As fire chief in Kingsburg, a small town in California’s Central Valley, Tim Ray has done more than battle blazes in the past few years. Actual fires here are relatively few, in fact. These days, Ray, a trim 52-year-old with clipped moustache and gentle eyes, oversees a kind of volunteer medical transportation service, hustling patients from this idyllic town — settled by Swedish immigrants in the 1870s and still bedecked with “Välkommen” welcome signs — as far as 20 miles away, to a hospital in Fresno.
Kingsburg’s hospital closed in 2010, so while some residents can seek treatment in nearby Selma, just five miles away, more complicated ailments, like strokes or heart attacks, require a trip to Fresno. That’s still within the so-called “golden hour,” when saving a life is most possible, Ray told me, as we sat one morning at the local firehouse. “But we’ve also had situations where we’re transporting a patient, and I get a call from a hospital letting me know there are no beds at a hospital where we’re about to take a patient.”
Kingsburg may be quaint, but the lack of a hospital is making life difficult for many of the 11,000 residents. All that remains of the Kingsburg Medical Center, opened half a century ago, is a mental health clinic that is ill-suited to provide emergency services or other kinds of medical care. Despite the proximity of Selma or Fresno, many residents are referred to the Tulare Regional Medical Center, 36 miles away. That distance is more than an inconvenience; on occasion, it can be life-threatening.
The lack of a hospital can also erode a community’s sense of security and affect its economy. Potential job-creators are more inclined to set up shop closer to hospitals, especially in urban areas, where doctors are more likely to set up practice.
“People here still talk about” Kingsburg Medical, Ray said. “They can still remember what it was like to have the hospital here.”
The fate of Kingsburg Medical is not an isolated tale of woe. It was one of more than 70 rural hospitals that have closed nationwide since 2010, about one per month.
According to the U.S. Department of Health and Human Services’ Office of Inspector General, rural closures are caused by a range of factors: the failure of communities to recover from the 2008 financial collapse; hospital mergers and other market trends; states’ refusal to expand Medicaid; and reduced demand for inpatient services. The Affordable Care Act and similar programs that provide Americans with medical insurance may have created an additional, unintended strain on rural health care.
“There are over 600 rural hospitals at financial risk” nationwide, Maggie Elehwany, vice president of government affairs at the nonpartisan nonprofit National Rural Healthcare Association, said. “Over 200 of these rural hospitals are extremely vulnerable to (closure) and are at high financial risk. Since 2010, the number of rural hospital closures has escalated each year. On this current trajectory, more than one-quarter of all rural hospitals (over 500) will close in less than 10 years.”
California’s Central Valley has seen three hospitals close since 2010, underscoring the national problem and serving, perhaps, as a wake-up call to other parts of the West, which has lost eight rural hospitals in the last six years. Some of the Central Valley’s eight counties now have as few as two hospitals to serve their populations.
Kingsburg Medical’s closure coincided with a steep decline in the growth of the town, which had grown rapidly from 2,310 people in 1950 to 11,382 in 2010 — a rate of between 24 and 54 percent every decade. But the estimated population for 2015 was just 11,824, a growth rate of only 3.9 percent from 2010.
The housing crisis and recession hit the Central Valley particularly hard in 2007. Unemployment climbed. The semi-rural suburban landscape was soon pockmarked by hollowed-out homes and neighborhoods.
Kingsburg Medical, which was already struggling before 2008, could not sustain itself in that environment. Kingsburg’s city manager, Alex Henderson, points to changes in the health-care industry, namely the move away from rural facilities to more regionalized hospitals, as a main factor. This led to the loss of revenue for Kingsburg Medical, and it drove doctors to larger facilities, where compensation is generally better.
In the end, Kingsburg Medical was unable to afford the equipment and infrastructure upgrades it needed to remain a viable hospital. “It’s like with everything else these days,” Ray, the fire chief, said. “The market determines everything, but somehow it seems to ignore this one need. I still have a dream that a large regional hospital will get built here, someday.”
The lack of a hospital or major health center can create a domino effect: Doctors don’t move in, hospitals are short-staffed and underfunded, and potential residents and businesses are discouraged from relocating by the lack of nearby health care. All of this affects the local economy. “Hospitals are large demanders of labor,” said Cristina Miller, an economist with the U.S. Department of Agriculture’s Economic Research Service, who has studied rural health care. “They offer local jobs, both for high- and low-skilled workers, everything from the obvious, like nursing, to janitorial to maintenance. An employee buys a house in the area, brings their family with them and demands public goods. Their kids will go to school there, they’ll buy gas and food there, money circulates. The idea is that there is spillover.”
Even if the hospitals in the Central Valley were to reopen, or a regional hospital was built to serve the area, attracting and retaining doctors would be difficult. There is more money to be earned in urban areas, and some doctors perceive small towns as offering a constricted social life.
Marie-Elizabeth Ramas was one of those who gave it a try. Until April, when she announced she was leaving, she was the medical director at the Mercy Community Rural Health Clinic, which focuses on uninsured, low-income families around Mount Shasta, a small town of 3,300 in Northern California.
Ramas is a soft-spoken African-American woman, who graduated from medical school in 2008 and went on to receive a National Health Service Corps scholarship for her commitment to primary care in underserved communities. She initially imagined that being a rural physician would give her more time to spend with her family. Instead, she felt stretched thin. “I was essentially on call 24/7, because of inefficiencies in the electronic record-keeping system, often spending 10 hours per weekend just catching up and making sure patients were safe,” she said. “I think that if the model doesn’t change, there just won’t be a health system in Mount Shasta, and that would devastate the community.”
In fact, there are few models that seem to work. The old ideal of the country doctor who carries a little black bag from house to house was buried under the fear of malpractice suits and insurance restrictions. And telemedicine, another potential solution, is not a cure-all.
These days, the Central Valley’s communities have become more reliant on the good will of neighbors and organizations to get the health care they need.
Dos Palos, a town of fewer than 5,000 people in the San Joaquin Valley, lost its hospital in 2006. As with other agricultural Central Valley communities, the closure reflected the region’s overall economic decline: There are two diners and a Subway, a small market and a Dollar General store, but most of the buildings here are boarded up. The median home price is just above $100,000, and the unemployment rate is more than 14 percent.
The town still has a clinic, which is owned by a Los Banos physician and overseen by Kathy Ebner, who is also the nursing director. Ebner, a single mother with two grown children and a reputation for patience and energy, moved here in 1999.
“It is almost like the town has given up on any hopes of ever having something in this community to attract more families to locate here. It is as if it is just OK where things are at,” she said. “But it is as destitute as you can imagine.”
As in Kingsburg, it fell to the Dos Palos fire department to “patch and transport” residents needing medical attention. The nearest hospitals are between 18 and 35 miles away.
And then there was a shortage of staffing over time, a more serious problem, according to Ebner. “Being in a rural area, which brings little desire for families to locate here, made it very difficult to provide registered nurses,” she said, adding that the clinic at one point recruited doctors from as far away as San Jose, an hour’s drive.
Despite all the difficulties, Ebner said she’s unlikely to leave.
“I have had many offers over the years to relocate, but I just can’t walk away,” Ebner said. “The residents, the staff, they become part of your family. We have all at some point helped each other to raise children or bury a loved one. You just don’t walk away from that.”
Elizabeth Zach is a staff writer at the Rural Community Assistance Corporation. This article was produced as a project for the USC Center for Health Journalism’s California Health Journalism Fellowship.