Williamson Memorial Hospital was more than the place where Carole Steele had surgery on her elbow. It was more than the place that treated her husband Samuel when his severe allergies make it hard for him to breathe.
One doctor there was her grandniece’s godfather. Another was a trusted friend.
Going to the hospital was “like going home to us,” the 73-year-old retired schoolteacher said. “For Samuel and I, that is the only hospital we have ever known.”
Now, in the middle of the coronavirus pandemic, the hospital will close its doors Tuesday after serving the community for more than 100 years. The only hospital in the coal mining community of Mingo County, West Virginia, Williamson Memorial filed bankruptcy last year.
And it’s not alone. As the deadly virus has spread beyond urban hotspots, many more small hospitals across the country are on the verge of financial ruin as they’ve been forced to cancel elective procedures, one of the few dependable sources of revenue.
Williamson Memorial and similar facilities have been struggling since long before the pandemic – at least 170 rural hospitals have shut down since 2005, according to University of North Carolina research on rural hospital closures.
But even as hospitals in cities like New York City and Detroit have been deluged with coronavirus patients, many rural facilities now have the opposite problem: their beds are near-empty, their operating rooms are silent, and they’re bleeding cash.
“It’s a scary time for small, rural hospitals right now,” said Michael Kozar, CEO of Northwest Florida Community Hospital in Chipley, Florida, a Panhandle town of about 3,500 people. “If you’re not in a surge market, you’re sitting there and watching your business go to zero.”
More than 100 hospitals and hospital systems around the country have already furloughed tens of thousands of employees, according to a tally by industry news outlet Becker’s Hospital Review. They’ve sent home nurses and support staffers who would be deemed essential under state stay-home orders.
And many of the rural areas with hospitals that have closed or are at risk of doing so have large elderly populations and patients with heart disease and elevated rates of health complications like obesity and diabetes, which can make the virus more deadly, according to experts. Rural communities also have higher rates of uninsured patients.
As of Saturday, more than 80% of rural counties nationwide reported positive cases of Covid-19, totaling more than 34,500 people, according to data from the University of Iowa.
If infection numbers rise in those areas, as public health experts predict, cash-strapped hospitals might not have the resources to handle a surge.
The crisis is a “match in a tinder box,” said Alan Morgan, CEO of the National Rural Health Association. “And when it lights – it’s going to be devastating.”
Closing during a pandemic
For years, rural hospitals have suffered because their patient populations are decreasing and they’ve been hit with reductions in federal funding through Medicaid and Medicare.
Nineteen rural hospitals closed in 2019, the most of any year on record, said Mark Holmes, a health policy professor and the director of UNC’s Cecil G. Sheps Center for Health Services Research, which has tracked the closings.
Slightly less than half of the 170 rural facilities that shuttered in the last 15 years have reopened in some form, finding second lives as nursing homes, rehabilitation centers or part-time urgent care clinics, Holmes said. But most of these provide a fraction of the services they once did.
Now, coronavirus has forced hospitals around the country to cancel non-essential procedures like colonoscopies, mammograms and physical therapy that helped many stay afloat.
“Facilities are just bleeding through cash right now,” said Ryan Kelly, executive director of the Mississippi and Alabama Rural Health Associations. “They’re just dying on the vine, and it opens up the question of who’s going to treat these patients when they close.”
The number of closed hospitals is almost guaranteed to rise in the coming weeks – starting with Williamson Memorial. A 76-bed hospital tucked into the wooded hills overlooking the riverside town of Williamson – home to West Virginia’s first building constructed entirely of coal – it’s been serving residents since around 1920.
Mingo County’s population has steadily declined in recent years, according to the Census Bureau. Many of the patients coming to the hospital have no insurance or depend on Medicaid and Medicare, which don’t fully reimburse the costs of treatment, said Dr. Donovan Beckett, who runs a clinic connected with the hospital.
By the time it filed for bankruptcy in October 2019, Williamson Memorial was more than $1 million in debt, according to court records.
Gene Preston came on as the hospital’s CEO a day after the bankruptcy filing. The plan was to work with Williamson Health & Wellness Center, which bought the hospital’s assets, and offload overhead as well as put an urgent care facility alongside the emergency room, he said. The ER generated the hospital’s greatest revenue, said Preston.
But along came Covid-19 and, following social distancing rules and governed by the fear of getting close to those possibly infected, fewer people went to the hospital. Emergency room visits dropped significantly and, like other health care facilities, Williamson Memorial stopped doing elective procedures, another dependable profit source, he said.
“If not for Covid, we were on track to work it out,” Preston said. “When Covid hit, every hospital that was looking at partnering with us retreated to solve their own issues.”
Beckett and Preston still hope to team with a business partner to reopen the hospital. State officials announced that the clinic had acquired the hospital’s assets on April 1. But Beckett fears finding such a partner may now be harder.
In the meantime, the clinic is jumping through numerous state and federal regulatory hurdles – which Beckett said could take months – to lay the groundwork in case a deal is struck.
Doctors at the hospital are used to treating patients who overdose on drugs, victims of grisly car crashes on the region’s winding mountain roads, and coal miners injured on the job. During their last days at work, the skeleton staff that remains at the hospital has tackled coronavirus, testing 35 people and treating two patients who came back positive.
“I’m always amazed at our population,” said Beckett, who grew up in Williamson. “We’ve had people that are coal mining families who have been through hard times, and they get through those by relying on each other.”
Despite its imminent shuttering, the importance of the hospital was highlighted last month when the National Guard inspected the facility as a possible overflow location to help with Covid-19 testing and treatment.
The looming closure is devastating news for patients like Steele, who knows that she and her husband are at elevated risk from the coronavirus. Now, if they do get sick, they’re going to have to drive across the state line to Kentucky or go to other hospitals that are at least 30 minutes away.
“We care about the people (at the hospital) and they care about us,” Steele said, her voice breaking a little. “We will do what we have to do, but we won’t enjoy it.”
Hospital workers furloughed: ‘This is uncharted water’
Usually, Dr. John Tedesco would be performing surgeries. But with most operations put on hold during the pandemic, the cosmetic surgeon, who treats a lot of skin cancer, has hardly seen the inside of his operating room in McAlester, Oklahoma, for weeks.
“We’ve put those folks off for now, postponed them,” Tedesco said of his skin cancer surgeries. “It doesn’t stop the cancer from growing. And it doesn’t stop anxiety from building that you’re left untreated.”
With surgeries on hold, Tedesco is seeing patients via telemedicine and doing administrative planning as the chief of staff at McAlester Regional Health Center to prepare the hospital for a return to some surgeries next week. And, hospital officials say, 352 employees in the hospital had their hours cut, while everyone else is facing a pay cut.
That’s the new normal in rural Oklahoma: Even health care employees who seem like they’d be the very definition of essential are seeing their work cut as hospitals struggle to stay solvent.
The staff has never faced anything quite like the pandemic, said David Keith, the hospital’s CEO, adding that more than a dozen surrounding counties depend on them.
“Within an hour’s drive, there’s no one else,” Keith said.
One reason why: Oklahoma, which has the nation’s second-highest uninsured rate, is a hotspot for rural hospital closings, with seven shutting down since 2016. The state government’s refusal so far to expand Medicaid under the Affordable Care Act has likely made an impact – multiple studies have found that states that didn’t expand the program have seen more hospital closures.
Oklahoma voters will decide in June on a ballot measure to expand Medicaid, while Gov. Kevin Stitt has proposed his own more limited plan for expansion.
Meanwhile, the pandemic has made it even harder for already financially vulnerable rural hospitals to survive. Seventy miles east at Eastern Oklahoma Medical Center, a 25-bed hospital in the small city of Poteau, CEO Bob Carter has spent the last few weeks shutting down two sections of his facility that brought in money – obstetrics and surgical departments.
The hospital has furloughed 52 employees, while Carter, his administrative team, physicians and mid-level nurse practitioners agreed to take significant pay cuts. “I think that speaks volume about life in a small community, in a small hospital,” he said. “It’s about taking care of each other.”
Stitt, one of the few US governors who hasn’t issued a sweeping statewide stay-at-home order, announced this month that his administration would allow elective surgeries to resume starting April 24, which some hospital leaders say will be a big help.
Still, while Carter said he is confident eastern Oklahoma will come out of this, fears about the hospital’s future – and what it would mean for the community if it closed – have kept him awake at night.
“This is uncharted water for every one of us,” Carter said.
Federal lifelines only go so far
The federal government threw struggling hospitals a lifeline last month – but rural hospital leaders say more help is desperately needed.
The relief package passed by Congress, known as the CARES Act, includes a $100 billion fund for hospitals and other health care providers to make up for coronavirus-related expenses or lost revenue.
For some hospitals, the relief won’t go very far. Eastern Oklahoma hospital received a $502,000 grant from the act – which will last just two weeks, Carter said. The hospital received $1.75 million in advances on its Medicare payments, but Carter said he was worried to use it because the hospital had to begin repaying that money in 120 days.
Dr. Randy Tobler is an OB-GYN and CEO of Scotland County Hospital in the northern Missouri town of Memphis. It applied for and received advanced funding from Medicare which will help the struggling hospital cover expenses through at least May, though the funding must be repaid.
In March, the hospital eliminated jobs and furloughed staff. All the clinicians took a pay cut, Tobler said.
“It makes me cry – so many people have banded together,” he said. “It’s like an Army platoon charging up the hill.”
The hospital has treated coronavirus patients like Danielle and Jake Bair, who tested positive after coming down with fevers and coughs late last month. They say their symptoms have since improved.
Being able to talk to a doctor who was intimately familiar with her own history as a cancer survivor was a huge help during the ordeal, said Danielle. Without Scotland, she’d have to drive an hour or two to get to the nearest hospital.
“When I’ve had to go to the doctor in other [places,] I have to re-explain my case,” Danielle said. “But when I go to my local emergency room here, they already know me. Not only does my doctor know me, but he has talked with his colleagues about my case. I know that I’m immediately getting the right care.”
Shuttered hospitals leave holes in care
As more rural hospitals face the possibility of shutting down, communities trying to understand what that would mean can look to Marks, Mississippi, a town in the state’s northwest, which lost its only hospital three and a half years ago.
Quitman County Hospital served patients in what has long been one of the US’s poorest counties – Martin Luther King Jr. preached about children in Marks “walking the streets with no shoes to wear” during his last Sunday sermon before his assassination. Many of those who came to the hospital’s emergency room had no insurance, and it couldn’t stay in business, local officials said.
Known locally as “the Q,” the single-floor hospital with about two dozen beds was a community institution and the county’s largest employer, said Lonnie Moore, a nurse practitioner who worked at the hospital. When it closed in September 2016, “it broke peoples’ hearts,” he said.
Now the county only has a part-time clinic operating across the street from the vacant hospital, with three doctors and several nurse practitioners splitting their work between three neighboring counties, said Moore, who works at the clinic.
The nearest hospital still open is about a 20-minute drive from Marks. Paul Hester, who’s worked for the county ambulance service since 1972, said one person from Quitman County has died in an ambulance while on the way to a neighboring county since 2016 – and there have been other close calls.
“Twenty minutes, compared to five minutes, makes a big difference,” Hester said. Having a 24-hour emergency room in the county would “help tremendously,” he said.
Quitman County only has 13 confirmed coronavirus cases so far – but that puts it in the top 11% of counties in the US by number of cases per capita, according to a CNN analysis of case data from Johns Hopkins University.
While the local clinic is providing some testing and treatment to people who test positive, patients who need to be hospitalized are being sent to neighboring counties.
“It’s very, very scary and nerve-wracking to be facing this without a hospital,” said Velma Wilson, the county administrator. “The numbers are going up, so if we do become a hotspot, managing Covid-19 would be a major concern for this area.”
Mary Williams, a nurse practitioner who started her career at the now-shuttered Quitman hospital, has two family members in the county who tested positive for Covid-19 and had to be driven long distances to get urgent care. One of her relatives had to be transferred to a hospital more than an hour away to be put on a ventilator for more than a week, Williams said. Another of her relatives spent time at the Veterans Affairs hospital in Memphis, Tennessee, before being released.
If the Quitman hospital was still in business, Williams said she thought both of her family members would be in better situations.
“If the hospital’s just down the street, you’re going to go there if you’re feeling bad,” Williams said. “If you know the hospital is miles away, you’re going to wait until you can’t take it anymore.”