The share of rural Americans who live in communities without a hospital grows each year. It’s part of an ongoing collapse in rural health care that has persisted for decades and isn’t improving, despite regulatory efforts to shore up small-hospital finances.

Since 2010, about 150 rural hospitals have shuttered and hundreds more have slashed services, leaving a growing number of America’s 60 million rural residents in health care deserts.

In this 2020 encore episode of the “Tradeoffs” podcast, Dan Gorenstein talks with Ñî¹óåú´«Ã½Ò•îl Health News chief rural health correspondent Sarah Jane Tribble about her yearlong effort to document the collapse of one rural Kansas community hospital. Nearly six years later, the residents of Fort Scott, Kansas, still live without a local hospital, a reality visited upon dozens more small towns in the years since.

“We’re talking about millions of lives affected by the kind of health care delivery that’s in these communities,” Tribble said. “Rural America, on a whole, is poorer, sicker and older than urban America. People whose lives are affected daily by chronic health issues.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Searching for the Nuns Who Ghosted Fort Scott

Host Sarah Jane Tribble sets out on a mission to learn more about the Sisters of Mercy, the nuns who founded Fort Scott’s Mercy Hospital and were once prominent leaders of the community. Tribble’s first glimpse into their lives takes her to an old convent. To learn more about the founding of Fort Scott’s hospital, listen to Episode Four.

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How’s Josh?

Before Fort Scott’s hospital shut down, Josh was a teenager coping with his aging grandparents and the emotional burden of his mother’s opioid death. The family’s troubles worsened after the hospital closed. Tribble gives Josh a call to find out his next steps. If you want to hear more of Josh’s story, we tell it in Episode Six.

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“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

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Family physician Maxwell Self is doing his same old job for a new employer. For two decades he was a doctor with Mercy Hospital. But when Mercy packed up and left, a federally qualified health center moved to town — into the hospital building itself — and hired Dr. Self.

The Community Health Center of Southeast Kansas does things differently.

“What CHC says really has teeth and they’re solid,” Self said. “There’s real follow-through. And I have a lot more, I feel like, freedom to take care of people the way I want to and to get them what they need.”

With nutrition counseling and mental health and addiction services, and even things like arranging rides for patients, the center offers people what they need to be healthy, clinic executives said — not only health care for when they’re sick.

In the final chapter of the podcast, we also meet Sherise Beckham, 31, who lost work as a dietitian at Mercy when the hospital closed — just as she was expecting her second child.

“Initially, I cried a lot because I would be losing my job as well as losing a place to have my baby,” Beckham said.

Beckham helps explain how much more difficult it can be to have a baby when a town loses full-service maternity care. Then, later when she gets a job at — where else? — the new CHC clinic, Beckham gives us a front-row seat to the new vision for health care in Fort Scott.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

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Josh is 17. He said he smokes marijuana. He struggles with anger.

He’s also juggling some extraordinary responsibilities for a teenager. Josh’s mother died of a drug overdose when he was 3 years old and he has lived with his grandparents ever since. When his grandfather’s heart started failing, Josh and his grandmother followed as his grandfather was shuttled from one regional hospital to another. The family couldn’t pay their light bill and struggled to find the money to pay for gas for the car. They wanted to stay nearby as Josh’s grandfather recovered in the hospital, but paying for a hotel was another financial burden.

Josh said he had to be there to help even though it meant missing school.

“I’m just taking care of my family. I’m doing what I was raised and taught to do,” he said. “Gotta survive. Family sticks together.”

To protect his privacy and because Josh was a minor when he shared his story, we are not including his last name.

In Chapter 6 of “No Mercy,” he talks about the health care challenges his family faces — and his own struggles growing up in a town where drugs are readily available but jobs aren’t.

The podcast also spotlights new health services now available in Fort Scott. Mercy Hospital, which closed at the end of 2018, did not provide addiction or behavioral health services, but the new community health center in town does.

“I get the privilege of working with hardworking, blue-collared folks and they oftentimes view, you know, depression, anxiety or bipolar disorder or battles with addiction as a weakness,” said Eric Thomason, director of addiction treatment and behavioral health services.

“And there’s no hardworking person that wants to just sit here and admit that they have a problem. And so a lot of times we avoid it. And what happens when we avoid chronic illness, regardless of if it’s diabetes, hypertension or depression, is it gets worse.”

Thomason said part of the health center’s work is convincing people to feel comfortable enough to come in and get help.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

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And to hear all KHN podcasts, click here.

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Sixty-five-year-old Karen Endicott-Coyan is living with a blood cancer.  Her chemotherapy takes less than 30 minutes. Before the hospital closed, it was just a short drive into the small town of Fort Scott, Kansas, for her to get treatment.

But these days getting to chemo means a trek on rural roads and narrow highways, driving help from her sister-in-law and some Ritz crackers tucked into her purse to steady her stomach on the way home. The whole trip should take less than three hours. Endicott-Coyan puts on her makeup, her diamond earrings and powers through.

“If I can help it, I’m not going to go over there looking like a sick person,” Endicott-Coyan said. “I don’t like looking like a sick person. That’s just me.”

Endicott-Coyan had a long career in hospital administration, and she uses that expertise to try to smooth out her newly fractured health care. But during every minute of the trip, a nagging worry at home steals her energy and attention. In this chapter of the podcast, host-reporter Sarah Jane Tribble goes along for the ride and is witness to the stress and frustration.

The journey illuminates one reason people in rural America are more likely to die from cancer than patients in metro areas.

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And check out Sarah Jane Tribble’s previous reporting on rural cancer care.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

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And to hear all KHN podcasts, click here.

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Ever since Mercy Hospital went “corporate,” things just haven’t been the same — that’s what lots of locals in Fort Scott, Kansas, said when the Mercy health system shuttered the only hospital in town.

It’s been years since Catholic nuns led Mercy Hospital Fort Scott, but town historian Fred Campbell is wistful for his boyhood in the 1940s when sisters in habits walked the hallways.

“Well, I had never, ever been in a hospital. And here came these ladies in flowing robes and white bands around their faces. And I was scared to death. But it wasn’t long ’til I found that, first thing I know, they had some iced Coca-Cola. I still remember them putting their hand on my head to see if I had a fever.”

For more than 100 years, Mercy Hospital — and the nuns who started it all — cared for local people. But in recent years, Fort Scott’s economy and the hospital’s finances faltered. Campbell hoped both could survive.

“Mercy Corporation, can you stay with us longer?” he wondered.

In Chapter 4 of Season One: No Mercy, podcast host Sarah Jane Tribble carries that question to Sister Mary Roch Rocklage, the powerhouse who consolidated all the Mercy hospitals in the Midwest.

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“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on , , , or .

And to hear all KHN podcasts, click here.

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Emergency care gets complicated after a hospital closes. On a cold February evening, when Robert Findley fell and hit his head on a patch of ice, his wife, Linda, called 911. The delays that came next exposed the frayed patchwork that sometimes stands in for rural health care.

After Mercy Hospital Fort Scott shut down, many locals had big opinions about what kind of health care the town needed.

“Words of experience is, you don’t know when that tragedy is going to happen,” Linda Findley said.

Fort Scott’s free-standing ER and the new community health center aren’t enough, she said.

“I mean, my gosh, you need to feel like you’re safe and could be taken care of where you’re at,” she said.

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“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

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And to hear all KHN podcasts, click here.

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Closing a hospital hurts. In Fort Scott, Kansas, no one was a bigger symbol for that loss — or bigger target for the town’s anger — than hospital president Reta Baker. Baker was at the helm when the hospital doors closed.

“I don’t even like going out in the community anymore, because I get confronted all the time,” Baker said. “Someone confronted me at Walmart. You know — ‘How could you let this happen?’”

The closure put Baker at bitter odds with City Manager Dave Martin, who some in town call “the Little Trump” of Fort Scott. Martin said his town wasn’t given the chance to keep the hospital open.

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“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

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Midwesterners aren’t known for complaining. But after Mercy Hospital Fort Scott closed, hardship trickled down to people whose lives were already hard. In Chapter 1, we meet Pat Wheeler, who has emphysema. Her husband, Ralph, has end-stage kidney failure, and the couple are barely making ends meet as they raise their teenage grandson. Pat is angry with hospital executives who she said yanked a lifeline from residents. “I don’t understand how they can just so blatantly close the hospital. I mean, I understand dollars and cents,” Wheeler said. “But at the same token, where’s the humanity? You know, what are people like us supposed to do?” she said.

Many others felt the same. Fort Scott City Manager Dave Martin felt betrayed. And former, longtime hospital worker Roxine Poznich said: “You just don’t know the pain that the employees were in — not just for themselves, but for the community. I mean, there were lots and lots of tears that I saw. And it was just very sad because those people, they were my family,” she said.

Each season, “” takes you somewhere new — to an overlooked part of the country to explore cracks in the American health system that leave people frustrated — and without the care they need.

The story begins in Fort Scott, Kansas. Rural. Deeply Christian. And sicker than other parts of the state. When Mercy Hospital shut its doors, the town’s sense of identity wavered. Season One “No Mercy” is about the people who remain, surviving the best way they know how. Host and investigative journalist Sarah Jane Tribble spent more than a year revisiting southeastern Kansas, where she grew up, to document the sparking tensions, anger and fear many people felt as they struggled to come to terms with the hospital’s closure.

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“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on , , , or .

And to hear all KHN podcasts, click here.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

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FORT SCOTT, Kan. ― 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 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.

‘You Will Be Taken Care Of’

Self has cared for his share of struggling patients in this town, where 1 in 4 children live 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.

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.

Randy Cason, president at Ascension’s Pittsburg hospital, drove to Fort Scott to tell the weekly chamber coffee that doctors needed to “counsel and educate” mothers that it’s no longer a 10-minute drive to the hospital.

Sherise Beckham, a former Mercy dietitian, was anxious on bed rest this spring while awaiting a baby. “You’re on a two-lane highway; a lot of times you get behind a semi, behind a tractor,” Beckham laughed. “Sometimes, you are lucky if you have cell service.”

Beckham’s delivery did not go as planned. After driving to Ascension’s Pittsburg hospital to meet her family doctor, she had an unexpected cesarean section, and the baby, whose heart rate dropped dramatically, was transferred to a neonatal intensive care unit an hour away from home in Joplin, Mo. Now, eight months later, the baby is healthy though he continues to see a physical therapist who monitors his developmental progress.

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 are largely rural and many are in the South, where the greatest number of hospitals have closed.

Signs Of Change

Catholic nuns founded the Fort Scott hospital more than a century ago and 89-year-old Fred Campbell still recalls a mantra etched in stone over the entrance of one old Mercy hospital building: “Dedicated to suffering humanity.”

“We always felt that, man, come hell or high water, you’re gonna be with us and you’re not going to abandon us,” Campbell said.

But exactly a year ago, its then-owner, St. Louis-based Mercy, a major health care conglomerate with more than 40 hospitals, declared it no longer financially viable.

Within weeks of Mercy closing, a newly built $9 million grocery store closed. A few weeks later, the cancer center closed and, by October, the town’s dialysis center had closed, too. John Leatherman, professor for the department of agricultural economics at Kansas State University, said there’s no doubt Bourbon County took “a big hit” when the hospital was shuttered.

Roxine Poznich lost her income when her job at Mercy ended. After more than 20 years at the hospital, the 73-year-old said she now finds herself paying for groceries with her credit card ― even though she is unsure whether she can pay the bill at the end of the month. “I’m scared,” Poznich said.

But Fort Scott economic development director Rachel Pruitt said the loss of the hospital has not affected the city’s sales tax revenue. Manufacturers like the community’s largest employer, Peerless Architectural Windows and Doors, with its 400 jobs, continue to expand ― just down the road from where Mercy’s 177,000-square-foot hospital building still stands.

City leaders say ideally the community would “right-size” its health care. That would include keeping the current outpatient clinics that provide primary care and an emergency department but also adding some inpatient beds, allowing residents with short-term hospitalization to stay local. Pruitt said there has even been talk of adding a wound center that could treat injuries among the town’s industrial workers.

And, though the mostly empty Mercy Hospital building feels like a white elephant, that too may soon change: Mercy recently announced it would donate land in a repurposed corner of its property to Community Health Center. Health center leaders have hired an architect for a new building that will probably be about 30,000 square feet. Wellness, imaging, walk-in care, a women’s health center, dental care and expanded primary and specialty care would be available.

ER operator Ascension declined requests for interviews, but spokeswoman Michelle Kennedy said the Pittsburg leadership team is “working on plans related to our presence in Fort Scott in the near future” but could not release details. City leaders say they are confident an ER will remain.

In the background, there is Reta Baker. Residents here denounced the former president of Mercy Hospital Fort Scott at the time of the closure. She sold her house and moved closer to her new job with CHC, at its headquarters in Pittsburg, Kan.

Baker, who started her career as a nurse at Fort Scott’s hospital in 1981 and grew up nearby, said she continues to “be engaged in a lot of conversations” about the community’s future. The next year will have growing pains, she said, but she believes the health care needed for residents is there.

“Now, we need to cement it,” she said.

This is the final installment in KHN’s year-long series, No Mercy, which follows how the closure of one beloved rural hospital disrupts a community’s health care, economy and equilibrium. Coming in 2020, a podcast from KHN with more voices and stories from Fort Scott, Kansas.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .