$44,000 for Air Ambulances, Hour-Long Rides to an ER—The High Cost of Healthcare in Appalachia

Rural hospitals are closing or downgrading at an alarming rate. That could be fatal.

Mason Adams

Pioneer Community Hospital of Patrick County, Va., closed in 2017, 18 months after filing for bankruptcy. (Photo by Mason Adams)

When Heather Edwards’ con­trac­tions began three months ear­ly, in March, she wor­ried about the long dri­ve to the hos­pi­tal from her home nes­tled in the Appalachi­an Moun­tains in Jonesville, Va., a town of few­er than 1,000 peo­ple. Edwards, 32, was car­ry­ing quadru­plets and hers was con­sid­ered a high-risk preg­nan­cy. The near­est hos­pi­tal with a neona­tal inten­sive care unit (NICU) was an hour away in Kingsport, Tenn., Hol­ston Val­ley Med­ical Center.

For the residents of rural Appalachia, long drives for emergency care are often a matter of life and death.

A decade ago she could have found an emer­gency room, if not a NICU, 10 min­utes up the road at Lee Coun­ty Region­al Med­ical Cen­ter in Pen­ning­ton Gap, Va., but the hos­pi­tal closed in 2013 due to low com­mu­ni­ty use, a lack of local physi­cians and Virginia’s refusal to expand Med­ic­aid, which left the state’s rur­al hos­pi­tals to pro­vide uncom­pen­sat­ed care to unin­sured patients. In 2012, the Lee Coun­ty hos­pi­tal was near­ly $2.5 mil­lion in the red.

Neigh­bor­ing coun­ties do have emer­gency rooms, but none offered the NICU care Edwards need­ed. She decid­ed to make the 44-mile dri­ve along twisty moun­tain roads to Hol­ston Val­ley Med­ical Center.

If I went to [a dif­fer­ent hos­pi­tal], they were just going to fly me to Hol­ston Val­ley or the [next] clos­est NICU,” Edwards says. It would have been a waste of time.”

Edwards bare­ly made it. Moments after she arrived, every­thing just broke loose, and I went into labor,” Edwards says. They tried to stop it and couldn’t. I had an emer­gency C‑section.”

Edwards con­sid­ers her­self lucky. For the res­i­dents of rur­al Appalachia, long dri­ves for emer­gency care are often a mat­ter of life and death.

(Heather Edwards deliv­ered quadru­plets at Holton Val­ley Med­ical Cen­ter in March. Edwards was dis­charged two days lat­er, but her babies remained in the inten­sive care unit for weeks. Dur­ing that time, Edwards drove from Jonesville to Kingsport, a two-hour round trip, almost dai­ly. Pho­to cour­tesy of Heather Edwards)

Lee County’s pop­u­la­tion reflects that of many rur­al com­mu­ni­ties in Amer­i­ca: aging, most­ly poor res­i­dents who strug­gle with long-term con­di­tions that require ongo­ing, often expen­sive, care. The medi­an house­hold income in Lee Coun­ty is $32,590 — less than half of Virginia’s $68,766 and slight­ly more than half of the nation­al $61,937. Lee County’s pover­ty rate is 28.2%, and about 12.5% of the county’s res­i­dents under 65 are unin­sured, high­er than the statewide aver­age of 10.2%, and the pop­u­la­tion is aging, with all age groups except 65 and old­er in decline.

Despite the need, 113 rur­al hos­pi­tals have closed across the Unit­ed States since 2010, accord­ing to the North Car­oli­na Rur­al Health Research Pro­gram at the Uni­ver­si­ty of North Car­oli­na. Anoth­er 673, about a third of those that remain, were at risk of clos­ing in 2016, accord­ing to the Nation­al Rur­al Health Association.

For me to dri­ve five miles more to get access to hos­pi­tal care is not a big deal,” says George Pink, deputy direc­tor of the North Car­oli­na Rur­al Health Research Pro­gram. But if you’re old or dis­abled, if you’re poor, trav­el­ing 4, 10, 16 miles — that could be a big enough bar­ri­er to for­go care.”


About six months after Edwards deliv­ered her babies, on Sep­tem­ber 1, Hol­ston Val­ley Med­ical Center’s NICU closed. On Octo­ber 1, Bal­lad Health, the non­prof­it that owns the hos­pi­tal, also down­grad­ed the trau­ma cen­ter from lev­el 1 to lev­el 3, mean­ing there would be few­er doc­tors and a small­er range of med­ical ser­vices. Now, the near­est lev­el 1 trau­ma cen­ter and NICU are in John­son City, Tenn., 66 miles from Jonesville; the next clos­est are 97 miles away in Knoxville, Tenn., 166 miles in Lex­ing­ton, Ky., and 206 miles in Roanoke, Va.

(The 4 clos­est lev­el 1 trau­ma cen­ters to Jonesville, Va.)

Protests began out­side the Hol­ston Val­ley hos­pi­tal May 2, the day after the state of Ten­nessee approved Ballad’s plans to close the NICU. Dani Cook, 46, joined because her grand­daugh­ter was born at Hol­ston Val­ley weigh­ing just over a pound; she learned about Ballad’s NICU plans a year and a day after her grand­daugh­ter came home.

I jumped on Face­book Live and said, That’s what hap­pens when hos­pi­tals put prof­it over peo­ple, in this case babies,’” Cook says. She has been involved in the protest ever since. She post­ed a wide­ly shared image on Face­book that lists dis­tances from rur­al area com­mu­ni­ties to the clos­est lev­el 1 trau­ma care cen­ter in John­son City, along with the ques­tion, Will you make it??!”

By late June, on the 58th day of the Hol­ston Val­ley protest, Bal­lad banned Cook from the hos­pi­tal grounds, with then-CEO Lindy White writ­ing that Cook repeat­ed­ly inter­fered with patient care by enter­ing patient rooms, dis­agree­ing with nurs­es and physi­cians over treat­ment plans.” As this issue went to press in ear­ly Octo­ber, the protests have con­tin­ued for more than 150 days.

Bal­lad has a vir­tu­al monop­oly in the region, part of an emerg­ing trend of rur­al hos­pi­tals owned by large non­prof­its oper­at­ing with lit­tle or no com­pe­ti­tion. With 21 hos­pi­tals serv­ing 1.2 mil­lion peo­ple, Bal­lad dom­i­nates rur­al, eco­nom­i­cal­ly depressed south­west Vir­ginia and north­east Ten­nessee as the lead­ing provider of inpa­tient hos­pi­tal services.

Bal­lad emerged in 2018 from the con­sol­i­da­tion of two com­pet­ing non­prof­its that ran up big debts: Moun­tain States Health Alliance and Well­mont Health Sys­tem. Ballad’s Direc­tor of Com­mu­ni­ca­tions Tere­sa Hicks says the debts were incurred due to waste­ful and unnec­es­sary dupli­ca­tion of ser­vices. The non­prof­it received a Cer­tifi­cate of Pub­lic Advan­tage (COPA) — which allows states to approve merg­ers in exchange for var­i­ous legal com­mit­ments — in Ten­nessee and a sim­i­lar coop­er­a­tive agree­ment in Vir­ginia to escape fed­er­al over­sight over poten­tial monop­oly prob­lems, includ­ing effects on pric­ing, access and quality.

In Vir­ginia, Bal­lad agreed to 49 con­di­tions as part of its coop­er­a­tive agree­ment, includ­ing a com­mit­ment to pro­vide 11 essen­tial ser­vices” that include things typ­i­cal­ly found in a hos­pi­tal, includ­ing emer­gency room sta­bi­liza­tion. It was a vic­to­ry of sorts for the Lee Coun­ty Hos­pi­tal Author­i­ty (LCHA), a group formed by the coun­ty board of super­vi­sors in 2014 in an attempt to keep the hos­pi­tal going.

As this issue went to press, Bal­lad offi­cials said the Lee Coun­ty hos­pi­tal would reopen as an urgent care cen­ter in Octo­ber, and as a crit­i­cal access hos­pi­tal by fall 2020, but the process has dragged on and locals remain skeptical.

Alan Bai­ley, who heads up Lee Coun­ty E‑911, a res­cue squad dis­patch­er, says, I’m not going to believe a word I hear out of the Bal­lad folks until I see the doors open and the peo­ple there.”

Even if the hospital’s emer­gency ser­vices return in 2020, J. Scott Lit­ton Jr., 46, a Lee Coun­ty native and mem­ber of the LCHA who has prac­ticed as a fam­i­ly physi­cian since 2003, says he doubts it will ever be what it once was. We had a ful­ly func­tion­al hos­pi­tal with an inten­sive care unit, a med­ical sur­geon and an oper­a­tion sur­gi­cal suite,” Lit­ton says. Prob­a­bly what we’ll get … is an emer­gency room and some crit­i­cal beds for access patients. But any­one requir­ing a car­di­ol­o­gy con­sul­ta­tion or sur­gi­cal con­sul­ta­tion is going to be trans­ferred” — to Big Stone Gap, Kingsport, John­son City or some­where else.

In their merg­er appli­ca­tion, Moun­tain States and Well­mont argued that con­sol­i­da­tion was the only way to main­tain high-qual­i­ty, cost-effec­tive care and local gov­er­nance. In 2018, Bal­lad closed four urgent care cen­ters — in Abing­don, Va., and John­son City, Kingsport and Greeneville, Tenn. — where its pre­de­ces­sors had main­tained com­pet­ing facil­i­ties. In addi­tion to down­grad­ing the trau­ma lev­el of the Hol­ston Val­ley hos­pi­tal in Kingsport, Bal­lad will down­grade anoth­er trau­ma cen­ter in Bris­tol, Tenn., in 2021.

Bal­lad offi­cials con­tend these changes will enable it to sur­vive in the fourth-low­est wage index area in the coun­try while cre­at­ing a bet­ter health­care sys­tem. Accord­ing to Ballad’s infor­ma­tion sheets, the changes will bet­ter inte­grate our high­ly-skilled trau­ma experts … to ensure assess­ment and rapid trans­port of patients to the cen­ter most appro­pri­ate for the patient’s needs.”

Cook and oth­er local res­i­dents believe these changes will mean high­er med­ical bills and a crit­i­cal loss of care access. Mul­ti­ple stud­ies have con­sis­tent­ly shown that hos­pi­tal con­sol­i­da­tions result in high­er prices for ser­vices, at least for those with pri­vate insur­ance. Ballad’s Hicks says that, since the merg­er, charges for physi­cian vis­its were reduced by an aver­age of 17%, and a 77% dis­count for unin­sured patients was adopt­ed. Hicks also says Bal­lad has increased eli­gi­bil­i­ty for free care, and offers no-inter­est pay­ment plans as low as $50 per month.

Whether con­sol­i­da­tion caus­es loss of access to ser­vices is more dif­fi­cult to assess. Nonethe­less, con­sol­i­da­tion can result in con­fu­sion and frus­tra­tion for patients as they adjust to changes in every­thing from drug prices to what ser­vices are offered at which facilities.

Tere­sa All­go­od, 67, has seen her med­ical costs sky­rock­et since the Bal­lad con­sol­i­da­tion. For four years, All­go­od received infu­sions of INFeD every three or four months to treat her lupus and oth­er autoim­mune dis­or­ders at Kingsport Hema­tol­ogy and Oncol­o­gy, known local­ly as Allen­dale. Each infu­sion took a day to admin­is­ter and cost around $3,500, she says. Once Bal­lad took over, how­ev­er, her reg­i­men changed. Bal­lad enrolled in a fed­er­al drug dis­count pro­gram called 340B, at which point Bal­lad took All­go­od off INFeD and put her on Fer­a­heme. Fer­a­heme infu­sions required com­ing in twice, sev­en days apart, and were much more expensive.

The bill for the first infu­sion that Bal­lad was respon­si­ble for was $13,449.28,” All­go­od says.

In late 2018, Bal­lad closed the Allen­dale facil­i­ty and redi­rect­ed patients to a new can­cer cen­ter at Indi­an Path Com­mu­ni­ty Hos­pi­tal in Kingsport.

Bal­lad again changed Allgood’s med­ica­tion, this time to Injectafer. All­go­od received two treat­ments in March and says she is still wait­ing for the bill.

Although All­go­od has now switched back to Fer­a­heme treat­ments with a dif­fer­ent provider, Ten­nessee Can­cer Spe­cial­ists in John­son City, she expects her month­ly insur­ance pre­mi­um to increase because of the more expen­sive treatments.

Folks end up in court with the attor­neys from Bal­lad suing these peo­ple who nev­er received a bill, and then their bills have been turned to col­lec­tions,” All­go­od says. Hicks says Bal­lad does not sue patients who have not received a bill.

Bal­lad filed 5,713 law­suits against patients in its 2019 fis­cal year, seek­ing pay­ment for unpaid med­ical bills. In Vir­ginia, Bal­lad first files a law­suit against patients, which — if Bal­lad wins the case — allows it to more aggres­sive­ly seek pay­ment, some­times by gar­nish­ing a patient’s wages.

Since Octo­ber 2018, Bal­lad has filed 88 suits (plus 16 wage gar­nish­ments) against patients in Lee Coun­ty. In neigh­bor­ing Wise Coun­ty, Bal­lad has filed 158 suits (plus 21 wage gar­nish­ments). When patients don’t appear in court, which is often, Bal­lad wins by default; when they do appear, they almost nev­er have a lawyer.

Bal­lad is not the only non­prof­it med­ical group to pur­sue debts via law­suits. It’s a stan­dard indus­try prac­tice, and one car­ried out by both of its pre­de­ces­sor com­pa­nies. To patients strug­gling on fixed incomes, though, it can feel like a pun­ish­ment for falling ill.


Rur­al areas strug­gle to pro­vide health­care access for a num­ber of rea­sons—includ­ing depop­u­la­tion, a nation­al nurs­ing short­age and the depar­ture of tal­ent­ed young peo­ple, which leave an old­er and poor­er patient pop­u­la­tion than in urban areas. Access to health insur­ance is anoth­er issue. George Pink says rur­al hos­pi­tals tend to serve a big­ger per­cent­age of unin­sured and Med­ic­aid patients than urban hospitals.

South­west Vir­gini­ans have had access to only one insur­er since 2017. For a brief peri­od in 2018, it appeared that 58 local­i­ties, most­ly in west­ern Vir­ginia, would be cov­ered by no insur­er in the fed­er­al mar­ket­place at all, before Anthem even­tu­al­ly became the lone provider.

The major­i­ty of the country’s 113 rur­al hos­pi­tal clo­sures are clus­tered in the South, coin­cid­ing with the fact that few South­ern states have expand­ed Med­ic­aid under the Afford­able Care Act, which pro­vides extra fed­er­al fund­ing to ben­e­fit rur­al hos­pi­tals. Despite Med­ic­aid expansion’s pop­u­lar­i­ty among vot­ers nation­wide, 13 Repub­li­can-dom­i­nat­ed state leg­is­la­tures in the South reject­ed Med­ic­aid expan­sion over con­cerns about costs — and, arguably, to deny Pres­i­dent Barack Oba­ma a polit­i­cal victory.

Vir­ginia lost two rur­al hos­pi­tals before it final­ly expand­ed Med­ic­aid in Jan­u­ary. Ten­nessee, which still has not expand­ed Med­ic­aid, has seen 12 hos­pi­tals close since 2010.


Lit­ton says before Lee Coun­ty’s hos­pi­tal closed, we would have patients come to the office all the time who were short of breath, hav­ing chest pain — and we’d put them in a wheel­chair and roll them down to the ER. Since the hos­pi­tal closed, we’ve had to call the ambu­lance or call heli­copters to get peo­ple to the care they need.”

Not all of those patients make it.

And with­out a hos­pi­tal close by, Lee County’s vol­un­teer res­cue squads have much far­ther to trav­el. For much of the 70-mile-wide coun­ty, the near­est hos­pi­tal is in Big Stone Gap, Va. In the west­ern­most end, it’s Mid­dles­boro or Har­lan, both in Kentucky.

The rur­al ter­rain adds to the trav­el time. We have iso­lat­ed areas with one road in and one road out,” says Lee Coun­ty Sher­iff Gary Par­sons. It may take you 45 min­utes to get an ambu­lance in, and 45 min­utes out before you hit a main road. That’s if you can even get an ambu­lance. If there are two crews [on duty], but they’re both tak­ing peo­ple to hos­pi­tals some­where else, you could have some­one hav­ing a heart attack, the dis­patch­er beg­ging for help — and an ambu­lance may still be an hour away.”

The county’s res­cue squads have seen their time spent on each emer­gency call swell since the hos­pi­tal closed. Jonesville Res­cue Squad went from an aver­age of 72 min­utes to clear a call in 2012, the year before the hos­pi­tal closed, to 112 min­utes for the first eight months of 2019, accord­ing to data pro­vid­ed by Alan Bai­ley. The squad in Pen­ning­ton Gap went from 63 min­utes in 2012 to 101 min­utes in 2019.

Bal­lad hos­pi­tals in south­west­ern Vir­ginia also use ambu­lance diver­sion on a reg­u­lar basis, accord­ing to region­al Emer­gency Med­ical Ser­vices. Hos­pi­tals go on diver­sion when they don’t have enough beds or staff to treat new patients in a time­ly man­ner, mean­ing ambu­lances must take patients else­where except in dire emer­gen­cies. Hos­pi­tal diver­sion has hap­pened so fre­quent­ly in recent months— includ­ing an inci­dent in which three Bal­lad hos­pi­tals in close prox­im­i­ty went on diver­sion simul­ta­ne­ous­ly — that the South­west Vir­ginia Region­al EMS Coun­cil sent a let­ter in an attempt to relieve ten­sions between hos­pi­tal staff and res­cue crew vol­un­teers. Hicks says the increased hos­pi­tal diver­sion was due to staffing issues, and that diver­sion rates have since returned to normal.

I could tell you sto­ry after sto­ry,” Lit­ton says. Joe Smith calls the ambu­lance because he’s hav­ing chest pain, and by the time the ambu­lance gets there and picks him up, Mr. Smith dies. That’s hap­pened mul­ti­ple times since the hos­pi­tal closed. Hon­est­ly, would a hos­pi­tal in the area have made a dif­fer­ence? Possibly.”

(Ger­ri Kulakowsky received a $44,111.71 bill for an air ambu­lance. Pho­to by Mason Adams.)


In a seri­ous med­ical emer­gency, first respon­ders often call heli­copters to fly patients to a large, well-equipped hos­pi­tal. Some­times the flights are cov­ered under insur­ance. In oth­er cas­es, a patient could eas­i­ly see a bill upward of $40,000.

Over the sum­mer, Bal­lad signed a con­tract to part­ner with Med-Trans, an air ambu­lance com­pa­ny. Eric Deaton, Ballad’s chief oper­at­ing offi­cer, says Bal­lad has no con­trol over what Med-Trans charges, but encour­ages employ­ers to join the AirMed­Care Net­work mem­ber­ship pro­gram, an insur­ance-like mem­ber­ship that pro­tects against out-of-pock­et trans­porta­tion costs for select companies.

Ger­ri Kulakowsky, 73, lives in Rogersville, Tenn., a moun­tain town of about 4,300. When she woke up dizzy one night in Novem­ber 2018, emer­gency respon­ders put her on a heli­copter to John­son City Med­ical Cen­ter. Kulakowsky is deaf and says first respon­ders mis­in­ter­pret­ed her slurred speech as a stroke; the dizzi­ness was caused by an inner-ear infection.

Kulakowsky did not have spe­cial­ty insur­ance for air ambu­lances and received a $44,111.71 bill for the flight.

Con­gress held hear­ings this sum­mer about sur­prise med­ical bills. A March 2019 study by the Gov­ern­ment Account­abil­i­ty Office found that the medi­an cost for pri­vate­ly insured patients of an air ambu­lance flight was $36,400, with most flights falling out­side insur­ance net­works, leav­ing patients on their own. The oth­er major pri­vate air ambu­lance com­pa­ny serv­ing peo­ple in south­west­ern Vir­ginia is Air Evac Lifeteam, and then there’s the Vir­ginia State Police. Patients in emer­gency sit­u­a­tions don’t get to choose which heli­copter picks them up — it often depends on a patient’s loca­tion, weath­er con­di­tions and the helicopter’s esti­mat­ed time of arrival — but if the state police arrive, there’s no charge. Even so, the bill charges are not typ­i­cal­ly what a patient will pay,” says Shelly Schnei­der, pub­lic rela­tions man­ag­er for Air Evac Lifeteam, like­ly because of insur­ance or settlements.

Kulakowsky still doesn’t under­stand her bill, which shows a mys­te­ri­ous cred­it for $41,672.45, even though she under­stands her insur­ance denied her claim.

Leg­is­la­tion to address sur­prise bills and low­er health­care costs intro­duced by Sens. Lamar Alexan­der (R‑Tenn.) and Pat­ty Mur­ray (D‑Wash.) has sat in a Sen­ate com­mit­tee since June. The law would require insur­ers to pay out-of-net­work providers the medi­an in-net­work rate for sur­prise costs like air ambu­lances. In response, Glob­al Med­ical Response, the par­ent com­pa­ny of Air Evac Lifeteam, Med-Trans and AirMed­Care Net­work, spent near­ly $900,000 on ads, many tar­get­ing Ten­nessee and Ken­tucky, urg­ing peo­ple to call their sen­a­tors and ask them to pro­tect access to air med­ical services.”


Fol­low­ing the Bal­lad merg­er, Ten­nessee estab­lished the COPA Local Advi­so­ry Coun­cil to col­lect com­mu­ni­ty input and to hold forums for pub­lic com­ment on Ballad’s annu­al report. In Feb­ru­ary, the coun­cil held a pub­lic hear­ing in Blountville, Tenn., in which physi­cians and activists expressed con­cerns about the merg­er and its effect on region­al health­care. In Sep­tem­ber, Vir­ginia cre­at­ed a sim­i­lar task force. The Fed­er­al Trade Com­mis­sion also held a pub­lic work­shop in June to assess the impact of COPAs.

Ballad’s vir­tu­al monop­oly has also emerged as an issue in a near­by Vir­ginia state house dis­trict race. Star­la Kiser, a physi­cian with a Nor­ton clin­ic, is run­ning as a Demo­c­rat for an open seat against Repub­li­can lawyer William Wampler III, who worked for a con­sult­ing firm that helped Ballad’s under­writ­ers refi­nance its debt after the merg­er (although Bal­lad says Wampler him­self was not involved). Kiser wrote an op-ed crit­i­ciz­ing Bal­lad and express­ing her fear that patient fatal­i­ties will increase due to the lack of local care dur­ing a med­ical emer­gency.” Kiser faces an uphill bat­tle in a dis­trict where Trump won 77% of the vote.

While health­care pol­i­tics plays out at the state and fed­er­al lev­el, clin­ics and health­care providers have sprout­ed up to fill gaps and pro­vide basic care in south­west­ern Virginia.

Stone Moun­tain Health Ser­vices oper­ates a num­ber of region­al clin­ics that offer a slid­ing scale for patients. The Health Wag­on, found­ed by a nun in 1980 oper­at­ing out of a Volk­swa­gen Bee­tle, runs mobile clin­ics used by many region­al res­i­dents, some of whom are man­ag­ing long-term ail­ments like dia­betes and heart con­di­tions. And Remote Area Med­ical, based in Rock­ford, Tenn., runs free clin­ics pro­vid­ing den­tal, vision and med­ical ser­vices to thou­sands of Appalachians.

Bal­lad points to one of its rur­al Ten­nessee hos­pi­tals as a great pro­to­type” for healthcare’s future in the region, replac­ing an aging hos­pi­tal in Uni­coi with a new facil­i­ty with few­er but tar­get­ed ser­vices and an ER. Bal­lad COO Deaton says it is busier than when we had an old­er facil­i­ty, because it meets the needs of the pop­u­la­tion.” Bal­lad was also required to keep it open as part of its COPA agree­ment with Tennessee.

Ballad’s new Uni­coi facil­i­ty does address a key rea­son why rur­al hos­pi­tals close: their inabil­i­ty to invest in new equip­ment and ser­vices to keep patients com­ing to their local hos­pi­tals, instead of bypass­ing them for more mod­ern facilities.

Over­haul­ing America’s health insur­ance sys­tem with a sin­gle-pay­er Medicare for All sys­tem could curb rur­al hos­pi­tal clo­sures, says Adam Gaffney, a crit­i­cal care physi­cian who teach­es at Har­vard Med­ical School and serves as pres­i­dent of Physi­cians for a Nation­al Health Pro­gram (PNHP).

There are real chal­lenges to pro­vid­ing com­pre­hen­sive health­care in sparse­ly pop­u­lat­ed areas that basi­cal­ly every nation faces (includ­ing attract­ing need­ed per­son­nel) that don’t entire­ly dis­ap­pear,” Gaffney cau­tions. How­ev­er, one crit­i­cal rea­son for clo­sures and dis­par­i­ties in access is resolved: the fact that health­care infra­struc­ture fol­lows profits.”

PNHP rec­om­mends that in a sin­gle-pay­er sys­tem, the fed­er­al gov­ern­ment pro­vide each hos­pi­tal a guar­an­teed glob­al bud­get to cov­er oper­at­ing costs. (This pro­vi­sion is includ­ed in the House Medicare for All bill, but not the Senate’s.) Hos­pi­tals wouldn’t have to rely on bring­ing in net rev­enue— or what non­prof­it sys­tems refer to as oper­at­ing mar­gins” — to cov­er invest­ments in new tech­nol­o­gy, ser­vices and facilities.

In our cur­rent sys­tem, if you don’t have oper­at­ing mar­gins, you can’t get the MRI machine or the new ward you need,” Gaffney says. If your com­peti­tor has these new facil­i­ties and ser­vices, you’re going to start hem­or­rhag­ing patients. That’s the essen­tial issue” behind hos­pi­tal closures.

He notes Medicare for All would solve anoth­er major fac­tor in clo­sures: the lack of reim­burse­ment from unin­sured patients or those with low­er-pay­ing insur­ance. Gov­ern­ment insur­ance would also pro­tect such patients from shock­ing bills.

In Sep­tem­ber, Alexa Beg­ley, 26, friend and cowork­er of Heather Edwards, was in the midst of her own high-risk preg­nan­cy, due Octo­ber 17. She had been see­ing an OBG­YN at Hol­ston Val­ley. Beg­ley learned, how­ev­er, that in the wake of the NICU clo­sure, her doc­tor would no longer deliv­er babies there as of Octo­ber 1, mean­ing Beg­ley would need to trav­el 63 miles from her home in Pen­ning­ton Gap to John­son City to give birth — an hour and a half drive.

With it being my third preg­nan­cy, you nev­er know how fast the baby can get here,” Beg­ley said. It’s scary. You may be deliv­er­ing in the car.”

For bet­ter or worse, Beg­ley deliv­ered her baby ear­ly, on Sep­tem­ber 20, at Hol­ston Val­ley, just 11 days before her doc­tor moved.

As Bal­lad and oth­er rur­al health sys­tems try to serve rur­al patients with­out run­ning mil­lion-dol­lar deficits, Beg­ley, Edwards and oth­er res­i­dents of south­west­ern Vir­ginia are left with a sense of pow­er­less­ness and uncer­tain­ty — not just for them­selves, but for their children.

How do you get up each day with that hang­ing over you? You just take it as it comes,” Beg­ley shrugs.

Mason Adams grew up in west­ern Vir­ginia and has cov­ered Blue Ridge and Appalachi­an moun­tain com­mu­ni­ties since 2001. He writes from Floyd Coun­ty, Va.
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