'How many more people have to die?': what a closed rural hospital tells us about US healthcare

When Missouri’s Twin Rivers medical center closed, executives claimed it was a ‘consolidation’ with a new facility – but residents say it points to a healthcare crisis

Cindy Anderson worked for 39 years at the only hospital in Kennett, a small city in rural, south-eastern Missouri.

Beginning as an administrator in the emergency room, Anderson saw Twin Rivers regional medical center pull thousands of people back from the brink after heart attacks or accidents.

Then in February 2018, the hospital was there for her own family. Anderson’s husband Ray, better known around town as Butch, woke at 4am unable to breathe properly before he fell into unconsciousness. Within minutes, an ambulance delivered him to the emergency room and on to a vent that saved his life.

So Anderson, like almost everyone else in Kennett, was alarmed when just a few weeks later Twin Rivers’ corporate owners suddenly announced its closure.

Once one of the largest commercial hospital operators in the US, Community Health Systems said the facility was being “consolidated” with a new medical centre it had recently built an hour’s drive along to the north.

In deciding to shut Twin Rivers, company executives made a calculation. Close one hospital and patients will be forced to use the other. Costs down, profits up.

Kennett’s council called a public meeting to address the “crisis for our city”. Hospital staff led ferocious criticism of CHS, with accusations of corporate greed and financial shenanigans. Doctors questioned why a profitable hospital was being closed.

When it was Anderson’s turn to speak, she described how Twin Rivers saved Butch’s life just weeks earlier. “That will not happen if this hospital goes away,” she said at the meeting. “I will tell you that if this hospital is gone, there will be a lot of lives lost.”

Anderson was to be proved tragically right.
‘How many more people have to die?’

The long-struggling people of Kennett, one of a string of small midwestern cities with a fading memory of prosperity and a main street on life support, have accepted one factory closure after another as part of the natural order of modern America.

The electric motor manufacturer went first. Then the trailer factory and most recently the hose-maker, robbing Kennett of hundreds of relatively well-paid jobs that supported a lot of other employment in one of the poorest parts of the country.

There are still jobs in the fast-food outlets lining the main road into the city but they do not pay nearly as well as the ones that have been lost. The low-cost Aldi supermarket in Kennett is closing at the end of the year because people have less money to spend in the city of about 10,000 where one in four of the population lives below the poverty line.

Each closure has compounded the sense of decline, underpinned by an understanding that it is hard for an isolated rural city to compete. But the announcement that the only hospital in all of sprawling Dunklin county was to shut was greeted like a terminal diagnosis.

At the council meeting, officials spoke of their “shock and pain”.

One hospital worker after another echoed Cindy Anderson’s warning.

“Heart attack patients are not going to make it,” said Tonia Swink, a nurse at the hospital who worked in healthcare for 38 years. “Stroke victims are not going to make it or they’re going to have severe disabilities”.

The doors were bolted for good on 12 June 2018, less than six weeks after the staff was told that the hospital where some had worked for decades was finished. The “Emergency Room” sign and other evidence the building was once a hospital was swiftly stripped away. Among the few remaining clues are spaces in the barren car park marked “Physicians Only”.

In a move that infuriated many in Kennett, CHS didn’t put Twin Rivers up for sale. Doctors suspected the company didn’t want a commercial rival reopening it and sucking away business from its new Poplar Bluff hospital 50 miles away. Instead, the company cut the power and left the building to rot.

One night in October, Cindy Anderson was again woken in the middle of the night by Butch struggling to breathe and called 911. The ambulance took about 10 minutes to arrive. Paramedics worked on Butch for another 20 minutes and then decided to drive him to a small, more basic hospital without an emergency room, 20 miles away in Hayti. By the time Butch finally saw a doctor, nearly an hour had passed since his wife called the ambulance.

Anderson doesn’t know whether the doctors in Hayti ever stood a chance of saving her husband, but within about quarter of an hour of arriving at the hospital she heard them stop trying to revive him. A few minutes later, a physician told her Butch was dead. He was 71 years old.

“I think they simply ran out of time. I believe that had the hospital been here they would have saved him. He’s not the only one,” said Anderson. “How many more people have to die? There are people dying in ambulances I think could have been saved.”

‘A dirt poor population are now left with no medical care’

Dr Dave Jain, who worked for 29 years as an internist at Twin Rivers and now runs his own clinic in Kennett, is asking the same question.

“We’re having probably three to five more deaths a month without having the hospital here,” he said. “I had a 35-year-old patient who started having chest pain. He needed to get to an emergency room but died on the way to the hospital. There are multiple deaths due to not having emergency services, mostly from heart attacks and accidents. There’s nowhere to stabilise them. If they’re having a heart attack, they’re dying before they get to the hospital. Plus the infant mortality rate has increased since the hospital closed.”

Dunklin county already has one of the highest post neonatal mortality rates in Missouri. Dr Andrew Beach, one of the few paediatricians left in Kennett, said the entire region of about 70,000 people is now without a full-time obstetrician.

“We’ve had babies delivered in parking lots. We’ve had women barely make it into the operating room to deliver. We’ve had babies delivered at Piggott hospital [half an hour away in Arkansas] where there are no OB [obstetrics] facilities and it’s basically drop in and boom, you get a baby. Obviously that’s not ideal,” he said. “Already a really oppressed population, dirt poor, are now left with no medical care either, or limited medical care.”

Julie Helfer, a nurse on the labour ward who gave birth to her own three children at Kennett’s hospital, now works for the county health department’s programme for low income mothers and children.

“A lot of our moms are having to travel long distances for routine appointments like ultrasounds,” she said. “But transportation is a huge issue for a lot of our moms. They don’t have a vehicle or even a way to get back and forth to their doctor’s appointments at the hospitals. If they go into labour, they cross their fingers and hope to make it.”

Dunklin county already had the second highest rate in Missouri of babies who die before their first birthday, after neighbouring Pemiscot. The mortality rate is about twice the national average in part because of the high number of premature births, particularly among African American women in the 80% white county.

The toll in lives since the hospital closed has yet to be calculated. Data for last year is still being collated and so doctors do not yet know the full impact but there is common agreement among physicians, nurses and those working with new mothers in Kennett that the number of deaths has risen.

In an attempt to soften the impact of losing Twin Rivers, doctors got together to open an “Urgent Care” clinic but it lacks the facilities to deal with trauma and other emergency cases, and is not open 24 hours.

“It’s been overwhelming,” said Dr Tim McPherson, who runs a practice in Kennett after working at the hospital for 35 years including as its secretary of medical staff when it closed. “Trying to triage these patients that are really sick, that need an emergency room, is getting to be difficult because we get them in the office and we try to figure out where to send them, and how are they going to get there.

“People have died as a result.”

‘It breaks my heart that they put money over people’

Kennett is not alone in losing its medical care. More than 160 rural hospitals and clinics have closed across the US since 2005 mostly under financial pressure. Hundreds more are at risk, including 14 in Missouri considered essential to the communities they serve.

But Twin Rivers did not go under because it was losing money. Terry Berry, chair of its board of trustees, told the Guardian that the hospital continued to be profitable up until its closure. Dr Jain and other physicians who worked at Twin Rivers said it made about $5m in 2017. Anderson said the same.

“I know that it was profitable because I worked in the business office at one point. I know that they made money off of it. It breaks my heart that they put money over people. I know that they have to make money … but they were making money,” she said.

CHS said it shut Twin Rivers because medical innovation has reduced demand for overnight stays. The company said that 95% of people treated at the hospital were outpatients who would be better served by the “larger resources” at the newer hospital in Poplar Bluff. It claimed that what it called the consolidation was “the most sustainable plan for the future”, implying that Twin Rivers was not financially viable because of falling revenues. But a senior company executive told a Wall Street conference that CHS was getting out of markets that did not have the potential for significant growth.

Doctors who worked at the hospital said the number of overnight stays fell in part because CHS sharply raised its prices in order to make more from the publicly funded Medicaid programme for low-income Americans. That drove away people with private insurance in need of non-emergency operations.

Dr Chancellor Wayne, a chiropractor who was elected Kennett’s mayor earlier this year, said Twin Rivers was charging $5,000 for an MRI so he sent patients to a hospital in Arkansas when they could get it for $800. Wayne accused CHS of closing Kennett’s hospital “out of greed”.

CHS did not respond to requests for comment.

As private business faded, so the number of specialists employed at the hospital dropped. Even then, it remained profitable.

“This hospital was closed mostly by the greed of the corporation,” said Dr Jain. “This hospital was making money and the hospital in Poplar Bluff owned by the same corporation wasn’t. But they had built a brand new hospital in Poplar Bluff that they couldn’t close and they thought if they closed the hospital in Kennett everybody would flood there.”

CHS finally put the abandoned hospital up for auction this month with a reserve price of a dollar. But because it has been closed for more than a year, regulations would require millions of dollars in renovations for it to reopen as a medical facility. Doctors in the city see the delay as a cynical move to discourage another company from taking it over.

But if CHS’s calculation was that patients would come flooding from Kennett to Poplar Bluff, then it got it wrong. Some people in Kennett in need of routine hospital care didn’t want to make the 120-mile round trip along a difficult road that flooded in winter.

They instead opted for an equally long but much easier drive to facilities in neighbouring Arkansas and Tennessee.

Anderson said others are boycotting CHS.

“What they didn’t bargain for was that people were going to be so mad at them that they wouldn’t go to Poplar Bluff,” she said. “I am blown away that that company would just leave all these people with no way to get medical treatment in an emergency. They just betrayed the people here.”

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