Our Hospital Saga

The closure of St. Mark’s Hospital prompts me to write this. Many very knowledgeable, experienced officials and residents of Fayette County and La Grange have worked very hard on this problem.

I was born in La Grange at the old Fayette Memorial Hospital (Victorian-style building) in 1951 and grew up on our farm near Ellinger. I went to Blinn and then was commissioned into the Air Force as a JAGC officer after finishing business and law school at UT-Austin in 1977. I started working for the Tarrant County District Attorney’s Office in Fort Worth in 1996. After retiring in 2017, I went back to work part-time for Tarrant County a couple of times and fully retired in November of 2022. I live in Fort Worth but spend as much time as I can on our farm property which my sister and I still own (and pay taxes on).

On Oct. 24, 2023, I was helping dig up some small trees at the Fort Worth church that my wife and I attend, preliminary to a new landscaping project. We started about 8 a.m. and were working fast, trying to finish by noon. About 9 a.m., I started having chest pains and became unconscious. I was having what is sometimes called a “widow maker” (STEMI) heart attack. Fortunately, one of the men working with me immediately called EMS. EMS arrived within 10 - 15 minutes and transported me to Harris Methodist Hospital ER and Cardiac Unit less than 15 minutes away. I “coded” in the ER but was shocked back and immediately prepared for heart surgery by cardiology staff.

The American Heart Association recognizes a “golden hour” usually exists after a heart attack begins in which survivability can increase significantly and potential heart muscle and neurological damage can be reduced if appropriate medical care can be provided within that one hour. Had I not gotten emergency cardiac care as quickly as I did, I probably would not be writing this. I have only had slightly elevated blood pressure and cholesterol – both treated with prescription medication in the past – but no known “heart condition” or obvious symptoms or warnings.

Although Fayette County is a wonderful place to live for many reasons, it seems it may not be the best place to live now if a person has or could have a significant medical problem and might need emergency care since it has no hospital or ER. Dr. Tom Mueller noted in April 2023 that: “According to the Texas Hospital Association, 21 rural Texas hospitals have closed in the last decade, more than in any other state. Many others have eliminated key service lines — as of last year, for instance, only 40% of Texas’rural hospitals still have a labor and delivery unit.”

St. Marks ended labor and delivery services in 2017.

The question is: How should hospital and emergency medical care be made available to County residents? Progressive Health Group of Mississippi may be the answer. The Record reported (FCR 10/31/23) that Progressive is a “for-profit group that started in 2019 that focuses on turning around struggling rural health care facilities” and “operates a number of facilities in Mississippi and Alabama.” Private companies however sometimes go bankrupt and often are sold or have changes in leadership/ management - good and not so good. A private company can of course always decide to just stop operations. St. Mark’s is a tax-exempt charitable (IRC 501(c)(3)) organization. The Record reported (FCR 11/24/23) that St. Mark’s board of directors gave Progressive a right of first refusal to buy the hospital facilities.

It may be that the County should somehow have an ownership interest in or substantial control of a community hospital – or at least meaningful, enforceable oversight. Otherwise, local officials have no management or decision-making authority in hospital operations and administration or even access to information. In Texas, state and local governmental entities are required to comply (with some exceptions) with the Texas Open Meetings Act and Texas Public Information (Open Records) Act. This allows for “transparency”/ mandatory disclosure that is intended to protect taxpayers and inform the public on matters of public interest, largely government spending. Private businesses are of course not subject to these statutory disclosure requirements.

Another way for a county to have a community hospital is by establishing a hospital district – a separate unit of government that operates on a non-profit basis. In 2019, Fayette County voters rejected a proposition to establish a hospital district.

The Austin Statesman reported on 4-22-2021 that: Medicaid eligibility in Texas is limited to pregnant women, children, people with disabilities and people over 65. Parents can also qualify for coverage if their monthly income is $200 or less for a family of two or $300 or less for a family of four. Under Medicaid expansion, eligibility would broaden to include adults who earn up to 138% of the federal poverty level — roughly $1,500 per month for individuals or $3,000 a month for a family of four. Advocates say expansion would dramatically reduce the number of uninsured residents and deliver billions of dollars to the state . . . .

. . . . [The State] would be responsible for paying 10 cents on the dollar, or between $600 million and $700 million a year. The federal government would match the state’s investment and contribute close to $6 billion a year . . . .

Governor Abbott opposes Medicaid expansion and has described Medicaid expansion “a tax increase waiting to happen. The best way to get health care insurance is through an employer.”

As of Oct. 4, 2023, 40 states, including Arkansas (2013), Louisiana (2016) and Oklahoma (2021), have adopted Medicaid expansion. The CEO of the Oklahoma Hospital Association has said that: “States that expanded Medicaid have found that the failure rate in those rural hospitals abated. States that didn’t expand will continue to have closures. The people of Oklahoma, in passing Medicaid expansion, really have thrown out a lifeline to all of these rural communities.”

If the State of Texas doesn’t want to expand Medicaid coverage, maybe it could provide more funding to rural hospitals directly.

It would seem that essential, minimum medical care for County residents would include an ER and physicians providing emergency cardiac care and trauma services and labor and delivery services. Even short delays in emergency care can cost lives. I never expected to have a heart attack when I did.

If a for-profit, private business sees buying the facilities of a closed hospital with a $13 million debt and operating it on a scaled-down basis (as an REH) to be a viable (profitable) business opportunity, why could not, and should not, a county open and operate a REH facility (or contract out management but yet be able to maintain control of the REH)? As described above, an REH is “a hospital with little more than an emergency room.” An REH would cost less to operate than an inpatient hospital. Is “a hospital with little more than an emergency room” enough to meet the needs of the community? Is that all that people want? Will the REH always at least “break even”? If a REH is operated through a hospital/ medical district and doesn’t break even, will the county (taxpayers) subsidize the REH by voting for additional taxes?

Rural health care is complicated and expensive. If people want health care, someone of course has to pay for it. I hope that Fayette County always has more cows than people (FCR 11/13/23) but lack of medical services puts people at substantial risk and undermines economic stability and viability of the community (existing businesses and jobs.) Reliance on private hospital ownership and/or operation can be tenuous. Without meaningful local government oversight and participation, private ownership and management of a hospital in a community dependent solely on it can be problematic. Private businesses will always focus on making a profit and want to provide (and are only able to provide) those services that will turn a profit. Rural health care should not be and probably is not an unsolvable problem.

The Record reported that St. Mark’s converted to a “Rural Emergency Hospital” in February, 2023. (FCR 10/6/23) Congress created the REH designation in the Consolidated Appropriations Act of 2021 and authorized rural hospitals to convert to REH status after Jan. 1, 2023.

Mississippi Today published an article on Aug. 31, 2023 on rural hospitals in Mississippi converting to REH designation, explaining that: “Rural Emergency Hospitals” have to end inpatient services and transfer emergency room patients to larger hospitals within 24 hours. In exchange, they get monthly stipends from the federal government and higher insurance reimbursement rates. For rural hospitals with an alreadysmall daily census, it can be a lifeline — instead of losing money on what few patients they have, the adjusted reimbursements help them break even or even profit. However, for the communities with only one hospital, it means the end of inpatient health care and a hospital with little more than an emergency room.

“Critical access hospitals” — another designation designed to improve hospital finances — are reimbursed by Medicare at a 101% rate, theoretically allowing a 1% profit. However, they must have 25 or fewer inpatient beds, be located 35 miles from another hospital, operate emergency services and transfer or discharge their patients within 96 hours.

Rice Hospital District (Eagle Lake) and Lavaca County Hospital District (Hallettsville) both operate as a “Critical Access Hospital.” The boundaries the Rice Hospital District are “coextensive” with the boundaries of Rice Consolidated Independent School District in Colorado County. The Rice HD is governed by a board of nine directors elected from the district at large which may impose a tax on all property in the district subject to district taxation.

The Centers for Medicare and Medicaid Services (CMS) is the federal agency that approves conversion of rural hospitals to REH status. Politico reported on Oct. 24, 2023 that only 16 rural hospitals in the U. S. had converted to REH status.

Fayette County is fortunate to have the EMS services and dedicated EMTs that it does. In addition to Fayette County EMS Services, there are ERs or hospitals in Brenham, Columbus, Hallettsville, Smithville and Bastrop available to Fayette County residents. These are all probably 30 – 45 minute trips from La Grange. Giddings doesn’t have a hospital ER. In its 2019 federal tax return (pg. 43) published on ProPublica, St. Mark’s stated that its service area includes Fayette County and Lee County.

Schulenburg is 17 miles from Hallettsville, 19 miles from La Grange and 22 miles from Columbus. Flatonia is 22 miles from La Grange, 25 miles from Hallettsville and 27 miles from Smithville. Those distances might put much of Fayette County (pop. 24,435) in what could be considered a hospital ER “desert.” The Texas Comptroller has noted that a 2019 study on hospital closures resulted in a rise in patient mortality rates of roughly 8.7 percent in rural areas due to increased transport time between incident and medical care.

By comparison to Fayette County, Colorado County (pop.20,360) has two (2) hospitals: -- Columbus Community Hospital in Columbus, a private 40-bed, acute care medical and surgical facility; -- Rice Medical Center in Eagle Lake, a 25-bed critical access hospital (CAH) with Trauma IV designation.

To be continued...with a look at public money available to hospitals.