By Bram Sable-Smith
The United States is facing a rural hospital closure crisis. At least 87 have closed across the country since 2010, about 700 more are at risk of closing and 41 percent operate with negative margins – i.e., they are losing money. If you are a health reporter in a rural state, chances are you’ve covered some aspect of this story. In fact, one challenge with covering this crisis is how to write about it with fresh and engaging angles with impact. Here are some lessons I learned while reporting a series of stories last year on the rural hospital in Pemiscot County, Mo., the state’s poorest county. (To do this reporting, I was supported by the very generous and very worthwhile Reporting Fellowship on Health Care Performance from AHCJ and the Commonwealth Fund).
Medicaid, Medicaid, Medicaid
In many ways the story of rural hospital struggles is a story of Medicaid, or the lack of it. Rural populations tend to be older, poorer and sicker than most, meaning they disproportionately rely on public insurance programs like Medicare and Medicaid. It’s not uncommon to find a rural hospital where public insurance makes up 80 percent or more of the payer mix.
The bulk of rural hospital closures have been happening in non-Medicaid expansion states. Missouri has lost four rural hospitals, North Carolina and Mississippi have lost five hospitals each, Tennessee has lost seven and Texas has lost 14.
To show just how important Medicaid funding is to the hospital in Pemiscot County, I pulled 15 years of the hospital’s 990 forms (a task that would be much easier now using AHCJ’s new website: hospitalfinances.org). The documents show the hospital’s profits each year, which peaked in 2006 at just over $3 million in net revenues.
The next year, sweeping cuts went into effect in Missouri’s Medicaid program that saw more than 100,000 Missourians lose their health coverage. At the time, about 40 percent of the Pemiscot hospital’s patients were on Medicaid, and nearly half of them lost insurance. The 990s reflect that change, showing the hospital’s net revenues dropping by $1.5 million the first year of the changes, then dropping another $2 million the following year as the hospital began operating at a loss.
Federal policies often aren’t made with rural health in mind
Rural health care seems to be an afterthought at best when it comes to federal health care policy. Take the 340B drug pricing program.
The program has its fair share of critics, and those perspectives are valid. PhRMA, in particular, has been critical of excesses in the program, designed to defray some of the cost of drugs for hospitals that serve a lot of low-income people. But the criticism (that the program has gotten bloated and is being used inappropriately) mostly focuses on large metropolitan hospitals. For rural hospitals, the 340B program has been a lifeline. The tiny hospital in Pemiscot County nets a little over $1 million a year from the program. That’s hugely significant for a hospital that nets /- $1million a year. Scaling back the program without consideration of rural health care could have disastrous effects for rural communities.
Similarly, the 2017 efforts to repeal and replace Obamacare (now unfolding again via a Texas-led lawsuit) would have had disproportionately negative consequences for rural hospitals. Whenever there’s conversation in Washington about health care, call up your local rural hospitals and see the reforms through their eyes.
Look for health and economic impacts
The loss of a rural hospital means losing life-saving services like obstetrics and access to an emergency room. But rural hospitals are not just the lone health care providers in their areas, They’re also often the largest employers in their counties, leaving rural residents and leaders desperate to keep them open.
While working to save rural health care is a noble effort, it can also open the door to exploitation. Rural hospital boards of directors are often made up of local leaders: cattle farmers, retired teachers and the like – community leaders who may not have a lot of experience in health care. That can open the door to questionable management contracts that put undue risk on local hospitals. If your rural hospital is publicly owned, you should FOIA their management contracts and bank statements to see if anything seems out of the ordinary.
Talk to administrators, board members, physicians
Many rural hospitals are still county-owned, with a board of directors made up of local community members and often physicians who grew up in the small communities where they practice. I’ve found these board members and physicians, as well as rural hospital administrators, to be very approachable and open to the idea of a reporter coming into their facilities.
If you’re looking for experts, the Rural Policy Research Institute (RIPRI) has a health panel of six academics from around the country. Another great resource is the National Rural Health Association. Their leadership are savvy and experienced explainers of rural health care, and their CEO was a journalist in a previous life.
Bram Sable-Smith, until recently the Health & Wealth Reporter at KBIA– Columbia, Mo., and Side Effects Public Media, is starting a freelance career in Madison, Wis. Read more of his reporting on rural hospitals:
- Trump Administration Rule Scales Back Program Keeping Rural Hospitals Afloat
- Vulnerable Rural Hospitals Face Tough Decisions On Profitable But Questionable Billing Schemes
- To Survive, Rural Hospitals Need To Grow—But The Demographics Don’t Add Up
- For Rural Hospitals Already on the Brink, GOP’s Proposed Medicaid Cuts Would Hit Hard
- As Rural Counties Lose Obstetrics, Women Give Birth Far From Home
- KBIA wins National Edward R. Murrow Award for Continuing Coverage for its coverage of the rural hospital crisis in Missouri
