance run. The ambulance au­thor­ity sends out bills, but in such a poor county, “there is no way to turn them over to col­lec­tions,” Smith said. Some peo­ple bring in $5 or $10 when they can. In 2016, the ambulance ser­vice wrote off more than $1 mil­lion in un­paid charges. “It has broke this county,” he said. With no hos­pi­tal in Hay­wood and 535 square miles to cover, the crews have been step­ping up their pro­to­cols. They can in­sert chest tubes, start in­tra­venous an­tibi­otics and in­tu­bate pa­tients to help keep air­ways open.

This move to­ward more ad­vanced care in the back of am­bu­lances is a rea­son the Ten­nessee Ambulance Ser­vice As­so­ci­a­tion named Hay­wood County’s emergency ser­vice the best in the state in Jan­uary. The im­pos­ing cut-glass tro­phy was bit­ter­sweet.

It ar­rived as the county mayor was los­ing a bat­tle with the county com­mis­sion­ers to raise taxes for a third straight year — to prop up the bud­get that the 911 calls have been eat­ing away.

So the county is cut­ting the ambulance ser­vice staff. By July, the num­ber of am­bu­lances at the ready will go back from three to two.

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