For the hundreds of rural U.S. hospitals struggling to stay in business, health policy decisions made in Washington, D.C., this summer could make survival a lot tougher.
Since 2010, at least have closed across the country, and nearly are at risk of closing. These hospitals serve a largely older, poorer and sicker population than most hospitals, making them particularly vulnerable to changes made to Medicaid funding.
鈥淎 lot of hospitals like [ours] could get hurt,鈥� says , CEO of Pemiscot Memorial Health Systems, which runs the public hospital in Pemiscot County, one of the poorest in Missouri.
The of the Affordable Care Act calls for deep cuts to Medicaid 鈥� the public insurance program for many low-income families, children and elderly Americans, as well as people with disabilities. The House version of the repeal law cuts Medicaid by $834 billion over 10 years, and the Senate revision of that bill cuts the program even more on a different timetable. The Congressional Budget Office has not yet scored the Senate version of the bill, but it said the House version would result in in the next 10 years.
Loss of coverage for small rural hospitals like Pemiscot Memorial, which depend on Medicaid. The hospital serves an agricultural county that ranks worst in Missouri for , including premature deaths, quality of life and adult smoking rates. Closing the county鈥檚 hospital could make those much worse.
And a rural hospital closure goes beyond people losing health care. Jobs, property values and even schools can suffer. Pemiscot County already has the state鈥檚 unemployment rate. Losing the hospital would mean losing the county鈥檚 largest employer.
鈥淚t would be devastating economically,鈥� Noble said. 鈥淥ur annual payrolls are around $20 million a year.鈥�
All of that weighs on Noble鈥檚 mind when he ponders the hospital鈥檚 future. Pemiscot鈥檚 story is a lesson in how decisions made by state and federal lawmakers have put these small hospitals on the edge of collapse.
Back in 2005, things were very different. The hospital was doing well, and Noble commissioned a $16 million plan to completely overhaul the facility, which was built in 1951.
鈥淲e were going to pay for the first phase of that in cash. We didn鈥檛 even need to borrow any money for it,鈥� Noble said, while thumbing through the old blueprints in his office at the hospital.
But those renovations never happened. In 2005, the Missouri legislature passed to Medicaid. More than 100,000 Missourians lost their health coverage, and this had an immediate impact on Pemiscot Memorial鈥檚 bottom line. About 40 percent of their patients were enrolled in Medicaid at the time, and nearly half of them lost their insurance in the cuts.
Pemiscot Memorial had plans for expansion and improvements that the county hospital was ready to make 鈥� and pay for 鈥� in 2005, before the state legislature slashed Medicaid rolls. (Bram Sable-Smith/Side Effects Public Media)((Bram Sable-Smith/Side Effects Public Media))
Those now-uninsured patients still needed care, though, and as a public hospital, Pemiscot Memorial had to take them in.
鈥淪o we鈥檙e still providing care, but we鈥檙e no longer being compensated,鈥� Noble said.
And as the cost of treating the uninsured went up, the hospital鈥檚 already slim margins shrunk, and it went into survival mode.
The Affordable Care Act was supposed to help with the problem of uncompensated care. It offered rural hospitals a potential lifeline by giving states the option to expand Medicaid to a larger segment of their populations. In Missouri, that would have covered about 300,000 people.
鈥淚t was the fundamental building block [of the ACA] that was supposed to cover low-income Americans,鈥� said聽, a St. Louis University health law professor.
In Missouri, Kerry Noble and Pemiscot Memorial became the poster children for Medicaid expansion. In 2013, Noble went to the state Capitol to for expansion on behalf of the hospital.
鈥淥ur facility will no longer be in existence if this expansion does not occur,鈥� Noble told a crowd at a press conference.
鈥淢edicaid cuts are always hard to rural hospitals,鈥� Watson said. 鈥淧eople have less employer-sponsored coverage in rural areas and people are relying more on Medicaid and on Medicare.鈥�
But the Missouri legislature voted against expansion.
For now, the doors of Pemiscot Memorial are still open. The hospital has cut some costly programs 鈥� like obstetrics 鈥� outsourced its ambulance service and has skipped upgrades.
鈥淧eople might look at us and say, 鈥楽ee, you didn鈥檛 need Medicaid expansion. You鈥檙e still there,鈥欌�� Noble said. 鈥淏ut how long are we going to be here if we don鈥檛 get some relief?鈥�
This story is part of a partnership that includes , and Kaiser Health News.
The Association of Health Care Journalists and The Commonwealth Fund are supporting a on rural health care by Side Effects Public Media and KBIA.