WASHINGTON – A patient who showed up at the hospital in the small farming town of Anson a few weeks ago with pneumonia or a bad infection could count on a bed for a couple days to allow them to recover.
But late last month Anson General Hospital, about 200 miles west of Dallas, converted to what is in effect an emergency only facility , designed to either treat patients and send them on their way or, in more serious cases, stabilize them and send them 30 miles down the road to Abilene. If there’s no space there, patients are forced to travel more than 200 miles to Lubbock.
In exchange, the hospital will survive. It will receive more than $3 million a year in federal funds and increased Medicare payments, making it one of the first in the nation to take part in a controversial new federal experiment to try to stanch the rise in rural hospital closures maintain some semblance of health care in those communities.
Anna Doan, who heads the hospital’s staff of 16 nurses, said the hospital’s patients, a large portion of whom are in their 70s or 80s, were struggling to understand the new arrangement, but it was a necessary decision.
“When you’re elderly, 30 miles is a long way to go,” she said. “But it’s essential we keep our hospital open to save lives.”
Nearly 150 rural hospitals have closed nationwide since 2010, part of a cycle of a shrinking rural population, rising supply costs and increased competition for medical staff – problems that only exacerbated during the COVID-19 pandemic.
No state has seen as many closures as Texas, which is at 26 and counting over the past 12 years , according to the Texas Organization of Rural and Community Hospitals.
The rural emergency hospital program, through which hospitals with no more than 50 in-patient beds can apply, is designed to act as a lifeline for rural hospitals, allowing them to “keep their doors open, even if they cannot afford a fully operational inpatient unit,” Sen. Chuck Grassley, R-Iowa, who led the passage of the program through Congress, said in 2020.
But questions remain as to how it will work, as ambulance services and city hospitals that are already overstretched are asked to handle the increased volume of patients coming in from the countryside. Some advocates for public health care worry the program will only increase the gap in medical care between cities and countryside.
A 2021 study by scientists at the University of Texas found Americans living in rural areas typically lived two years less than their urban counterparts.
“It’s like putting lipstick on a pig,” said Kristie Loescher, a health care management professor at the University of Texas McCombs School of Business. “We have this rural health care crisis, and instead of finding ways to fund more health care services we’re just going to leave you with urgent care. And if you need to see an (obstetrician) or get administered antibiotics for a couple days, you’re all going to need to go to the city.”
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National trend
From Washington state to Florida, some 68 rural hospitals around the country are predicted to take the money and convert to emergency-only status, according to a report by researchers at the University of North Carolina in 2021. The program is expected to see the greatest interest in states that have opted not to expand Medicaid as allowed under the 2010 Affordable Care Act – often referred to as Obamacare - foregoing billions of dollars in federal health care funding and leaving their hospitals with higher volumes of uninsured patients.
The study predicts that almost half the hospitals that will apply for the emergency program are in Kansas, Texas, Nebraska and Oklahoma, among the ten states in the country not to have expanded Medicaid over Republican objection to the federal healthcare law.
So far, at least three hospitals in Texas have converted to emergency-only status, Anson General Hospital, St. Luke's Health Memorial Hospital in San Augustine and St. Mark’s Medical Center in La Grange.
They are the first hospitals in the country to do so, after the Texas Legislature passed emergency legislation in January that allowed hospitals to close their inpatient beds and claim the funding. And at least two more Texas hospitals are in the process of applying, Crosbyton Clinic Hospital outside Lubbock and Falls Community Hospital in Marlin, said John Henderson, president of the Texas Organization of Rural and Community Hospitals.
“It’s not a decision people are excited about or proud (of), but if it gives them a path to stay open,” he said.
At Anson General, the decision to covert to emergency-only status was a long time coming.
The hospital struggled for years under the financial pressures of serving a shrinking and increasingly elderly population – the number of people living in Anson and surrounding Jones County has declined 5 percent since 2000 to less than 20,000, according to the Census Bureau.
Its outlook worsened during the COVID-19 pandemic as costs rose and many elderly patients avoided the hospital out of fear of getting sick, causing admissions to drop off, said Ted Andrews, the hospital's president. And the $270,000 a month Anson will now receive from the Center for Medicare and Medicaid Services will stabilize its finances and allow it to stay open, even if it means closing inpatient beds and a program that allowed seniors to recuperate from strokes and accidents in the hospital and avoid admission to a nursing home.
“We have lost a number of rural hospitals in Texas, and I can assure you we would have been on that list in the next few months if we didn’t do what we did,” Andrews said. “This was the only option we had.”
How the program will work in Texas, where some towns are many hours away from the closest urban hospital, remains to be seen.
Rural patients were already going to cities for most surgery, not just cancer and heart conditions but even relatively simply procedures like the removal of tonsils or an appendix. But now rural hospitals will need to find ambulance services with capacity to take a much larger volume of patients to cities.
And within the rural emergency hospital program, there is no funding for transportation or provision about what to do with patients if the hospital can’t find them a bed elsewhere – under the rules they can only keep a patient 24 hours - said Brock Slabach, chief operating officer of the nonprofit National Rural Health Association.
“For some communities with resources nearby who can transfer patients methodically this might work very well,” he said. “But when we’re talking about areas where patients are having to travel longer distances to transferring facilities and there’s inadequate EMS services. I don’t think we know yet how this is going to work. As I look at it, this program is just one answer. It’s not a holistic approach.”
