Rural Hospitals Are Dying, and So Are Their Patients

It is a dreary Monday on the East Coast, and I have a dreary story of American neglect and misery for you: the Washington Post published a remarkable story this weekend on the desperate times at a rural hospital in Oklahoma, whose staff worked for weeks without pay while the hospital struggled with bankruptcy.

The hospital was deep in debt, owing hundreds of thousands in payroll and the cost of medical services. The dwindling staff had been working weeks without pay, pulling 12 or 16 hour shifts for no money; one of them had gone into $100,000 of debt for the crime of having a baby, because the hospital doesn’t provide health insurance for its employees. A hospital where even the staff can’t get out from under the financial oppression of the American healthcare system.

It’s largely a story of rural America’s decay. The story follows one of the only two physicians at the hospital, James Graham, who had worked even “while on dialysis through two kidney transplants,” and all the people he had watched die young—and all the people he still works tirelessly to try and save. One of his patients is 82 and still works at a refinery, hardly able to stand from pain in his back and hip. He takes calls on his cellphones from patients in pain, and sits with patients’ families through theirs:

He drove away from the hospital and into the adjacent neighborhood, passing the first home, with a collapsed front porch and windows blown out by a tornado. “I sat with that lady as she died four years ago, and now this house just rots away,” he said. He turned onto another block and drove past a bungalow where the owner had died of lung cancer at 58. Next was a suspected drug overdose. Next was a midnight heart attack in the bathroom, and Graham had checked for a pulse and then stayed to pray with the new widower until his children came from Wichita.

It’s not just that rural hospitals themselves are crumbling; it’s that their patients need more care now than ever. According to the Post story, in the last decade, emergency room visits to rural hospitals increased 60 percent. This makes sense, given America’s decreasing life expectancy, aging population, and the increase in deaths from overdoses; overdose deaths are more common in rural areas despite the rate of drug use overall being lower, according to the CDC. Suicide rates in rural counties, too, are nearly double the rates in urban counties, in large part because so many homes have guns.

Given all this, rural hospitals would be struggling and overburdened even if it weren’t for America’s vicious healthcare system; the profit-based system we have makes it far worse.

Rural hospitals have patients that are disproportionately poorer, sicker, and less likely to be insured; that means the cost of care is high, but the likelihood of having to care for patients who cannot pay for that care sets them up for debt. They also have more vacant beds; when hospitals are forced to fight on the private market for their existence, turnover is key, like they’re a goddamn restaurant. More than a fifth of rural hospitals are at a high risk of closure.

The richest country in the world should be able to provide healthcare to people in rural areas—in all areas—without medical staff having to work without pay. This is a simple proposition, and it is one that could potentially be answered by single-payer.

The Medicare for All bill introduced by Rep. Pramila Jayapal would use a system called global budgets, instead of the current model of Medicare paying a fee for each service. It’s a simple idea: Instead of hospitals charging fees for individual services and billing Medicare as if it were an insurance company—but one that pays far less—regional health directors would set the budgets for hospitals. This would incentivize hospitals to provide quality care, instead of whatever services make the most money. As it stands now, you have doctors ordering unnecessary tests because they’re big money-makers, which is how you get an ER charging $12,000 for treating a bee sting.

Obviously, getting global budgets under Medicare for All wouldn’t be the end of the fight. Just as various British governments have cut NHS budgets, it’s not a guarantee that budgets would be set at a level necessary to provide quality care. This is true of every service the government provides, from education to the Post Office; there is always a risk of underfunding and neglect, and that risk must always be fought.

That problem is not an argument for the government not providing those services, it’s an argument for funding those services properly. It is impossible to argue that this could be worse than the current situation, where you have rural hospitals existing only on the superhuman strength and generosity of their workers.

Maybe there are incremental tweaks that would help hospitals like Fairfax Community Hospital; maybe if Medicaid and Medicare paid higher rates, they could have kept the lights on longer. But the taxes required to fund that would be fought by every selfish billionaire who fights Medicare for All, too.

When you get to the point where octogenarians are working full-time to make ends meet, houses are rotting away when their owners die, and hospitals can’t even insure their own workers, it’s hard not to see all of this as an indictment of the current system, and that the time for tweaks and patches has long passed.