With many rural hospitals on the financial critical list, Congress created a Rural Emergency Hospital model in 2021 to help deliver critical care to struggling communities in Nebraska and elsewhere.
Two years in, the Bipartisan Policy Center has issued a report which showed care is improving where the system has been implemented but more work is needed. Under the model, 32 Rural Emergency Hospitals in 14 states have been established.
Julia Harris, health program director at the center, said the plan is preserving health care options for rural residents.
"If you start seeing hospital closures go down, that's a success measure," Harris asserted. "Because this should be what helps them meet the needs of the community and stay open rather than being forced to close."
Harris pointed out under the Rural Emergency Hospital model, a rural facility can offer emergency department, observation, outpatient care and skilled nursing facility services in a distinct unit. Warren Memorial Hospital in the town of Friend is currently the only such facility in Nebraska.
Harris noted the growth of the model is reducing the number of rural hospital closures but acknowledged challenges remain in operational flexibility and the availability of financial assistance. She emphasized they studied states across the Midwest, looking for hospitals and communities which could benefit from a Rural Emergency Hospital.
"The reason we chose Kansas and Nebraska is because there was some modeling done to see which states would have the most hospitals eligible for this model," Harris explained. "Those were two states that had a lot of potential REHs. "
Other recommendations in the report included support for prescription drug discounts, more flexibility in converting to Rural Emergency Hospital status, timely payments to speed the process and more funding for providing technical and operational assistance, with what are called technical assistance centers.
"There is a federal TA center to help hospitals that are trying to consider their pros and cons," Harris observed. "We advocate for continued funding for that TA center to be able to continue to do this sort of advising and help states make these choices."
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By Ilana Newman for The Daily Yonder.
Broadcast version by Eric Galatas for Colorado News Connection for the Public News Service/Daily Yonder Collaboration
One rural Colorado town is working to turn an irrigation ditch into a walking trail to connect the community, get people outside, and grow their recreation economy.
In 2022, Monte Vista, Colorado received a Recreation Economies for Rural Communities (RERC) grant, which helped the city strategize to revitalize main streets and grow their outdoor recreation economy. What’s now known as the Lariat Ditch Project came out of the RERC planning process.
The city of Monte Vista, population 4,070, sits in the middle of the San Luis Valley, a high elevation valley known for agriculture and access to some of the tallest mountains in the state. The region is known for their potato production, as well as growing barley, hay and alfalfa, according to their city manager, Gigi Dennis.
Dennis saw developing the local economy through tourism and recreation as a way to support agriculture and get people to “think about Monte Vista in a different light.” She wants people to think of the city as an active, enjoyable place to visit and not just an agricultural community.
Local nonprofit organization San Luis Valley Great Outdoors (SLV GO!) applied for and received the RERC grant on the city of Monte Vista’s behalf in 2022 and has since been involved with creating the plan to develop more of a recreation economy in the area. Mick Daniel, executive director of SLV GO!, said they saw a lot of potential for Monte Vista to benefit from more planning around outdoor recreation.
“We were sitting in the middle of like 8 million acres of public land….it kind of felt like there just wasn’t a lot of coordination between our public land managers, our communities, our recreationists,” Daniel said. The planning grant created an opportunity for all of those disparate groups to come together and create a cohesive strategy for the future of the city.
RERC is a program in partnership with the EPAs Office of Community Revitalization, the Forest Service, the USDA, the Northern Border Regional Commission, the Appalachian Regional Commission, and the Denali Commission.
It provides planning assistance for rural communities to grow their recreation economies. This can look like Main Street revitalization to support bringing visitors into the community, building infrastructure like trails, or creating community consensus on how to attract visitors and manage natural resources.
The Lariat Ditch Project takes a two mile stretch of open irrigation ditch that Daniel said is often filled with trash, pipes it, and places a trail on top.
In conversations with the ditch company, Monte Vista city planner Dwayne Enderle said “they were more than happy to look at placing the ditch into a concrete culvert and placing the walkway on top”. Especially because, according to Daniel, the company was experiencing a huge loss in water due to “seeping through the walls of the ditch”.
The trail would connect main street businesses in Monte Vista to their homes and other recreation opportunities around the area, including passing a half mile from the recently renovated Sky Hi Complex, a conference and event center that hosts Colorado’s oldest professional rodeo.
“What if we can connect this community to these valuable recreation resources? Maybe we don’t think about them as outdoor recreation, but a rodeo pretty much is outdoor rec,” said Daniel. The ditch also passes near downtown, the high school, the golf course, tennis courts, and through several neighborhoods.
The idea to build a trail along or on top of the ditch has been floating around the community for over a decade, Daniel said. But funding has, and continues to be, a challenge. The city of Monte Vista applied for a grant through the University of Colorado in 2024 to fund the project, but as of early January 2025, Dennis said that they have not yet been awarded any funding.
“It’s a $12 million project, which is phenomenal for Monte Vista because my general fund tax base is only about four and a half million dollars…It will be hard to fulfill if we don’t get the grant funding.” Dennis said.
Building trails to connect communities to the outdoors is something that SLV GO! is doing around the region. The Lariat Ditch trail would become a part of the “Heart of the Valley”, a system of trails that will connect the communities of the San Luis Valley to each other and to the public land that surrounds the area.
“You could potentially get on a bike or an e-bike and ride to the BLM or the Forest Service or ride over to dinner in Del Norte or lunch in Del Norte and maybe ride back,” said Daniel.
While these trail systems might also add appeal to tourists visiting the towns, for Daniel, developing the region’s recreation economy looks mostly like appealing to locals, not visitors.
Other towns in the valley, like South Fork, close to Wolf Creek Ski Area and located on the Rio Grande river, and Alamosa, the larger town closer to Great Sand Dunes National Park, see more tourism than Monte Vista. But Daniel knows that small business owners in Monte Vista would also love to see more visitors.
“I think by making it more livable for the people who live there, tourism will be a very pleasant side effect, not a bad side effect. The great thing about tourists is that they go home. They spend money, they go home,” he said.
Ilana Newman wrote this article for The Daily Yonder.
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By Anya Petrone Slepyan for The Daily Yonder.
Broadcast version by Eric Tegethoff for North Carolina News Service Service for the Public News Service/Daily Yonder Collaboration
In the 1930s, women employed by the Works Progress Administration rode pack horses through the mountains of eastern Kentucky, bringing books to rural residents in hard-to-reach places. Nearly a century later, Kirsten Crawford Turner is carrying on that tradition, with the help of a truck and a U-haul rather than a horse and saddle bags.
Turner grew up in Shelby, North Carolina in the Appalachian foothills, an area pummeled by Hurricane Helene in September 2024. Though she now lives in Greenville, South Carolina, she saw the extent of the damage the hurricane caused during frequent trips up the mountain to bring food and supplies to family members in the Asheville area.
"I saw all the devastation and I thought, 'what can I do?'" Turner said in an interview with the Daily Yonder. "I cannot operate heavy machinery. I cannot rebuild this whole area. What can I do that would be impactful and make a difference?"
As a military wife and mother of three, Turner has been through difficult seasons herself, and said that she always found solace in reading. She had also learned about the historic packhorse librarians from a number of books, including Kim Michele Richardson's The Book Woman of Troublesome Creek. So she thought, why not take books to people like a modern-day packhorse librarian?
She began by asking friends and neighbors for gently used books that she could deliver on her trips up the mountain. The project grew quickly in the months following the hurricane.
"It started with one box of books on my porch," Turner said. "Now I have thousands of books [to give away] in my house."
Books for Burnsville
On November 2, 2024, Turner and her husband pulled into the parking lot of the West Burnsville Baptist Church in rural Yancey County, North Carolina. Along with a handful of volunteers, including Turner's parents, they started passing out thousands of books that had been donated from around the country.
More than 500 people attended the event, including Burnsville residents Jamie Black and her 10-year-old daughter Jenavieve, a voracious reader who had been anxiously awaiting the event for weeks. The family had been without power for a month, but Black had seen a post about the event on Facebook and thought it would help her daughter, who like other children in the area, had missed a significant amount of school.
"Books take you away on an adventure," Jenavieve said in an interview with the Daily Yonder. "It doesn't matter what's going on around you if you're reading a good book."
That's one of the ideas behind the 21st Century Packhorse Librarian project, according to Turner.
"I think [reading] gives people a respite from their own story, so they can really process and heal from their trauma more gently," Turner said.
More than 100 people in North Carolina were killed by Hurricane Helene, and the September storm caused a record-breaking $59.6 billion in damages, according to the state budget office. Over 5,000 homes will need to be rebuilt, with thousands of businesses damaged or closed as a result of the storm. North Carolina Governor Josh Stein is urging state legislators to increase recovery spending, even as President Trump, who visited North Carolina in late January, is enacting plans to dissolve the Federal Emergency Management Agency.
Since October, Turner has organized events in nine communities in western North Carolina, and given away more than 9,000 books for free. The books are arranged by age group, and there is no limit to how many books people can take.
"I don't put a limit on it. Because say someone is taking four tote bags full of books - that person could have lost their whole house and all their books," Turner said.
Donations have poured in from across the country, Turner said, with people driving from as far as Texas and Ohio to deliver books. People can also donate books through Turner's Amazon wishlists, as well as by mail.
A number of children's authors associated with Christian publishing and media organizations such as Story Warren and Rabbit Room have donated books. Turner, who is Christian, has also made sure to keep high-quality, large-print bibles in stock.
Though she isn't able to read everything that comes through, she tries to curate her selections. She avoids books with sexually explicit content and references to the occult, and prioritizes books that she considers to be healing and uplifting, especially classic literature. Many of the books on her wishlists are the same as those distributed by the original packhorse librarians nearly a century earlier.
"There's a lot to say about the power of story in the classics," Turner said. "Bless those kids, they love Diary of a Wimpy Kid and I can't stand that book. I bring it for them, but I also try to get a good book in their hands as well."
Bearing Witness
According to its Facebook page, the primary mission of the 21st Century Packhorse Librarian project is to "distribute quality literature, free of charge, throughout the Blue Ridge Mountains, ensuring that individuals and families - especially in rural and remote areas - have access to great books."
But Turner has found that her role goes beyond handing out books to those who want them. She spends most of her time at each event talking to people, and hearing their stories. This is both rewarding and challenging, Turner said.
"I get to carry a little bit of their burdens for them, and hear how much bringing books means to them. But it's also a bit emotionally overwhelming at times, because we hear not only stories from the storm, but all sorts of things we wouldn't imagine we'd hear," she said.
Turner also uses her platform on Facebook to bring awareness to the destruction in communities she visits, posting pictures of places like Marshall, North Carolina, that were devastated by the storm. She says bearing witness to the communities' distress is part of her mission to keep attention on the ongoing recovery efforts.
"The rest of the world has moved on with their lives, and people aren't thinking about it anymore," Turner said. "I don't want anyone to feel forgotten."
Recovering from disasters like Helene takes years, but Turner is in it for the long haul.
"People keep asking me how long I plan to do this. And the answer is always 'as long as God wants me to," Turner said.
And though the project was born as a response to the hurricane, Turner feels the books she brings help address a deeper need in the Blue Ridge Mountains.
"The more I hear, the more I realize that these books aren't just disaster relief, they're life relief."
Anya Petrone Slepyan wrote this article for The Daily Yonder.
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By Liz Carey for The Daily Yonder.
Broadcast version by Mark Richardson for Minnesota News Connection for the Public News Service/Daily Yonder Collaboration
When rural patients incur medical bills they can’t pay, the impact of the debt reaches far beyond their own personal pocketbooks, a new study has found.
Medical debt also impacts the hospitals that can’t collect on the debt and the communities they serve, according to a research brief from the Rural Health Research Center at the University of Minnesota. Although medical debt is something all communities have, it hits rural communities harder, Carrie Henning-Smith, co-director for the center, said.
Researchers interviewed rural hospital administrators in seven states – Arkansas, California, Illinois, Texas, Vermont, Washington and West Virginia – to look at the implications of medical debt on rural communities at large.
“We know how widespread medical debt is,” Henning-Smith said in an interview with the Daily Yonder. “We weren’t particularly surprised by anything we heard, but I think one thing that stands out to me is that this is not just an issue of healthcare facilities passing on big bills to patients and then patients shouldering that burden.”
“This is really an issue that impacts individual patients, whole communities, and healthcare facilities, and I think smaller rural facilities that have a more tenuous bottom line are some of the most impacted,” she said.
Research indicates that about 44% of all U.S. adults are affected by medical debt, and that $88 billion in outstanding medical bills is currently in collections across the country. Researchers found the debts impact a rural hospital’s ability to continue paying their employees. With fragile bottom lines, rural hospitals are less likely to absorb the debt, respondents said.
A respondent from a Midwestern state said to the researchers, “One of the statistics that I think is really relevant is that we are about a $150 million organization… and 65% of those dollars go back in the form of compensation and benefits to our employees. So when we have medical debt that becomes excessive and we’re struggling to collect on the work that we do, it impacts our ability to employ [providers] and to serve our patients.”
With less revenue coming in, most respondents said, they are less likely to invest in equipment upgrades and their facilities, as well as less likely to hire more staff. Additionally, respondents said it’s harder to collect on that debt.
“It’s a non-recourse issue. We can’t go back and take back what we’ve done,” a Southern state administrator told researchers. “You can’t repossess anything medical like you can with a car or a home or anything like that when there’s financial troubles. We end up really just getting unpaid, mostly.”
Researchers found that much of the blame for the debt issue is not solely because of patients who are underinsured. In many cases, insurance companies and other payers – including Medicare, Medicaid and Medicare Advantage – are not covering the cost of care that the hospitals provide.
“They need to have their cost recouped for the care that they provide,” Henning-Smith said, “and when they have patients who are uninsured or underinsured or when they are dealing with insurance companies and payers that are not providing a sufficient amount to pay for the cost of the care, then the facility suffers and the patients and community suffer too.”
“It’s clear that our payer system is broken and that we have people whose care is not compensated at all or not at the rate that it needs to be to keep these facilities financially thriving,” she said.
Even if a patient is insured, some hospital administrators surveyed pointed out that underinsurance can create problems for patients and hospitals as well. High deductibles and plans with limited coverage options shift the responsibility for payment from the insurance company to the patient.
An administrator from the Midwest told the researchers, “Even the people who have the ability to pay, when you have more things like a high deductible health plan, no matter what your income is, it’s not easy for very many people if you have a $5,000 deductible. When that bill comes, that’s a difficult thing.”
Alan Morgan, CEO of the National Rural Health Association, said when rural hospitals don’t get paid, the impact is far reaching. Hospitals are typically among the largest employers in rural communities, and if a hospital fails because it can’t pay its bills, the whole community suffers.
“We’re in the midst of a hospital closure crisis and declining points of access to care in rural communities and it is because of bad debt, period,” Morgan said in an interview with the Daily Yonder. “When a hospital has to find ways to write off bad debt… for a lot of these rural hospitals, they’re operating on the margin and carrying large amounts of debt and uncompensated care that sometimes drives them to closure.”
When hospitals close due to financial problems, the economic hit on the community is multi-faceted, he said. The lost jobs not only reduce tax revenue coming into the community, but also impact the amount of consumer dollars being spent in the community. It means less income for businesses indirectly linked to the hospital, like flower shops, he said. And once the hospital closes, getting new families and businesses to move there becomes more difficult.
Fixing the issue will mean reforming how rural hospitals are reimbursed, Henning-Smith said.
“The message needs to continue to be about payment reform and understanding that medical debt is a widespread issue that’s not going away, but it’s not an individual issue and it’s not a matter of personal and individual responsibility,” she said. “It’s a community and a collective and a societal issue that if we don’t address, it’s not going to only impact the health and access to care of individuals, but it’s also going to impact availability of care in rural communities and places that need that care the most.”
Liz Carey wrote this article for The Daily Yonder.
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