Like so many small-town hospitals, this one in Kansas is struggling to stay alive
"I had to figure out how to cut a
Seemingly everything conspires against keeping the
People in small towns are older and sicker than those in cities and suburbs.
They're more likely than their counterparts in metro areas to rely on
They also are more likely to have no insurance coverage at all.
It doesn't help that
Voters here have repeatedly voted to tax themselves to save the hospital, most recently adding a 1 percent sales tax. Still, the two-story facility nearly missed payroll early this year, saw nearly 10 percent of its staff sacked and limps by on 12-year-old computers.
Dean, who took the helm less than two months ago, has an uneasy hope about keeping the operation afloat by putting a budget-cutter's eye to everything that goes on.
But it wouldn't take much -- some unexpected expense, an unanticipated loss of revenue -- and
If
"We're in true survival mode, constantly," Dean said. "If we're going to go down, we're going to go down swinging."
Yet he sees potential haymakers from the vast, and vastly complicated, American medical system that subsidizes the particular costs of rural health care even as market forces make the finances of medical services in remote places increasingly untenable.
The latest, evolving version of the American Health Care Act, or "Trumpcare," that would repeal and replace the Affordable Care Act, or "Obamacare," could easily disrupt the already fragile equation that holds the
If people with pre-existing conditions were put in high-risk insurance pools, for instance, some could expect to see unaffordable premiums. If they, in turn, started showing up at the
If existing Affordable Care Act subsidies for insurance went away, leaving some poor and middle-income patients unable to afford insurance, that would be another tough blow.
"If they pull that subsidy," Dean said, "the impact is obvious."
Remotely troubled
In April,
A study released this year by iVantage Health Analytics counted at least 80 rural hospital closings this decade, most of them grouped across the country's lightly populated midsection. Roughly two in five small hospitals, the study said, lose money.
The same report noted that states that didn't expand their
Neither
Other changes in the industry push health care dollars to large city hospitals. Small facilities, like the
At the same time, private insurance policies carry ever higher deductibles. That means patients feel the direct cost, and choose urban hospitals that often charge less.
"Rural patients with high-deductible plans are becoming more price sensitive and showing a willingness to travel greater distances to reduce their healthcare costs," the iVantage report said.
The Rural Relevance Study by Anonymous h17rsKuLc on
When the federal government imposed cuts in 2013 on
Part of Obamacare also slashed federal payments to hospitals to compensate them for unpaid patient bills. The Affordable Care Act aimed to balance that out by putting more people on
In states such as
"These things start to add up," said
When the century-old
In its latest "Hospital Strength Index," iVantage estimated that 673 hospitals across the country stood "vulnerable or at risk" for closure. Those hospitals treat patients 11.7 million times a year and employ 99,000 people.
In
Part of the problem comes from an exodus of patients. The emptying out of rural America has moved steadily for more than a century. Its hospitals are emptying at a faster clip.
The
Increasingly, that business goes to
Imagine you're a 60-year-old guy with chest pains, said
"The expectation of the medical consumer has changed," McCue said. "Everybody wants to see a specialist."
That drives patients north on
"It's tricky. There's politics," he said. "It could very easily be perceived as threatening" the local doctors' practice.
"You don't take care of heart attacks in small hospitals anymore," he said. "The larger centers are big enough that they can afford all the high-stakes stuff."
If patients come to expect the highest level of specialty -- whether it's needed or a wise use of insurance dollars -- what's a doctor to do? Being just close enough to
"We're rural, but we're not frontier," he said. "An admission to a rural hospital today requires that the patient be sick enough to truly need hospital care, but not so sick as to require highly technical/specialized care, which is likely not available in the rural hospital."
A community without
Would it be so awful if a place like
The
Emergency care posed the biggest hole to fill. Communities had to buy more ambulances to speed patients to bigger cities. Folks in
A study led by a Harvard researcher looked at 195 hospital closures between 2003 and 2011 found "no significant difference" in death rates among people who lived in areas where a hospital had closed and those who lived elsewhere. An older study looking at data from rural areas the 1980s "did not detect significant effects of hospital closures on mortality."
Dean, the
Anderson, the physician who's practiced there for decades, said: "Will there be more deaths? Not many. But some people might not survive the ride."
Quality of life would deteriorate, he said. Go to
"It's a whole lot easier," he said, "to be admitted in your home town."
The hospital also is part of what makes
"The public belief is that we need health care locally and available," said
He wonders whether the town could hold on to Tect and GKN, its two aerospace manufacturers.
"It would make it harder to recruit more businesses like that," said
With more than 130 workers, the hospital is one of the biggest employers in town. Those workers might move, or at least commute, to
"That's more people we could lose," said
That's one reason voters, by more than two-to-one, voted in 2015 for a new hospital sales tax. That subsidy helps, but it's barely more than a rounding error in the facility's budget.
Meanwhile, surgical nurse
"We've got the equipment here, and it's sitting here doing nothing," she said.
Dugan worries about what might happen to the community if everyone had to go to
"These are our friends and neighbors," she said. "They count on us."
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