Fort Scott, Kansas – Dr. Max Self grabbed a sanitary wipe and cleaned off the small flashlight in his hands. More than 20 years as a family doctor in rural Fort Scott, Kan., has taught him a few tricks: "I've got my flashlight. See? Look, you want to hold it?"
Two-year-old Taelyn's brown eyes grow round and her tiny hand reaches out. But, first, Self makes sure she opens her mouth wide and he peers down. Behind him sits another staff member _ a medical scribe. Self's scribe gives him the ability to "focus on people," rather than toggling between a computer screen and the patient. It's a new perk he didn't have when he worked at Mercy Hospital.
That beloved hospital closed one year ago and, in the passing months, the small town's anger and fear evolved into grief, nervousness and _ lately _ pragmatic hope. Most of the handful of physicians in town stayed, taking jobs at a regional federally qualified health care center that took over much of the clinic work from Mercy. The emergency department, after closing for 18 days, was reopened temporarily _ run by a hospital 30 miles south.
It's not "all gloom and doom, although we all wish we had a hospital – no doubt about it," insurance agent Don Doherty said during the town's weekly Chamber of Commerce coffee on Dec. 12.
Nationwide, death rates have been higher in rural America compared with urban areas since the 1980s, and the gap continues to widen. More rural residents live with chronic conditions, like diabetes, that affect their daily lives, and there is a higher percentage of older residents. Rates of smoking and premature births are relatively high, and people often die younger here than the national average.
Since 2010, 120 rural hospitals have closed across the country _ 19 in this year alone, according to data from the University of North Carolina's Cecil G. Sheps Center for Health Services Research. A national analysis of Medicare cost reports found that 21% of the nation's remaining rural hospitals are at high risk of closing.
"Frankly, it's not getting better," said Dr. Daniel DeBehnke, study co-author and a managing director with Navigant's health care practice.
A year ago, after Mercy gave a 90-day notice that it would close, City Manager Dave Martin said the betrayal felt by city leaders led to lawyers and calls with other health care systems about taking over the facility. Now, Martin has realized "we will not have – or do we need – a hospital."
But, if not a hospital to care for rural communities like Fort Scott with its 7,800 residents, what is needed? The answers to that question play out every day here and could hold lessons for the rest of the country.
1 in 4 children lives in poverty in town
Self has cared for his share of struggling patients in this town, where 1 in 4 children lives in poverty, and its main corridor – U.S. 69 – is lined with fast-food restaurants. But Fort Scott is "not far off" from what it needs to be healthy. Sure, residents have to travel south 30 miles to Pittsburg, Kan., or north 90 miles to the Kansas City, Kan., area to be hospitalized, but "you will be taken care of," he said.
Self's new employer is Community Health Center of Southeast Kansas, which as a federally qualified health center gets a higher level of government reimbursement for Medicare and Medicaid patients than Mercy did, said Jason Wesco, executive vice president at CHC.
The center can also gain grants to take care of the uninsured, which is important in states like Kansas that did not expand Medicaid, though Wesco said it has not received any for Fort Scott.
Wesco estimates 90-95% of the health care offered before the hospital closed is still available locally. And services have been added, including a much-needed therapist on-site for behavioral health and telehealth access to a psychiatrist and substance abuse services.
"Drive up there, go into the parking lot, you're like 'There's a lot of people here,'" Wesco said. CHC's Fort Scott facilities have filled more prescriptions and done more mammograms in a month than the hospital "ever did," he said.
Local residents like 28-year-old Eliza Oliver, whose daughter, Taelyn, easily passed her annual wellness check with Dr. Self, said it's much less expensive to get care and prescriptions at the new health center. That part is great, Oliver said, but she still worries about the future of emergency care in town and where people can deliver babies.
Another Catholic hospital chain, Ascension Via Christi, which has a facility 30 miles away in Pittsburg, Kan., stepped in at the last minute to operate Mercy's old emergency room, signing a two-year agreement. This was vital: While much of the rest of Mercy Hospital Fort Scott had been underused and patient rooms sat empty, the ER handled nearly 9,000 people the year before it closed.
Mercy Hospital delivered more than 230 babies between July 2017 and June 2018. A few months ago – after the hospital closed – Oliver drove a friend who was in labor across the Missouri border more than 20 miles to deliver. "We had to jet over there and even though we made it in time, it's nerve-wracking," Oliver said.
Without a hospital, new mindset needed
Not having a community hospital does require a new mindset. The community still has an obstetrician, but doctors send patients out of town to have their babies. By June this year, Ascension's Fort Scott ER staff had delivered three babies for expectant mothers who didn't leave enough time.
Recent research by Katy Backes Kozhimannil, an associate professor at the University of Minnesota School of Public Health found that rural residents have a 9% greater chance of dying or suffering complications such as heart failure, stroke and the need for blood transfusions during childbirth compared with non-rural residents.
Federal policymakers have said they want to do better. President Donald Trump's administration this year set new Medicare payment policies that included more telehealth services and changed some payments for rural hospitals. Seema Verma, the administrator for the Centers for Medicare & Medicaid Services, also promised a new rural health payment model and "a lot of people are waiting with bated breath," said George Pink, a senior research fellow at UNC's Sheps Center.
CMS declined to comment on the timing of the proposal.
Congress, too, has made overtures to passing legislation. Maggie Elehwany, lead federal lobbyist for the National Rural Health Association, said the Affordable Care Act's promise that hospitals would have more insured patients and less bad debt "never really unfolded in rural America." The 14 states that have not adopted Medicaid expansion are largely rural and many are in the South, where the greatest number of hospitals have closed.