A half-dozen Gouldian finches greet patients with their chirps from a cage in the waiting room of the Boone Health Primary Care clinic in Mexico, Missouri. The birds belong to Dr. Peggy Barjenbruch who, alongside Dr. Michael Quinlan, has served the Mexico community for decades.
That looked like it might come to an end this past fall, when the hospital they were associated with, Audrain Community Hospital, closed suddenly.
Audrain Community Hospital was a community fixture since its founding in the 1980s, but in September it joined a growing list of rural hospital closures.
More than 130 rural hospitals in the U.S. have closed over the past decade. Dozens of those closures happened in the Midwest, including 10 in Missouri, amid the pressure of shrinking populations and lower reimbursement for care due to uninsured patients.
In many rural towns, local hospitals are community fixtures. When they close, the entire community feels the ripple effects, and access to critical health care is put in jeopardy.
For Barjenbruch and Quinlan, the closure brought uncertainty.
“We always thought that we were big enough to keep on going," Quinlan said.
Hospital closures leave patients in a tough spot
Quinlan, a Mexico native, grew up with the hospital at the heart of the Mexico community. It closed shortlyafter changing ownership for the second time in two years. Noble Health Corporation, based in Kansas City, Missouri, had acquired the hospital in 2021.
After increasing internal turmoil at the company, Noble sold the hospital to Texas-based Platinum Team Management, which shuttered the facility. Quinlan said toward the end, staff were working without pay to keep serving the community.
In the wake of the closure, the Audrain County health department had to scramble, setting up a phone line to answer patient questions, said CEO Craig Brace.
“We had a nurse dedicated to dig into those questions and find answers and make that available," Brace said.
But some of those questions didn’t have easy answers. The closure of the local hospital means the nearest option for emergency care and other inpatient services is 40 miles away, in Columbia.
Quinlan said that’s left his patients in a difficult situation.
“You’ll hear some mornings that, ‘Oh I had chest pain at 2 a.m. and I just was waiting to see if I could see you guys,” he said. “...We don’t want to take a chance on that.”
Patients have also put off important appointments like cancer screenings, Quinlan said, holding out hope that the hospital will reopen.
There’s no sign of that happening soon, but other providers have moved in. MU Health openedtwo clinics in Mexico in the summer, including an urgent care center. And Boone Health acquired Quinlan’s outpatient clinic in October.
Boone Health CEO Troy Greer found benefits in the move for both his health system and the community.
"It allows Boone to continue to grow in those areas to serve their needs, but also [creates] a more convenient place for those people to use Boone services,” Greer said.
But stepping in to run the hospital, isn’t something Boone or any other institution is in a position to do, according to Greer.
Emergency care is hard to replace
One option for emergency care that has proliferated in other states is the freestanding ER — an emergency department that's not attached to a hospital. Freestanding ERs can often provide faster care than traditional ERs, but can also come with higher price tags.
While much of the freestanding ER wave has come in suburban areas, they may be an option for rural towns as well, said Dr. Cedric Dark, anassistant professor of emergency medicine at the Baylor college of Medicine in Houston who studies freestanding ERs.
"When we’re talking about rural hospital closures, I feel like you at least ought to be able to keep the ER open as a freestanding ER because people in those communities still need access to emergency care,” Dark said.
Regulations in several states, including Missouri, effectively ban freestanding ERs. According to the Missouri Hospital Association, the state does not recognize or license freestanding ERs.
That means communities like Mexico have to find other ways to keep their hospitals open, whether that be through private equity firms or individual investors.
Quinlan and Brace had been hopeful about a potential investor who had expressed interest in reopening the hospital. But according to Quinlan, Platinum recently sold the property to another buyer.
Instead, Quinlan said the recently enacted federal rural emergency hospital designation is a consideration. That would allow the hospital to reopen its emergency department and provide outpatient care.
However, Quinlan said there are also plans drawn up to open a micro-hospital at a different location – offering emergency services and some inpatient care – if Audrain Community doesn’t re-open.
This story comes from a collaboration between KBIA, Side Effects Public Media, based at WFYI, and the Midwest Newsroom — an investigative journalism collaboration including IPR, KCUR 89.3, Nebraska Public Media News, St. Louis Public Radio and NPR.