Dan Gorenstein: There’s a crisis that’s gripped rural America for years.

News clip: These days the term critical condition doesn’t just apply to the sickest of patients in a hospital. The words could also apply to a number of our small towns that suddenly have no hospital at all.

DG: Policymakers have pledged to bring relief to rural patients, but the issue persists.

Today we hear from a journalist who spent a year embedded in one town whose hospital shut its doors.

From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

Sarah Jane Tribble: Hello, I’m Sarah Jane Tribble. I’m a senior correspondent with Kaiser Health News in Washington, D.C. But I grew up in the middle of America, in Kansas.

DG: Sarah Jane Tribble has been a reporter for more than 20 years working at newspapers and radio stations across the country.

SJT: I started out of school in the 1990s covering health care on the business desk at a newspaper in Wichita, Kansas. So rural health was maybe not broken out by definition as rural health, but I’ve long been accustomed to reporting about it.

DG: Recently, Sarah Jane has been focused on a different Kansas town — Fort Scott — where she spent a full year reporting on the town’s health care needs and experiences as it dealt with the closure of its only hospital.

That reporting is the basis for the first season of a new podcast from Kaiser Health News and St. Louis Public Radio called Where It Hurts.

SJT: Let me set the stage for you a little bit. 60 million Americans live in rural America, so we’re not talking about a small percentage of the population. We’re talking about millions of lives affected by the kind of health care delivery that’s in these communities. Rural America, on a whole, is poorer, sicker and older than urban America. People whose lives are affected daily by chronic health issues. They have diabetes at higher rates. They smoke at higher rates, obesity at higher rates. These are communities that lack mental health services. They lack addiction services. So their lives are affected by health care in many ways.

DG: There are lots of hospital closures as well, right?

SJT: Right, on average, one or two rural hospitals close every single month. Over the last decade, a total of 130 some hospitals have closed, but 33 of those have been in the last two years. So that gives you kind of an idea of the magnitude of the problem we’re dealing with.

DG: As you say, there are lots of hospitals closing in rural America. Why did you pick Mercy Hospital in Fort Scott? And also real quick, before we get any further, where is Fort Scott? I know, I’ve been to Kansas, and I know it’s sort of a rectangle shape. So where is it at?

SJT: So you fly into Kansas City and you drive two hours south and you hit Fort Scott, you drive another hour south, and you hit my hometown. And I picked it because I knew that Mercy Health System, which is based out of St. Louis, it’s a regional health system, I knew they had closed another hospital in southeastern Kansas in 2015. So I got the call from my mom about this hospital closure. She said, can you believe it? We’re losing another hospital. So I went in with the expectation of trying to figure out why is this happening here, and what does that mean for the rest of the country?

DG: After that phone call from her mom, Sarah Jane flew out to Fort Scott in December of 2018, right before the hospital was set to close. 

She was just planning on doing a quick one-off story, talking with all the major stakeholders.

SJT: I landed an interview with the president of the closing hospital, Reta Baker, and she was emotional and gracious, and she was from the region, so she spoke from the heart.

Where It Hurts: RETA BAKER: I feel a deep love and a deep passion for the community, and I will go down working hard for the community. And they say a good captain goes down with their ship. 

DG: She talked with the city manager, a man named Dave Martin. 

Actually, he sought her out.

SJT: He wanted to make sure that his town came out looking good.

Where It Hurts: DAVE MARTIN: And I just want everybody to know that I feel like we are in a very good place. And I’ve tried to talk to people about that.

DG: And most importantly, she talked with the people of Fort Scott. People who worried about what it would mean to lose their hospital.

SJT: They were angry, they were in denial, they didn’t want their hospital closed. 

Where It Hurts: PAT WHEELER: I don’t understand how they can just so blatantly close the hospital. I mean, I understand dollars and cents. But at the same token, where is the humanity, you know? What are people like us supposed to do?

SJT: The hospital had been there for 132 years, started by nuns. It was part of the community, part of their DNA. And so I wrote it all up and turned it in. And the editor came back to me and said, “You know, I think this could be a podcast.”

DG: So Sarah Jane went back to Fort Scott, where she quickly figured out that this story was about a lot more than a hospital closing.

SJT: After the hospital closed, there was the big grocery store that closed down. They didn’t say it was directly related to the hospital, but it closed within about the same period of time because of not enough customers. Then the cancer center said it wouldn’t stay open, the town was changing too much. Then months later, the dialysis center closed. So this trickle down effect is because of the decline of the area and the loss of the hospital.

DG: But the hospital shutting down did more than just exacerbate the town’s economic problems. 

It left the people of Fort Scott feeling abandoned.

Where It Hurts: PAT WHEELER: They took more than a hospital from us. 

SARAH JANE TRIBBLE: What else did they take? 

PAT WHEELER: They took our security, our dignity, our lifeline. A lot of people’s lifeline.

DG: Did you want people to understand the anger off the bat?

SJT: Yes, yes, I did, because that anger was so, so vitriol when I went to Fort Scott. People were angry that Mercy had left. They were angry that the nuns who founded this hospital, you know, more than a century ago, had abandoned them. This is a place that, you know, its name was on the local ambulances, it ran the ambulance service. The local ambulance was always at the Friday Night Football games. So all the parents knew the kids were going to be OK if something happened on that field because Mercy was there. That’s the kind of thing that really impacts a community. Well, Mercy’s not going to be there anymore. What’s going to happen?

DG: This is where a lot of stories about closing rural hospitals end: angry communities feeling betrayed, wondering what’s going to happen next.

But Sarah Jane wanted to understand why hospitals in places like Fort Scott were closing.

More on that, after the break.

MIDROLL

DG: Before the break, Sarah Jane Tribble was just starting her yearlong reporting on Fort Scott, Kansas, and she wanted to know why the town’s hospital was closing.

It didn’t take long to find the answer.

SJT: Not enough patients. The weekend before I arrived to interview Reta Baker, the former president of Mercy Hospital, there were zero patients in the beds. And the average census the previous year, average daily census was nine patients.

Where It Hurts: RETA BAKER: Whether we like to say it or not, health care is a business and yes, we are not for profit. But that doesn’t mean we don’t have to have a profit.

DG: Kansas is one of 12 states that has not expanded Medicaid, and with nearly 1 in 5 people in Fort Scott living in poverty according to the Census Bureau, many people in town can’t afford to go to the hospital.

And it wasn’t much better for people with private insurance.

SJT: In Fort Scott, there’s a large manufacturing base. And there’s a school district that’s a large employer as well. They had high deductible health plans, $2,500, $5,000 deductibles. That’s a pretty large stretch to reach before you get any insurance coverage for your care. The other thing about high deductible health plans is insurance companies will encourage you to shop around for the best price. So if you need an MRI or CT scan, you may drive right past Mercy Hospital into Kansas City. So that was also happening. People who loved Mercy, would drive right past it because they could get cheaper care.

DG: At the end of day, Sarah Jane realized the hospital wasn’t meeting the town’s needs.

SJT: A hospital is for treating surgeries and emergencies, and once you get to a hospital, as one guy in Fort Scott told me, it’s too late, right? Like you’re already sick. And what these communities have experienced is a lifetime of illnesses. These are preventable illnesses, chronic illnesses. And so what rural communities and really much of the nation needs isn’t necessarily hospitals, but more resources to take care of their everyday health needs.

DG: Health needs like the ones Pat Wheeler and her husband Ralph live with.

Where It Hurts: PAT WHEELER: I’m just a small-town girl. I have always lived in small towns, and I love this small town.

SARAH JANE TRIBBLE: She told me her husband was sick.

PAT WHEELER: You know, he’s had a tough road. The kidneys have really been a major problem. Thankfully, we have — thank goodness — dialysis here in Fort Scott.

SARAH JANE TRIBBLE: And about their money problems.

PAT WHEELER: We’ve been trying to apply for the state for help to try to help pay for the medical bills.

DG: At one point, you write, and this is a very sobering line. You say, “It was as if Pat’s troubles defined her more than anything else.”

SJT: She’s in her 60s, and it has been a life that’s had a lot of pain in it. She’s been a long time smoker as has her husband. Both have emphysema. Her husband has kidney failure. And you can connect the dots with Pat to the hospital closure, not necessarily because she was using it, but because of what she wasn’t getting from the hospital that she may have needed.

DG: Another line early in the episode that really caught my ear, Sarah Jane, was when you said again talking about Pat that her life is, “An example of some of our country’s toughest health care problems.” How do you think introducing Pat and Ralph to Kaiser Health News’ audience of people on the Hill, in statehouses around the country, movers and shakers in health care. How do you think introducing Pat and Ralph could influence health policy decisions?

SJT: What did you think of Pat and Ralph, Dan?

DG: I thought that Pat summed it up well when she said, effectively, my life is hard, but what am I going to do about it? 

Where It Hurts: PAT WHEELER: What’s the alternative? What’s the alternative?

DG: I’m just going to keep doing the best that I can.

Where It Hurts: PAT WHEELER: You can either dwell on it and get more depressed or you deal with it and you go on

SJT: I want our audience to know that there are people out there, they’re not giving up. Once you hear their voices and you understand their lives, then you can say that you know a little bit more about what’s needed in the communities where folks like Pat live.

DG: I know you are a journalist, you are not a policy wonk, you are not a lawmaker. But very few people get to spend a year embedded in a community really trying to understand it the way you did. So, Sarah Jane, I’m really curious, in your mind, what prescriptions came out?

SJT: I think that we cannot go in assuming that every rural community needs a hospital and we also cannot assume we know what a hospital is by definition. What I found in Fort Scott was a lot of people who thought they needed the hospital, but what they needed was maybe some other kind of health care services that might be better provided by a different facility. When the 90-year-old town historian says he wants a hospital to come back, what’s he actually talking about? He remembers when the nuns were with him at 2 in the morning taking care of him because his tonsils came out and he was there for several days, right? That’s not going to happen today. And if the hospital’s not providing that today, well, what are they providing? And is that something every single community needs? I’m not sure it is. Maybe some communities need it. It should be the decision of those communities, perhaps, but I’m not sure every community needs it.

DG: You’ve talked about this a little bit in our conversation, and you talk about it the second episode of the podcast. This story, this series is personal to you. Why? Beyond the fact that you grew up not far from Fort Scott.

SJT: This season, No Mercy, is dedicated to my older sister, Maggie. She was living in Kansas City when she died from pancreatic cancer at the age of 46. When I went on my first trip to Fort Scott, I flew in and I stepped off the plane and I had a ton of text messages from my family. Maggie had been put in the hospital again, and it was the beginning of her final stages of living, and she died early on in this reporting process. My sister and I were very close in age, and this was a process of grieving this year, 2019, when I went back so many times. I went back for reporting, I went back for family. Every time I went back to report on a story, I made sure I traveled to my parents’ house. And the people in Fort Scott would ask me, are you going to see your parents? They were invested in that. And some of them still call and ask me how everything’s going from a personal standpoint, because they knew that I had lost my sister.

DG: How did reporting on Fort Scott and Fort Scott going through its grieving process help you grieve?

SJT: I think being home helped with the grieving process, being able to, one, frequently see my family, but also being in the Midwest with the big open skies and seeing the places that I grew up familiar with and, you know, going out and standing in a pasture with cows, that just made me feel better. It fills up your soul to be back home, wherever home is for you. I also want to give credit to the people of Fort Scott. They’re strong, they’re courageous, they’re not giving up. And so to spend time with people like that is also good for the soul, if you will.

DG: What was really important to Maggie? What did she care about?

SJT: I didn’t expect that question, Dan. What was important to Maggie was sharing stories and making sure other stories were heard. She’s the reason I’m a journalist. She took high school journalism and she made it look so easy and was having so much fun, I decided to follow her. Imagine having your little sister come behind you the year after and then bigfooting, trying to write stories when you’re trying to write stories. It was a very frustrating situation for both of us, but she’s the reason I did it. I became a journalist because Maggie was first on the newspaper staff.

DG: If she could be here right now, if she could see this, this series that you’ve done, what would she think? What would she say?

SJT: I think she would be thrilled that people in Fort Scott, Kansas, are being heard honestly in a way that their voices are out there so that people can listen and learn from them.

DG: Sarah Jane, it’s been a pleasure talking to you.

SJT: Thank you, Dan.

DG: Sarah Jane Tribble is the host of the first season of the new podcast Where It Hurts.

The first two episodes are out, and new episodes drop every Tuesday. 

You can find it wherever you find our show or at WhereItHurts.show

I’m Dan Gorenstein, this is Tradeoffs.