Williamson, West Virginia Life in central Appalachia requires a resolute spirit, and Loretta Simon is an optimist.

Simon served as both head nurse and chief operating officer of Williamson Memorial Hospital until it closed its doors, just past 1 a.m. on April 21, 2020. The 76-bed hospital—the staff of which was known as “Your Friends on the Hill”—had been struggling financially. There were potential buyers, but the pandemic temporarily derailed that process.

“Things happen for a reason,” Simon says. Lessons have been learned with the closure, perhaps the most critical of which is that rural hospitals must leverage the full resources of their communities in order to survive.

Fortunately, Williamson Memorial is a survivor. It’s now scheduled to reopen, most likely in the fall, and Simon is busy making preparations to return to work. The hospital’s new owner is the Williamson Health and Wellness Center, a federally qualified health center that over the past few years has been a catalyst in the community for a wide range of public health initiatives.

The plan is for Williamson Memorial and Williamson Health and Wellness to work in concert—in effect, to reopen the hospital while taking every measure to keep people out of it. The health of the community and viability of its hospital will be dependent on a successful symbiosis.

Rural communities throughout central Appalachia and across America are struggling with the question of how to continue providing hospital care. In some cases, the answer is the merging of hospitals or acquisition by an outside entity, solutions that offer economy of scale—purchasing power, consolidated administration, access to advanced technology—but come at the risk of the loss of attention to the community’s needs and concerns.

The other option, maintaining an independent hospital, is increasingly difficult. Doing so requires rethinking.

Hospitals have been cornerstones of rural communities. The question for those communities today is whether they can save their hospital, and, if not, what are the consequences?

“When you lose your community hospital,” says Williamson Mayor Charlie Hatfield, “tumbleweeds.”

‘I made preparations to die’ 

The University of North Carolina’s Cecil G. Sheps Center for Health Services Research documents 138 rural hospital closures since 2010. A study released in spring of last year found that one in five rural hospitals was at risk of closure due to financial stress. With the precipitous drop in revenue throughout the pandemic, many more are now in jeopardy.

The first consequence of a hospital closure is the loss of the emergency room. Access to specialty care is diminished. Then there’s the economic ripple effect. In many rural communities, the hospital is the biggest employer. When it closes, tax revenue plummets and other businesses suffer.

News of the closure of Williamson Memorial hit the community hard. Generations of families have worked in the hospital, and generations of babies have entered the world there.

There’s another hospital just a couple of miles from Williamson, across the Tug Fork River in Kentucky. But crossing state lines creates issues with insurance, both public and private. The closest in-state hospital is 35 minutes away in Logan. Neither hospital is home to “Your Friends on the Hill.”

Mingo County, of which Williamson is the seat, faces considerable health care challenges. It’s ranked as the second-least healthy county in a state that’s consistently at or near the bottom in health outcomes.

Williamson’s population (about 2,500) has declined apace with its economy. Young people leave in pursuit of better opportunities, and its hospital’s patients, like those in most rural hospitals, tend to be older, sicker, and with lower income than the national average. Rural hospitals also serve a higher percentage of patients who are uninsured, meaning they provide a lot of care for which they’re never reimbursed.

The Williamson Health and Wellness Center plays a vital role in the community, offering medical, dental, and behavioral care, as well as chronic-disease management and wellness coaching, all on a sliding-fee scale. No one is turned away.

“We started looking at the community holistically,” says Donovan “Dino” Beckett, who was born and raised in Williamson and is now the health center’s co-founder, CEO, and chief medical officer.

The center’s mission is to address the social determinants of health, and it’s structured around the conviction that health care extends to housing, employment, transportation, and more. The center delivers fresh fruit and vegetables throughout Mingo County and oversees a community garden in a public housing complex. It operates a medically assisted addiction treatment program—a House of Representatives investigation found that between 2006 and 2016, almost 21 million prescription painkillers were delivered to two Williamson pharmacies located four blocks apart—and recently received funding for a workforce development initiative to help get those in the program back to work.

In 2013, the health center launched a CDC-funded community health worker-based program addressing diabetes, then leveraged that success to confront congestive heart failure and chronic obstructive pulmonary disease. Community health workers are foundational to the center’s success.

Melissa Kennedy, 54, had long suffered from rheumatoid arthritis, type 2 diabetes, and hypertension. “I made preparations to die. I mean, I was that sick,” she says. “I thought, ‘I can’t go on.’”

Kennedy was put in touch with Jerome Cline, a Williamson Health and Wellness Center community health worker. Cline’s first question on their initial visit, she recalls, was, “‘What did you have for breakfast?’ And I said, I’m a cereal eater. ‘What kind did you have?’ I said, Cocoa Pebbles. He said, ‘Melissa, you don’t know anything about sugar?’ And I said, Not one thing.”

Incrementally, through counseling and encouragement, Kennedy’s health has improved. Cline’s “care and guidance,” Kennedy says, “has changed my life.”

Hope amidst declining health care

“I’m hopin’,” Andrea Haas says with conviction.

The Remote Area Medical clinic has come to Jellico, Tennessee, in Campbell County, on the Kentucky border. It’s offering free health care.

Haas’s hope for today is that her teeth will get pulled. She’s suffered all her life from grand mal seizures, and with each episode she bites her tongue. “They said one wrong, good bite and I could lose my tongue,” Haas says. The plan is to extract her teeth and, later, replace them with better fitting dentures.

It’s 9:30 a.m. Haas, 31, arrived last night. The gates opened at midnight, the clinic doors at 6 a.m. It’s first come, first served.

In March, Jellico Medical Center officially shut down after not having admitted a patient since November. “I’m hopin’,” Haas repeats, this time in reference to the hospital reopening. She worries about those who now must drive to Knoxville or Kentucky to see a doctor, and even more about those with no means to make the trip.

Local news sources have reported that an Indiana-based health care system is reopening the hospital, but promises have been broken before. The former owner was Florida-based Rennova Health. Rennova also previously operated Jamestown Regional Medical Center, an hour and a half to the west along the Cumberland Plateau, but shuttered it in June 2019.

Rennova still operates Big South Fork Medical Center in the Scott County town of Oneida, about halfway between Jellico and Jamestown. But employees there recently reported—not for the first time—that the company was behind in issuing paychecks, and that they wouldn’t be returning to work until paid. The hospital’s only doctor, Deepak Reddy, now lives in the hospital to be immediately available around the clock.

Campbell County ranks 93rd worst in health outcomes of Tennessee’s 95 counties. Scott County ranks 91st.

Across the nation, 12 states have not yet adopted Medicaid expansion as allowed for under the Affordable Care Act. None of the eight states with the most rural hospital closures has implemented expansions. (Voters in two of those states, Missouri and Oklahoma, last year approved ballot measures to expand.)

Six of those non-expansion states are in the Appalachian region, Tennessee among them. Tennessee has experienced more hospital closures per capita than any state. “I don’t understand how we can continue to pass up those dollars,” says Jacy Warrell, director of the Rural Health Association of Tennessee.

Old men out of young men’

Forty miles to the east of Jellico, the Cumberland Gap opens into southwest Virginia, an isolated pocket of picture-postcard Appalachia.

This is coal mining country, or once was, and pneumoconiosis, or black lung disease, is prevalent. A 2018 study of three clinics in the region found what was believed to be the largest cluster ever recorded of an advanced stage of the disease: progressive massive fibrosis. Young men arrive at Stone Mountain Health Services’ black lung clinic in Lee County in wheelchairs.

“It makes old men out of young men,” says Teresa Tyson, executive director of The Health Wagon, based in the town of Wise, a legend in this region for its care of the most neglected.

There’s also a high incidence of asthma, COPD, and emphysema.

“I love southwest Virginia with all my heart. I will die here,” says Wendy Welch, director of the Graduate Medical Education Consortium of Southwest Virginia. “But southwest Virginia is not a prize very many people want to fight over.”

Lee County is Virginia’s westernmost. In 2013, it lost its hospital, in the town of Pennington Gap. The hospital is now scheduled to reopen in July under ownership of the region’s new health care behemoth, Ballad Health.

Ballad is the product of the merging in 2018 of two hospital systems—Mountain States Health Alliance and Wellmont Health System. They were competitors in southwest Virginia and eastern Tennessee, an arrangement most health care observers in the region agree was impractical.

In exchange for approval of the merger, the hospital systems signed agreements with Tennessee and Virginia regulators committing to addressing persistent public health concerns. Ballad selected as its primary areas of focus substance misuse, tobacco use, obesity, and childhood trauma.

The mandate, says Tony Keck, Ballad’s vice president for system innovation and chief population health officer, is to “turn the battleship from being a hospital-based system to being a community health improvement organization.” That’s not just a promise, Keck says. “We actually had to commit to a $308 million investment in community health improvement over the next decade.”

With a merger comes the consolidation of services. Ballad is headquartered in Johnson City, Tennessee, and its administrators made decisions that didn’t sit well with many non-Johnson City residents. Top-level neonatal ICU care was moved from Holston Valley Medical Center in Kingsport, Tennessee, to Johnson City Medical Center, 25 miles away. Top-level trauma units at the two hospitals were consolidated in Johnson City. For folks in Pennington Gap, that’s an hour-and-15-minute drive.

A recurrent concern when services are consolidated is that the most difficult to serve, those most in need, will be forgotten.

Much work needs to be done to rebuild trust in Lee County, Virginia. Lee County Hospital was owned by Wellmont Health System. Its closure took the community by surprise. “It was very abrupt,” says Greg Edwards, who serves as chair of the council that operates Stone Mountain Health Services. Wellmont had invested in upgrading the ER, and, Edwards says, had told the district’s congressman that they had no intention of closing. “They just took off, shut it down, closed.”

“So then you have Ballad come in and say, ‘We’ll put these broken pieces back together,’” Welch says. But the decision to close the hospital was made “by the same men who are now going to be taking up senior leadership in the new system.”

The prevailing attitude in southwest Virginia regarding Ballad Health is “too soon to tell.” Reopening the hospital in Lee County will be a critical step in rebuilding trust.

Ballad, Welch says, “needs to step up its game with listening to community members, but I think they can.”

A resolute spirit

“I’m optimistic that rural communities have the potential to solve this problem,” Jacy Warrell, the director of the Rural Health Association of Tennessee, says. “I think what needs to happen is for policymakers and administrators to really listen to the needs of the community and become partners in solving these issues. I think the answers are there.”

“It used to be we were going to provide every single service in our community, and I think people realize we can’t do that,” Jim Kaufman, who heads the West Virginia Hospital Association, says. The most essential question now, he contends, is, “How do we get creative?”

Increasingly, more communities will turn to outside entities, as the financial damage inflicted on hospitals by the pandemic is expected to accelerate mergers and acquisitions.

But, says Alan Morgan, CEO of the National Rural Health Association, “I think there is a role for a small, independent hospital that has a strategic alliance with a larger health system.” That role will be to focus on preventative health and chronic care management, Morgan says, and on “empowering the community to take control of their own health, as opposed to just treating them only when they show up in the emergency room.”

Burgess Dalton worked in underground coal mines for some 25 years and now suffers from stage 4 chronic obstructive pulmonary disease. Jerome Cline has regularly scheduled visits with him, and in between those visits he shows up as needed with antibiotics or a steroid shot. Prior to their visits, Dalton was in the emergency room every month or two; it’s been 14 months since he was last there.

That, of course, is the objective—keeping people out of the hospital. Meanwhile, Loretta Simon prepares for the reopening of Williamson Memorial. She’s been helping administer COVID-19 vaccines at a drive-through site. “To be able to see the faces, to connect our purpose with that patient—that’s been my driving force.”

It was a rough winter in Williamson. Then one spring morning, Simon arrived for work, and it was as if, overnight, every bud had blossomed. “It gives hope,” she says. “Where flowers bloom, there’s hope.”