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Rural Texas can be a very dangerous place to be badly injured or really sick.
From 2010-20, 26 hospitals in 22 Texas communities in rural Texas closed, according to the Texas Organization of Rural and Community Hospitals, known as TORCH.
The Texas institutions were folding at a faster rate than their counterparts in other parts of the country — where rural health care is also regularly described as a crisis situation. Nationally, 138 rural hospitals closed during that period, according to the University of North Carolina’s Cecil G. Sheps Center for Health Services Research.
That’s not to say rural health is no longer in crisis or that hospitals in rural parts of the state are thriving — just that none have failed since January 2020.
“I tell people that we limped into the pandemic, and we limped out of it,” says John Henderson, CEO and president of TORCH.
He still describes the overall situation as a crisis, but said federal stimulus payments and helpful tweaks to Medicaid reimbursement and other budget help from the Texas Legislature got them through the two years of pandemic.
Two years is good after years of closures. But those federal payments were tied to COVID-19 and will run out. Meanwhile, the persistent problems in rural health care in Texas return to legislative attention every two years, sometimes holding their ground but somehow never resulting in real remedies.
“Some [hospitals] say they’re better off now, that their communities are grateful they were here,” Henderson says. “But I’ve got four or five on my list who are still headed for trouble.”
Slightly over half of the rural hospitals in Texas — they’re defined as hospitals in counties with fewer than 60,000 residents — are “vulnerable,” according to the Chartis Center for Rural Health.
About 3 million people live in rural Texas, according to the federal government’s Rural Health Information Hub. That’s just more than 10% of the state’s population. Hospitals are few and far between, and other problems — like the paucity of access and availability to broadband, and the high number of uninsured Texans — make it more difficult.
An example: Telemedicine helps a lot in rural hospitals, bringing expertise to places that don’t have it. But telemedicine is delivered over broadband, and if that’s not available, telemedicine isn’t available, either.
Money is a problem. Medicaid rates in Texas are low, and the state has the most uninsured people of any state, both in percentage and raw numbers.
Rural hospitals are among those that have asked legislators to expand Medicaid under the Affordable Care Act, but that’s been a political taboo in the Texas Capitol since it became law under the Obama administration. Expansion wouldn’t cover everyone, but it would cut into the numbers, and rural hospitals would be some of the beneficiaries.
Henderson isn’t as pessimistic as you might expect, saying legislators are generally sympathetic to the troubles in rural health care.
“We have their ear,” he says of the state’s legislators. “When attention wanders is when money comes up. They struggle with spending a bunch of money on it.”
The state’s population is concentrated geographically in a triangle formed by the Dallas-Fort Worth area at the top, the Houston area on the bottom right and the San Antonio-Austin corridor on the bottom left.
That’s where a lot of the political power resides, but rural Texas has more clout than some might think: It’s a stronghold of conservative voters in a state where Republicans have been in power in all three branches of government for more than two decades. Legislators are listening, even if they haven’t figured it out.
“I wouldn’t say it’s been ignored, but it’s not fixed,” Henderson says. “This is going to persist.”
