By Taylor Sisk for KFF Health News.
Broadcast version by Shanteya Hudson for North Carolina News Service reporting for the KFF Health News-Public News Service Collaboration

On a mid-August morning, Christopher Harrison stood in front of the shuttered Martin General Hospital recalling the day a year earlier when he snapped pictures as workers covered the facility’s sign.

“Yes, sir. It was a sad day,” Harrison said of the financial collapse of the small rural hospital, where all four of his children were born.

Quorum Health operated the 49-bed facility in this rural eastern North Carolina town of about 5,000 residents until it closed. The hospital had been losing money for some time. The county’s population has slightly declined and is aging; it has experienced incremental economic downturns. Like many rural hospitals, those headwinds drove managers to discontinue labor and delivery services and halt intensive care during the past five years.

Prospects for reopening seemed dim.

But a new hospital designation by the Centers for Medicare & Medicaid Services that took effect last year offered hope. As of August, hospitals in 32 communities around the country have converted to the rural emergency hospital designation to prevent closure. The new program provides a federal financial boost for struggling hospitals that keep offering emergency and outpatient services but halt inpatient care.

The REH model “is not designed to replace existing, well-functioning rural hospitals,” said George Pink, a senior research fellow at the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, which has documented 149 rural hospitals that have either closed or no longer provide inpatient care since 2010. “It really is targeted at small rural communities that are at imminent risk of a hospital closing.”

The program hasn’t yet been used to reopen a closed hospital.

With guidance from health consultants, Martin County officials asked federal regulators to explore the possibility of adopting the REH model and were ultimately given the go-ahead.

If successful, Martin County could become one of the first in the nation to convert a shuttered hospital to this new model.

Ask members of a community that has lost its hospital what they miss most, Pink said, and it’s almost invariably emergency services. Count Harrison among them, especially after a medical crisis nearly killed him.

Harrison, who lives in a smaller crossroads community a few miles south of Williamston, began experiencing leg pain in February. Under normal circumstances, Harrison said, he would have gone to his primary care doctor if his leg began to hurt. This time he couldn’t, because the practice closed when the hospital folded months earlier.

Then, one morning he awoke to find his foot turning black. It took him 45 minutes to drive to the closest hospital, in the town of Washington. There, doctors found blood clots and he was flown by helicopter to East Carolina University Health Medical Center. A doctor there told him that he’d probably had the blood clots for close to a year and that he was lucky to be alive. The medical team was able to save his foot from amputation.

Harrison, like many other community members, now had firsthand experience with the consequences of a shuttered hospital.

The state legislature’s decision last year to expand Medicaid has meant fewer North Carolinians are uninsured, which means fewer hospital bills go unpaid. But health care is evolving: Many procedures that once required inpatient care are now performed as outpatient services. Dawn Carter, the founder and a senior partner of Ascendient, a health care consulting firm working with the county, said the inpatient census at Martin General in its last few years ranged from five or six a day to a dozen.

“So you’re talking about a lot of cost, a lot of infrastructure to support that,” she said.

With no emergency care within a half-hour radius, Martin County administrators believe a rural emergency hospital would be a good fit and a viable option. REH status allows a hospital to collect enhanced Medicare payments, an annual facility payment, and technical assistance.

Carter said the team will present to the state Department of Health and Human Services a set of drawings of the portion of the building they intend to use to see if it meets REH regulations.

“I’m hoping that process is happening in the next several weeks,” she said, “and that will give us a better idea of whether we have a handful of really quick and easy things to do or if it’s going to take a little more effort to reopen.”

Officials then will take proposals from companies interested in running the hospital.

Carter said the expectation is that, initially, the facility will be strictly the emergency room and imaging department, “and then I think the question is, over time, where do you build beyond that?”

And the rebuilding could prove a challenge from the start. Many former staff members have taken positions at nearby health care facilities or left the area. The effects of that exodus will be compounded by the widespread difficulty in recruiting health workers to rural areas.

It’s early yet, Pink said, to assess the success of the rural emergency hospital model. “All we have are armchair anecdotes.” It seems to be working well in some communities, while others “are struggling a little to make it work.”

Pink has a list of questions to assess how an emergency hospital is faring in the long run:

• Is it at least breaking even? And if not, do administrators foresee a solution?


• How is the community responding? If someone believes they have an issue that might require inpatient care, Pink suggested, perhaps they’ll bypass the REH for a hospital that can admit them. And to what extent does bypassing their doors carry over to all services?


• Are patients happy with the care they’re receiving? Are the clinical outcomes good?

The rate of rural hospital closures rose through 2020, then dropped considerably in 2021. Congress had passed the CARES Act, and the Provider Relief Fund offered a financial lifeline, Pink said. That money has now been distributed, and the concern is that “many rural hospitals are returning to pre-covid financial stresses and unprofitability.”


If the trend continues, he said, more rural hospitals may turn to the REH model.


Ben Eisner serves as Martin County’s attorney and interim manager. He acknowledges that the health and well-being of this community require a lot more than a hospital. He cites, for example, a new nonprofit with a mission to address the social determinants of health.


Advancing Community Health Together was created in response to the hospital closure. Composed of community members, its focus is addressing inadequate health care access and poor health outcomes as a consequence of generational poverty, said Vickey Manning, director of Martin-Tyrrell-Washington District Health.


“We can’t address rural health care in a vacuum,” Carter said. Her organization, Ascendient, is part of the Rural Healthcare Initiative, a nonprofit commissioned by the North Carolina General Assembly to study sustainable models of health care for rural communities.


Like most of rural eastern North Carolina, Martin County is in transition, Eisner said. Diminishing family farms, less industry. “And so the question becomes,” he said, “‘What happens for all these communities? What happens next?’ And it’s an answer that is not yet fully written.”


Harrison, still relying on crutches to get around, recently drove 45 minutes north on U.S. 13 to the town of Ahoskie to have a doctor examine his foot. He said a hospital that offers basic emergency care isn’t a perfect solution, but he’ll have some peace of mind once the cover is peeled from that sign and his local hospital reopens.




Taylor Sisk wrote this story for KFF Health News.


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It is National Rural Health Day and experts are flagging research showing increasing health disparities between urban and rural places, including in South Dakota.

A new advisory from the American Heart Association shows between 2010 and 2022, cardiovascular death rates increased a whopping 21% among young adults in rural areas, especially after the onset of COVID-19. In urban areas, the rate increased only 3%.

Dr. Karen Joynt-Maddox, associate professor of medicine at Washington University, chairs the association's presidential advisory committee and said the change is due to a mixed bag of increased risk factors in rural areas.

"If you put that on top of a real problem with health care infrastructure and access in rural areas, you sort of have a perfect storm for worsening cardiovascular health."

Joynt-Maddox noted traditional risk factors include high blood pressure, diabetes and obesity, which have been increasing in rural areas over the last few decades. Other contributing factors, she said, include poverty, food insecurity, depression and substance use disorder.

Tim Nikolai, Midwest senior rural health director for the American Heart Association, said rural communities have less access to resources like health care and grocery stores with fresh produce. Even access to high speed internet contributes to health outcomes. Health care providers are stretched thin, Nikolai added.

"It stretched hospitals and health care providers to try to serve the needs of their community the best way they can," Nikolai observed. "And that's something we're trying to collaborate with them on, is how can they meet people where they are?"

Nikolai listed some work happening in South Dakota including offering blood pressure monitoring at local libraries, installing four new Public Health AmeriCorps members across the state and the town of Spearfish prioritizing public CPR training and AED access.

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More than 38 million Americans live with diabetes, including nearly 1 million Georgians.

The Georgia Department of Public Health estimates another 230,000 people in the state may have diabetes but don't know it.

During National Diabetes Month, Dr. Griffin Rodgers - director of the National Institute of Diabetes, Digestive, and Kidney Diseases at the National Institutes of Health - emphasized the importance of managing diabetes early to prevent serious health complications.

"Diabetes can damage blood vessels and nerves," said Rodgers, "so the patients that have it have a higher risk of developing conditions like a heart attack or a stroke, diseases of the kidneys and the eyes and the teeth, as well as the lower extremities."

Between 2014 and 2018, diabetes led to over 100,000 hospitalizations and 154,000 emergency-room visits in Georgia.

But Rodgers said diabetes is preventable and manageable. He added that regular wellness visits - where blood sugar, blood pressure, and cholesterol are checked - are key to staying healthy.

Rodgers said a healthy diet is a major part of managing or preventing diabetes.

He suggested eating plenty of fresh produce, whole grains, and lean proteins like fish - and cutting back on sugary drinks by choosing water instead.

Regular exercise and seven to eight hours of sleep each night are also important.

"On the physical activity side, 30 minutes a day, five days a week for most adults is what's
generally recommended," said Rodgers. "Just walking. And if you can't do the 30 minutes all at one time, breaking it into either two 15, or three 10-minute intervals is sufficient."

Early signals that diabetes could be a problem include frequent urination, constant thirst or hunger, fatigue, blurry vision, nausea, unexpected weight loss, or tingling in your hands and feet.

Rodgers said managing diabetes can be as simple as focusing on "the A-B-Cs of care" - checking your A1C, blood pressure and cholesterol levels, and quitting smoking.




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California could be in for some big cuts to health care for low-income families under a second Trump administration, according to health experts.

Policy specialists at the nonprofit KFF said they are bracing for Trump allies in Congress to make major reductions to Medicaid expansion under the Affordable Care Act, in order to pay for big tax cuts promised by the president-elect.

Larry Levitt, executive vice president of health policy at KFF, said it would force states to backfill or raise costs.

"For the ACA, simply letting enhanced financial aid expire after next year would result in big out-of-pocket premium increases, reduced enrollment and more people uninsured," Levitt projected.

Robert F. Kennedy Jr., President-elect Trump's choice for Health and Human Services Secretary, did not say much on the campaign trail about funding for Medicaid or the Affordable Care Act, so his positions are unclear. Kennedy has expressed skepticism about vaccines and has said the U.S. should stop putting fluoride in drinking water.

Jennifer Kates, senior vice president and director of the Global Health and HIV Policy Program for KFF, said the Centers for Disease Control and Prevention cannot require states to follow its recommendations on vaccines and fluoridation.

"That's up to states and local governments," Kates explained. "But CDC can recommend, and if those recommendations are not being made or being watered down or changed, that sends a message to states, to schools, to parents."

Health advocates are also raising concerns DACA recipients could lose access to health plans sold on the state marketplaces created under the Affordable Care Act. Changes to so-called "public charge" rules could make families with mixed immigration status hesitant to use Medicaid benefits.


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