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Denise Truax’s office in Bowie is decorated with inspirational quotes and family photos.
She’s lived in the small north Texas town her whole life and raised her family here, too. They’ve had a lot of good moments in Bowie. But they’ve had heartbreaking times that are hard to forget.
“I remember the night my little nephew was so sick,” Truax recalled. “It was Halloween. It was so dreary, so foggy.”
Truax’s 9-week-old nephew was taken to Bowie Memorial Hospital that night in 2015. Since he was so young, Truax said he’d recently had the usual tests and exams done to ensure he was healthy, and everything was fine.
However, the doctor treating him that night noticed something in her nephew’s blood work results.
“They said, ‘We think this baby has cancer,’” said Truax. “I thought, ‘No.’ Who checks blood on a 9-week-old? Who hears of a 9-week-old having cancer?”
Her nephew was transferred to Cook’s Children’s Medical Center in Fort Worth – more than an hour south of Bowie. The Emergency Medical Service (EMS) with Cook’s was able to come to Bowie to pick him up. Twelve hours later, he was diagnosed with Acute Lymphoblastic Leukemia.
“It hadn’t been picked up by anybody, to no fault of their own because who thinks about a 9-week-old having leukemia?” Truax explained. “It was tragic for our whole family.”
Even though the diagnosis was devastating for their family, Truax said she was grateful that the doctors in Bowie were able to find out what was wrong. They were told he would only live another two weeks, but she thinks Bowie’s doctors bought them more time.
Right when her family needed the hospital the most, Truax got more bad news.
“Then [the hospital] closed,” said Truax. “He was diagnosed around the first of November, and by November 5, Bowie Hospital had closed.”
With the hospital closed, Truax’s nephew continued to be treated in Fort Worth – an hour away from Bowie. Since they caught it early, he was able to see his first birthday – but died just one week after.
“Cook’s Children’s [Hospital] did everything they could for him,” said Truax. “We all got a little over a year with him. Losing a child, for my niece and my brother because he was my brother’s grandson, is traumatic. It was tragic for our whole family.”
Residents in Bowie and surrounding communities are at risk without their hospital. After facing years of financial trouble, it closed once in 2015, and reopened briefly before closing again in 2020.
The community of 5,000 residents no longer has immediate access to healthcare – a trend seen in many rural towns across Texas.
American Public Media Research Lab data shows that 24 rural hospitals have closed in Texas since 2005 – the most of any state in the U.S.
When the hospital closed in 2015, Truax said the community was devastated.
“The sadness, I mean, that was historical,” said Truax. “We were all lending a hand, it seems like, trying to help people find jobs. People got very sad during that time, whether they worked at the hospital or they might need the hospital.”
For residents in Bowie, their closest options are now in nearby Nocona and Decatur, which are both 25 miles away. But Truax said it’s scary to not have medical access in town.
“We need something locally,” said Truax. “I will say, I’m 50-years-old and I’ll have friends tell me all the time that when we retire, we’re going to have to move if there’s not a hospital close by that’s open. I don’t want to retire somewhere where there’s not going to be hospitals and urgent care and medical services.”
Rural hospitals like the one that was in Bowie are up against many obstacles. They often face low reimbursements from insurance companies, and that’s if their patients are insured. Many of the hospitals rely on patients and Medicare payments, but their populations are older or declining.
Perhaps the biggest part of that problem can be traced far back.
In 1965, the Medicare and Medicaid programs were established by the federal government in the Social Security Act. The programs, Medicaid especially, were a large source of income for hospitals – Medicaid is supposed to cover people with low-incomes who can’t afford services on their own. Those reimbursements have gotten lower due to federal budget cuts.
“Those cuts included a 2% reduction in all Medicare payments to all doctors, hospitals and providers,” explained Don McBeath, government relations director for the Texas Organization of Rural and Community Hospitals (TORCH).
A 2013 report from The Washington Post found that with the 2% budget cut, the Medicare cuts would cause an $11.1 billion loss to hospitals nationwide. The reduction was suspended temporarily last May, as part of the first COVID-19 relief package. However, McBeath says it will likely go back into effect once the national emergency is over.
Aside from the budget cuts, McBeath said there are multiple reasons the closures are happening. Not only are Medicare and Medicaid reimbursements to medical facilities not high enough to keep up with the increasing costs of providing healthcare, but the amount of uninsured Texans increases every year and many rural communities are seeing a decline in population.
“It creates a recipe for disaster because a hospital is like any other business,” McBeath said. “It’s expensive to operate, and you have to bring in enough money to pay for the costs to operate. If you look at a rural hospital, there are some days where some of them don’t have a single patient. Or other days, maybe five or six patients.”
The problem McBeath described is a sentiment echoed by all the communities visited for this project, including a small area in West Texas called Crosby County.
West Texas Deserts
In Crosby County, the Crosbyton Clinic Hospital offers limited services. The Crosbyton EMS has just two ambulances – one of them serves as a back-up, while the other is used mostly for transporting patients to Lubbock.
Even with the proximity to Lubbock, it’s still vital that areas like Crosbyton can have a financially-stable hospital.
Steve Beck is the Chief Administrative Officer for Covenant Health and acts as a liaison to Crosbyton Clinic Hospital. After working in rural health the majority of his career, Beck knows the importance of keeping them open.
“It’s critical for us that they survive because we need them to survive,” said Beck. “We need to provide that primary care out there because one of the biggest challenges we have today is how sick patients are when they come to Covenant.”
Beck said the problem also comes down to the ongoing labor shortage in the healthcare industry.
Data from the APM Research Lab found that 129 of Texas’s 254 counties were experiencing shortages of primary care providers in 2019. As of July 2021, that number had jumped to 228 – increasing by 99 counties in just two years.
The problem extends nationally as well. According to an APM report, the U.S. will face a shortage of up to 122,000 physicians by 2032. Rural communities will be hit the hardest, as fewer than 10 percent of U.S. physicians practice in those areas.
The financial and staffing problems facing Crosbyton’s clinic are being echoed by the EMS station in the nearby town of Ralls. Sarah Jamerson, the-then EMS director, explained the problem in detail as she showed us the town’s only ambulance in April.
“It sounds terrible, but it would make the service run more efficiently and really give us a little more security if we had more calls to run,” said Jamerson. “But we have a population of less than 1,500 people. So not a lot of calls turns into not a lot of money.”
Jamerson grew up in Ralls, where her family has a long history in healthcare. Even as she gave this tour, she still made it clear that she wanted to take care of the EMS.
Jamerson first spoke with Texas Tech Public Media in April, and she expressed her personal frustration about the situation. Between UMC, Ralls, and teaching certification courses to help staffing problems, she often spent 110 hours a week working.
She resigned in June. A few weeks later, the station was temporarily shut down.
This created somewhat of a panic in the small town. Residents began sharing news articles about the closure and expressed their shock on social media. Some began organizing “vigils” at the town’s square – right across from the EMS station and the City Hall.
If Ralls EMS closed, the town would be served by Crosbyton EMS, which was already handling Crosbyton and the rest of Crosby County’s 5,000 residents.
Beck said the EMS is designated as both a transport service and a 9-1-1 service for Crosbyton, and has only one full crew and two trucks, one of which is not for regular use.
“If you have a crew that’s transferring a patient into Lubbock, you have a good 30-45 minutes to travel in and then go through the process to hand off that patient,” Beck explained. “Then they have to turn around and drive back to Crosbyton, so you’re talking about a two-hour time span. When that happens, that county is now without that service.”
Closing the Gap
Over in East Texas, there’s an area that’s already lost its one hospital, but there’s a team working to resuscitate it.
Randy Lindauer is an Indiana native who has helped reopen medical facilities in five states. He’s spent 44 years of his life working in rural healthcare, and now he’s come to Grand Saline on a mission – to reopen the Van Zandt Regional Hospital.
“I think God chose me to start turning around hospitals, and that’s what I started doing,” said Lindauer.
The hospital in Grand Saline closed in 2019, leaving about 60,000 residents in the surrounding areas without a nearby hospital. This made the county become one of the 71 Texas counties without a hospital, according to APM Data.
However, it’s not just Texas. Nationwide, there have been 136 rural hospital closures in the last decade.
Earlier this year, however, a Facebook post was being shared stating that the hospital was looking to hire. Lindauer was brought in by Innate Medical Solutions’ CEO Dr. Gary Martin to renovate and manage the hospital, and have it reopen.
Lindauer went to work. He did the lawn work, which had been overgrown by the time he got there, and replaced the dirty, old sign that was outside.
“It looked like something in the movies before I got here,” Lindauer recalled. “It really did, it was horrific.”
Lindauer has spent so much time at the Van Zandt Regional Hospital, that he has set up a temporary living space for himself inside one of the hospital’s old patient rooms.
“I’m here 24/7,” said Lindauer. “You never know when a pipe is going to break and when you put in 18 hours a day, [you] just need a place to lay your head.”
Like Lindauer, Martin wanted to bring the hospital back to the rural community. He has helped with smaller projects, but a full-scale hospital is a different task.
“This is our first dip putting our toe in the pool here of hospitals,” said Martin. “We’ve never done a hospital before this.”
But this hospital in particular has had a lot of trouble in the last decade alone. Court documents show that since 2009, the hospital in Grand Saline has undergone four name changes, two closures and at least four changes in management.
Lindauer and Martin planned to have the hospital open by May of this year. However, the months came and went, and by December, Grand Saline was still without a hospital.
In November, Texas Tech Public Media received a message from a private source that stated three of the employees, including Lindauer, were no longer working at the hospital. Not only that, but the vision for the hospital changed – Martin was now turning it into a specialty hospital.
Martin explained that the team had made a series of miscalculations – he said he took on the overhead costs too quickly, and that state health codes were difficult to meet. The hospital was built in 1947. Updating it to bring things up to code, and changing licenses, would take even more time and money than he had anticipated.
“To bring that up to [code], it would almost be cheaper to tear down and rebuild [the hospital],” said Martin. “So I’m thinking, this is one of the reasons people don’t do what I’m trying to do here, because it’s so cost prohibitive.”
Martin said he still plans to open the hospital in Grand Saline.
What can be done?
Expanding Medicaid in the near future seems to be out of the picture for Texas. Instead, the state currently has the 1115 Medicaid waiver, which is largely used to reimburse hospitals for uncompensated care. It was meant to be a temporary waiver while the state transitioned to Medicaid expansion, as the two are very similar. But in 2012 the U.S. Supreme Court ruled that states couldn’t be forced to expand Medicaid.
Texas has had that waiver in place since 2011.
According to the Texas Comptroller website, the current waiver was renewed in 2017 for five years and worth $25 billion. The waiver reimburses hospitals for uncompensated care that covers low-income patients or those without health insurance, and also pays for health care projects.
In April, the Biden Administration rescinded changes to the 1115 Waiver agreement that would have extended the program for another 10 years. However, a federal district judge temporarily reinstated the 10-year extension in August.
“The 1115 is the backbone of supporting Medicaid – we’re not going to expand Obamacare,” said U.S. Representative Jodey Arrington in September.
For the last five years, Arrington has been a Republican representative for Texas’ 19th Congressional District. His district includes a large majority of West Texas and the rural communities that lie within the region.
Arrington said that the state legislature has worked on expanding telemedicine and telehealth through rural broadband infrastructure. In November, however, Arrington joined the rest of the Republican representatives in the U.S. House of Representatives to vote against the Build Back Better Act. The act ultimately passed in the House and is now waiting for vote in the Senate. It includes funding to train new rural health care providers and increase access to telehealth.
Arrington did introduce legislation last year that gives rural hospitals the choice between keeping in-patient services or just having emergency care services, which TORCH experts said would help rural hospitals stay open and keep their Medicaid and Medicare benefits. The same experts say expanding Medicaid is the key, but Arrington disagrees.
“I think the decentralized model, more market-based models that provide competition and choice are the best way to go,” said Arrington. “I don’t think we’re anywhere close to making improvements in that regard in Washington.”
John Henderson, the CEO of TORCH, said expanding Medicaid would be a good deal for the state in the long run, according to data from the organization.
“What we show is Texas stands to gain $4 billion and cover an additional million uninsured Texans if they would expand,” said Henderson. “It’s 100 percent political, we continue to be a very conservative state. You just knew when you got that Supreme Court ruling in 2012, that Texas was going to be at the end of the line.”
Henderson added, “It’s part of Medicaid expansion as part of the Affordable Care Act, and our statewide officials have been against that publicly for a decade now.”
Henderson said national data shows 70 percent of rural hospital closures are in states that haven’t expanded. Henderson believes Medicaid expansion could get passed if it ever came to a public vote.
“Even in Oklahoma recently, they passed Medicaid expansion not because the state legislature did it, but because they allowed voters to vote,” said Henderson. “I think if it were ever on the ballot [in Texas], it would probably happen. But as long as it depends on the governor and lieutenant governor and Senate leadership in Texas, until that changes, we probably won’t do it.”
During the state’s third special session this year, the legislature passed Senate Bill 8, which would allocate some of the state’s $16.3 billion of COVID-19 relief funds to various initiatives, which included $75 million given to rural hospitals.
Henderson gives credit to the state legislature and the federal government for how they have made progress with Telemedicine, CARES Act funding and with Medicaid payments. But, he adds that having incentive programs for innovation around telehealth and primary care, as well as grant-funded projects in rural communities, would go a long way.
“All those things together add up to making a better outcome and story for all of rural Texas,” said Henderson. “We talk about death by 1,000 paper cuts, but what we need to be talking about is survival by 1,000 incremental improvements instead. Having a little bit of stimulus, having a little bit of support at the state level, all that incrementally helps these hospitals survive.”
Edited by Fernanda Camarena
This story is part of a collaboration with The Texas Newsroom through FRONTLINE’s Local Journalism Initiative, which is funded by the John S. and James L. Knight Foundation and the Corporation for Public Broadcasting.