DAVID GREENE, HOST:
Those watching today as Senate Republicans unveil a health plan include people who depend on rural hospitals. These small facilities are sometimes the only hospitals for miles. Many serve the red parts of your political map, which voted for President Trump and sent Republicans to Congress. And many rely on Medicaid, which would be reduced substantially under the House Republican version of the health bill. Bram Sable-Smith of member station KBIA reports from a hospital that would be affected.
BRAM SABLE-SMITH, BYLINE: Kerry Noble says when a rural hospital closes, the effects ripple beyond health care...
KERRY NOBLE: We're the largest employer.
SABLE-SMITH: ...Through the economy, property values...
NOBLE: Housing is depressed enough here as it is.
SABLE-SMITH: ...Even education.
NOBLE: You could eventually even sacrifice some of your schools.
SABLE-SMITH: Noble is CEO of Pemiscot Memorial Health Systems, the lone public hospital in the poorest county in Missouri. Its struggle for survival shows how decisions made by state and federal lawmakers have put these small hospitals on the edge of collapse.
NOBLE: OK. So...
SABLE-SMITH: In his office in Pemiscot County, Noble thumbs through blueprints from a happier time.
NOBLE: This was the master facility plan.
SABLE-SMITH: Back in 2005, things were very different. The hospital was doing well, and Noble commissioned a $16 million plan to replace the outdated facilities.
NOBLE: We were going to pay for the first phase of that with cash. We weren't even going to have to borrow any money for it.
SABLE-SMITH: But those renovations never happened. In 2005, way before the Affordable Care Act, Missouri cut Medicaid drastically. More than 100,000 Missourians lost their health coverage. Nearly half of the Pemiscot County hospital's Medicaid patients lost their insurance, but they kept coming to the hospital.
NOBLE: We're still providing care, but it's just that we're no longer being compensated.
SABLE-SMITH: And as the costs of treating the uninsured went up, the hospital's income went down. Forget renovations; the hospital went into survival mode.
SIDNEY WATSON: Medicaid cuts are always hard for rural hospitals.
SABLE-SMITH: Sidney Watson is a professor at Saint Louis University. She says rural hospitals were thrown a potential lifeline under the Affordable Care Act. States had the option to expand Medicaid. And in Missouri, that would have covered 300,000 people.
WATSON: It was the fundamental building block that was supposed to cover poor, low-income Americans.
SABLE-SMITH: And in 2013, Kerry Noble took to the state capitol to make a case on behalf of his hospital.
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NOBLE: We will no longer be in existence if this passage of this expansion does not occur.
SABLE-SMITH: But the Missouri legislature voted against expansion. The hospital is still in existence, for now at least. But they've cut expensive units. They no longer deliver babies. They outsource their ambulance service, and they're just barely breaking even.
NOBLE: People might look and say - well, see, you didn't need Medicaid expansion; you're still there.
Yeah. But how long are we going to be here if we don't get some relief?
SABLE-SMITH: But relief for rural hospitals is not what's being debated in Washington right now. Under the GOP House plan, even states like Missouri that did not expand Medicaid could see tens of thousands of people losing coverage. For NPR News, I'm Bram Sable-Smith in Missouri.
STEVE INSKEEP, HOST:
This story is part of a reporting partnership with NPR, Side Effects Public Media and Kaiser Health News.
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