At 5 p.m. on July 7th, the hospital in Stamford (40 miles north of Abilene) closed. At that jarring moment, an organization that had met community needs 24/7/365 for more than 50 years ceased to exist. More than 80 good jobs disappeared. But there was virtually no media coverage. We were transfixed at that moment by a soccer team in a cave in Thailand.
Texas leads the nation in hospital closures, with 15 since 2013 — almost double any other state — and they have all been rural. Part of the reason is geography. Texas is huge and still has more than 150 rural hospitals. But factors like declining volume, demographics (rural populations are generally older, poorer, sicker and less educated — not a recipe for success), leadership and policy are also in play.
Texas’ political leadership intentionally balked at Medicaid expansion and outsourced that federal program to health plans that continue to squeeze providers. Our political leaders do not acknowledge the fact that Texas leads the nation in uninsured population and lags other states in health outcomes — both major public health issues. The Texas economic miracle has misfired when it comes to insuring our workforce. Rural hospitals have generally misdirected advocacy efforts to complaints rather than solutions, and traditional funding requests rather than investments in innovation.
A recent report from the Rural and Community Health Institute (RCHI) at Texas A&M, in collaboration with Episcopal Health Foundation, referenced 75 additional rural Texas hospitals at risk of closure, asked “What’s Next?” and challenged rural communities to stretch their thinking and reimagine service delivery.
We understand the consequences of closures in human terms, but a closure in Bowie also captured a direct causal relationship between the loss of a rural hospital and an overall decline in tax base, jobs and rural infrastructure. We shouldn’t expect overall healthcare spending to go down as rural hospitals shutter unless we find ways to fill the void and play offense in terms of diagnosis and treatment. Robust primary care clinics and home health services, telehealth connections to specialty physicians, EMS enhancement and expansion of mid-level provider deployment are all ways in which rural communities might sustain care in an environment where traditional inpatient hospitals are highly vulnerable.
This is understandably a scary exercise for small hospital leaders and doctors who feel threatened; they carry responsibility for their communities and hesitate to trust broadband connections when lives are on the line.
The study also suggests consideration for geography. A closure that’s within 20 miles of the next hospital is different from a closure that’s 60 miles from help. Reaction and debate around this will vary based on a person’s address and/or medical condition. Upper respiratory infections, headaches, flu and pneumonia have less urgency than heart attacks, strokes, laboring moms or rattlesnake bites. Because rural hospitals truly do improve rural quality of life and there is interdependence between urban and rural provision of care, Congress should establish a new “step down” hospital designation. This would allow a less expensive alternative, but still provide lifesaving emergency treatment for small and remote communities.
I write this as a former rural hospital CEO and relatively new rural hospital advocate, knowing the solutions may not always favor our membership. But we should be strong enough to have a thoughtful and honest policy conversation, and transition from a last-man-standing or a kicking-the-can strategy to regional and statewide collaboration that includes policymakers and serves our citizens. One-size-fits-all simply doesn’t work for rural Texas; everyone acknowledges that. We can find Texas solutions that fit.