Rural Health Care Woes are Not an Unsolvable Problem

Here is the second part of La Grange native Russ Friemel’s guest column about our hospital situation in the aftermath of St. Marks Medical Center’s closure in October. The first part ran in last Friday’s newspaper.

The Texas Legislature has a lot of public money at its disposal. The Texas Senate recently passed Senate Bill 1 that would allocate $500 million for the next two years to the “school voucher” program, allowing eligible students to receive up to $8,000 to help pay for the costs of private or charter schools. Rural Republican and Democratic Texas House members have been largely opposed to SB 1 because they believe it hurts rural public school funding. It seems the Legislature could appropriate significant amounts of money for rural hospitals.

On September 25, 2023, the Governor’s Office announced that $4.5 million in funding was made available by the State for four (4) Rural Emergency Hospitals, specifically Crosbyton Clinic Hospital, Anson General Hospital, Falls Community Hospital and Clinic in Marlin, and St. Mark’s Medical Center in La Grange. Up to $1.1 million was available to each hospital through a two-year grant — $750,000 for the first year and $375,000 for the second year. The Fayette County Record reported that St. Marks closed on Oct. 12, 2023. The hospitals had until Oct. 13, 2023 to apply for the grants. The Texas Legislature appropriated $25 million per year for rural hospitals beginning Sept. 1, 2023. According to the Texas Hospital Association, there are (or were) about 147 rural hospitals in Texas.

$25 million divided among 147 rural hospitals is about $170,000 each. Not a lot for each hospital.

Former County & District Attorney John Wied suggested (FCR 10/24/23) that it might be possible to negotiate a reduction of the $13 million existing debt on the Hospital. Enhanced County EMS services (including “mobile ICU” vehicles), the Legislature increasing State funding for rural hospitals and/ or expanding Medicaid, Rural Emergency Hospital (REH) designation, ownership and operation of facilities by a private company or large Texas hospital system or establishing a hospital district are all measures that could aid in improving availability of emergency and medical services.

Texas has not accepted the Medicaid expansion which is part of the Affordable Care Act, also known as ObamaCare. The expansion would pay 90% of all hospital bills of uninsured Texans coming to rural hospitals.

The Texas House of Representative rejected Medicaid expansion by a vote of 80 to 68 in 2021.

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 . . . .

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 in-patient 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.