“Dedicated to the Future of Health Care in the Tri-State Area,” the sign declares. “May 11, 1981.”

More recent placards posted at the facility’s entryways are ominous, however. “Closed,” they say. “No Trespassing.”

The Keokuk hospital, which served rural areas of Iowa, Illinois, and Missouri, closed in October 2022. But new owners plan to reopen the hospital with the help of a new federal payment system. The Rural Emergency Hospital program guarantees hospitals extra cash if they provide emergency and outpatient services but end inpatient care.

“We’ve been without a hospital for over a year — and I don’t think anybody in Keokuk or the surrounding areas will be picky in any way, shape, or form,” said Kathie Mahoney, mayor of the town of about 9,800 people. She said residents would prefer to have a full-service hospital with inpatient beds, even though those types of beds had been used sparingly in recent years.

The revival of the Keokuk hospital would mark a small victory in the nationwide struggle to save rural hospitals, which continue to close due to staffing shortages, low reimbursement rates, and declining patient numbers. The new federal program, which went into effect in January 2023, is meant to stem the closures. But there have been growing pains, said George Pink, deputy director of the North Carolina Rural Health Research Program, which tracks hospital closures and conversions.

Just 18 of the more than 1,700 eligible rural hospitals nationwide have applied for and won the new designation. Many hospitals are reluctant to give up inpatient services entirely, and some are concerned about how other payment streams could be affected, rural health leaders say. The new designation’s unclear definition of “rural” has also caused confusion.

“We are still in an era of rural hospital closures,” Pink said. Nine hospitals closed in 2023, and that number could rise in 2024, he said. An influx of federal relief funds during the pandemic kept struggling hospitals afloat, but now that money is largely gone.

The Rural Emergency Hospital program is the first new federal payment model for hospitals since 1997. Dora Hughes, acting chief medical officer of the Centers for Medicare & Medicaid Services, said the new model’s criteria are outlined by statute and “hospitals should consider specific circumstances before making the decision to apply.”

The federal agency is providing outreach to rural communities and welcomes feedback, Hughes wrote in an email to KFF Health News.

Now, rural health leaders and federal lawmakers are working quickly to tweak the new program to attract more applicants, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association.

Currently, facilities that convert to rural emergency hospitals receive a 5% increase in Medicare payments, plus an average annual payment of about $3.2 million, in exchange for giving up their expensive inpatient beds and focusing solely on emergency and outpatient care. Rural hospitals with no more than 50 beds, like Keokuk’s, that closed after the law was signed on Dec. 27, 2020, are eligible to apply for the program and reopen with emergency and outpatient services.

More than 100 rural hospitals nationwide have inquired about converting, said Janice Walters, interim executive director for the Rural Health Redesign Center, which has a federal grant to provide technical assistance to hospitals that want to apply.

But only about a quarter of those inquiries are likely to become a rural emergency hospital, and persuading more troubled hospitals to make the leap would require regulators to make changes, Walters said.

Her advice? “Give them 10 beds to just take care of their community.”

In a journal article published last year, general surgeon Sara Schaefer worried about the unintended consequences of getting rid of rural inpatient beds. Schaefer, who spent six months of medical school at a small rural Idaho hospital, said she saw firsthand how difficult it was for the hospital to transfer patients to bigger facilities, which were often too full to take them.

“There has to be a better way,” said Schaefer, who is also a research fellow at the Center for Healthcare Outcomes & Policy at the University of Michigan.

The rural health association’s Cochran-McClain said lawmakers are considering changes that could allow the hospitals to:

• Keep overnight beds for patients who need moderate levels of care, such as those with pneumonia or in need of physical therapy after surgery.
• Allow participation in a federal drug discount program called 340B, which provides hospitals with extra revenue.
• Keep inpatient psychiatric or rehabilitation units open.
• Clarify eligibility, including which facilities qualify under the definition of “rural” and whether the hospitals that closed before the 2020 date in the law can apply.

Updates to the law could affect communities nationwide. In Fort Scott, Kansas, where the hospital closed in late 2018, Mayor Matthew Wells said the community wants the eligibility date pushed back. U.S. Sen. Jerry Moran (R-Kan.) introduced a bill in December that, if passed, would push eligibility back to 2015.

“This is a matter of life and death to my community,” Wells said. “I see a clear path, but the federal regulations in particular make that path nearly impossible.”

In Holly Springs, Mississippi, hospital chief executive Kenneth Williams said he doesn’t understand the federal definition of “rural.” His hospital, Alliance Healthcare Hospital, was one of the first to win the new Rural Emergency Hospital designation in early 2023. He laid off staff and shut down his inpatient beds. Then, CMS officials called to tell him they had made a mistake.

“And I said, ‘Wait a minute,’” Williams said. The hospital, which is about an hour south of Memphis, Tennessee, doesn’t meet the current criteria of rural, they told him. Williams, an internal medicine doctor, bought the hospital in 1999 and has been trying to keep it running since.

Federal regulators are now asking Williams to convert the facility into another type of Medicare payment model, such as the sole community hospital with inpatient beds that it was before. Williams said that would be difficult: “What kind of transition can I make, especially with reduced services?”

In Keokuk, the hospital fits the current requirements. Insight Health Group, the Michigan company that bought the shuttered facility last March, plans to apply for the new federal designation as soon as it obtains state permits under new Iowa regulations tailored to rural emergency hospitals. It would be the first such hospital in the state.

Like many other rural hospitals struggling to survive, Keokuk’s shuttered several key departments years ago, including its birthing and inpatient psychiatric units. In 2021, the last full year it was open, the hospital averaged fewer than three inpatients per night, according to data posted by the Iowa Hospital Association.

More than half of the three-story building would remain mothballed if the facility reopened under the new designation, but the emergency department could serve patients again as soon as late summer, said Atif Bawahab, Insight’s chief strategy officer.

Bruce Mackie has worked 32 years at the hospital, including 10 years as director of plant operations. The new owners kept him on to watch over the building. Beds, high-tech scanners, and lab equipment remain, but most of the clocks have stopped. “It’s spooky,” he said.

Even if the services are more limited than before, Mackie said, “everybody wants the hospital to reopen. This city needs an ER.”

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“Escuché al agente de seguros y, básicamente, hizo publicidad de Medicare Advantage”, dijo Timmins. El agente describió la cobertura menos costosa y más amplia que ofrecen los planes, financiados en gran parte por el gobierno, pero administrados por compañías de seguros privadas.

Para Timmins, que ahora tiene 76 años, lo más lógico desde el punto de vista económico era inscribirse. Y su decisión le resultó muy bien, durante un tiempo.

Luego, hace tres años, notó que tenía una lesión en el lóbulo de la oreja derecha.

“Tengo antecedentes familiares de melanoma. Así que me lo tomé en serio”, dijo Timmins sobre la lesión, que más tarde los médicos diagnosticaron como melanoma maligno. “Empezó a crecer y a ser bastante dolorosa”.

Timmins descubrió entonces que su inscripción en un plan Premera Blue Cross Medicare Advantage significaba una red limitada de médicos y la necesidad potencial de aprobación previa, o autorización previa, de la aseguradora antes de recibir atención.

La experiencia, explicó, hizo más difícil recibir atención médica y ahora quiere volver a Medicare tradicional, administrado por el gobierno.

Pero no puede. Y no es el único.

“Tengo muy poco control sobre mi atención médica”, afirmó, y ahora aconseja a sus amigos que no se inscriban en los planes privados. “Creo que las personas no entienden en qué consiste Medicare Advantage”.

La afiliación a los planes Medicare Advantage ha crecido sustancialmente en las últimas décadas, atrayendo a más de la mitad de las personas que cumplen los requisitos, principalmente mayores de 65 años, con primas de bajo costo y ventajas, como seguro dental y oftalmológico. Y a medida que la cifra de pacientes en los planes privados de Medicare se ha disparado hasta alcanzar los 30,8 millones de personas, también lo ha hecho la preocupación por las agresivas tácticas de venta de las aseguradoras y sus engañosas afirmaciones sobre la cobertura.

Los afiliados, como Timmins, que se inscriben cuando están sanos pueden verse atrapados a medida que envejecen y enferman.

“Es una de esas cosas que pueden gustar al principio, por sus primas bajas o nulas y porque reciben un par de prestaciones adicionales: de visión, dentales, etc.”, explicó Christine Huberty, especialista en prestaciones de la Greater Wisconsin Agency on Aging Resources.

“Pero cuando realmente necesitan utilizarlo para cuestiones más importantes”, añadió Huberty, “entonces se dan se dan cuenta de que, ‘Oh no, esto no me va a ayudar en absoluto'”.

Medicare paga a las aseguradoras privadas una cantidad fija por cada inscrito en Medicare Advantage y, en muchos casos, también abona primas, que las aseguradoras pueden utilizar para ofrecer prestaciones suplementarias. Huberty señaló que esas prestaciones adicionales funcionan como incentivo para “conseguir que la persona se afilie al plan”, pero que luego los planes “restringen el acceso a muchos servicios y la cobertura de cosas más importantes”.

David Meyers, profesor de servicios, políticas y prácticas de salud en la Facultad de Salud Pública de la Universidad Brown, analizó una década de inscripciones en Medicare Advantage y descubrió que un 50% de los beneficiarios, rurales y urbanos, abandonaban su contrato al cabo de cinco años. La mayoría de esos afiliados cambiaron a otro plan Medicare Advantage en lugar de al Medicare tradicional.

En el estudio, Meyers y sus coautores reflexionan sobre el hecho de que cambiar de plan podría ser un signo positivo en un mercado libre, pero también podría indicar un “descontento no medido” con Medicare Advantage.

“El problema es que una vez que uno entra en Medicare Advantage, si tiene un par de enfermedades crónicas y quiere dejarlo, aunque no satisfaga sus necesidades, es posible que no pueda volver a Medicare tradicional”, explicó Meyers.

Medicare tradicional puede ser demasiado caro para los beneficiarios que vuelven de Medicare Advantage, añadió. En Medicare tradicional, los afiliados pagan una prima mensual y, luego de alcanzar un deducible, en la mayoría de los casos deben abonar el 20% del costo de cada servicio o artículo no hospitalario que utilicen. Y, según Meyers, no hay límite en la cantidad que un afiliado puede tener que pagar como parte de ese 20% de coseguro si acaba utilizando muchos servicios.

Para limitar lo que gastan de su bolsillo, los afiliados a Medicare tradicional suelen contratar un seguro complementario, como la cobertura del empleador o una póliza privada Medigap. Si tienen bajos ingresos, Medicaid puede proporcionarles esa cobertura complementaria.

Pero, según Meyers, hay una trampa. Mientras que los beneficiarios que se inscribieron primero en Medicare tradicional tienen garantizado el acceso a una póliza Medigap sin precios basados en su historial médico, las aseguradoras Medigap pueden denegar la cobertura a los beneficiarios que vengan de planes Medicare Advantage o basar sus precios en la cobertura médica.

Sólo cuatro estados —Connecticut, Maine, Massachusetts y Nueva York— prohíben a las aseguradoras denegar una póliza Medigap si el afiliado padece enfermedades preexistentes como diabetes o cardiopatías.

Paul Ginsburg es un ex miembro de la Medicare Payment Advisory Commission, también conocida como MedPAC. Se trata de una agencia del poder legislativo que asesora al Congreso sobre el programa Medicare. Ginsberg aseguró que la incapacidad de los inscritos para cambiar fácilmente entre Medicare Advantage y Medicare tradicional durante los períodos de inscripción abierta es “un problema real de nuestro sistema; no debería ser así”.

El gobierno federal ofrece cada año períodos de inscripción específicos para cambiar de plan. Durante el de inscripción abierta de Medicare, del 15 de octubre al 7 de diciembre, los afiliados pueden cambiar sus planes privados por Medicare tradicional, administrado por el gobierno.

Los afiliados a Medicare Advantage también pueden cambiar de plan o pasarse a Medicare tradicional durante otra ventana de inscripción abierta, del 1 de enero al 31 de marzo.

“Hay muchas personas que dicen: ‘Me encantaría volver, pero ya no puedo contratar Medigap, o tendré que pagar mucho más'”, explicó Ginsburg, que ahora es profesor de políticas de salud en la Universidad del Sur de California.

Timmins es una de esas personas. Este veterinario jubilado vive en una comunidad rural de la isla de Whidbey, al norte de Seattle. Es un paisaje agreste e idílico y un lugar popular para casas de fin de semana, el senderismo y las artes. Pero también es un poco remoto.

Aunque suele ser más difícil encontrar médicos en las zonas rurales, Timmins cree que su plan de Premera Blue Cross complicó aún más la atención médica, sobre todo la dificultad para encontrar especialistas y acudir a a las citas.

Casi la mitad de los directorios de los planes Medicare Advantage contenían información inexacta sobre los proveedores disponibles, según la revisión federal más reciente. A partir de 2024, los planes Medicare Advantage nuevos, o en expansión, deberán demostrar que cumplen con las expectativas federales en materia de redes o sus solicitudes podrían ser denegadas.

Amanda Lansford, vocera de Premera Blue Cross, declinó hacer comentarios sobre el caso de Timmins. Dijo que el plan cumple con los requisitos federales de una red adecuada, así como el tiempo de viaje y las normas de distancia “para asegurar que los miembros no experimenten obstáculos cuando buscan atención”.

Medicare tradicional permite a los beneficiarios acudir a casi cualquier hospital o médico de Estados Unidos, y en la mayoría de los casos no necesitan aprobación para obtener servicios.

Timmins, que acaba de terminar la inmunoterapia, afirmó que no cree que le aprobaran una póliza Medigap, “por mi problema de salud”. Y si consiguiera una, dijo Timmins, probablemente sería demasiado cara.

Por ahora, aseguró, se queda con su plan Medicare Advantage.

“Me estoy volviendo mayor. Van a pasarme más cosas”.

También existe la posibilidad, concluyó Timmins, de que su cáncer reaparezca: “Soy muy consciente de mi mortalidad”.

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“I listened to the insurance agent and, basically, he really promoted Medicare Advantage,” Timmins said. The agent described less expensive and broader coverage offered by the plans, which are funded largely by the government but administered by private insurance companies.

For Timmins, who is now 76, it made economic sense then to sign up. And his decision was great, for a while.

Then, three years ago, he noticed a lesion on his right earlobe.

“I have a family history of melanoma. And so, I was kind of tuned in to that and thinking about that,” Timmins said of the growth, which doctors later diagnosed as malignant melanoma. “It started to grow and started to become rather painful.”

Timmins, though, discovered that his enrollment in a Premera Blue Cross Medicare Advantage plan would mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. The experience, he said, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.

But he can’t. And he’s not alone.

“I have very little control over my actual medical care,” he said, adding that he now advises friends not to sign up for the private plans. “I think that people are not understanding what Medicare Advantage is all about.”

Enrollment in Medicare Advantage plans has grown substantially in the past few decades, enticing more than half of all eligible people, primarily those 65 or older, with low premium costs and perks like dental and vision insurance. And as the private plans’ share of the Medicare patient pie has ballooned to 30.8 million people, so too have concerns about the insurers’ aggressive sales tactics and misleading coverage claims.

Enrollees, like Timmins, who sign on when they are healthy can find themselves trapped as they grow older and sicker.

“It’s one of those things that people might like them on the front end because of their low to zero premiums and if they are getting a couple of these extra benefits — the vision, dental, that kind of thing,” said Christine Huberty, a lead benefit specialist supervising attorney for the Greater Wisconsin Agency on Aging Resources.

“But it’s when they actually need to use it for these bigger issues,” Huberty said, “that’s when people realize, ‘Oh no, this isn’t going to help me at all.’”

Medicare pays private insurers a fixed amount per Medicare Advantage enrollee and in many cases also pays out bonuses, which the insurers can use to provide supplemental benefits. Huberty said those extra benefits work as an incentive to “get people to join the plan” but that the plans then “restrict the access to so many services and coverage for the bigger stuff.”

David Meyers, assistant professor of health services, policy, and practice at the Brown University School of Public Health, analyzed a decade of Medicare Advantage enrollment and found that about 50% of beneficiaries — rural and urban — left their contract by the end of five years. Most of those enrollees switched to another Medicare Advantage plan rather than traditional Medicare.

In the study, Meyers and his co-authors muse that switching plans could be a positive sign of a free marketplace but that it could also signal “unmeasured discontent” with Medicare Advantage.

“The problem is that once you get into Medicare Advantage, if you have a couple of chronic conditions and you want to leave Medicare Advantage, even if Medicare Advantage isn’t meeting your needs, you might not have any ability to switch back to traditional Medicare,” Meyers said.

Traditional Medicare can be too expensive for beneficiaries switching back from Medicare Advantage, he said. In traditional Medicare, enrollees pay a monthly premium and, after reaching a deductible, in most cases are expected to pay 20% of the cost of each nonhospital service or item they use. And there is no limit on how much an enrollee may have to pay as part of that 20% coinsurance if they end up using a lot of care, Meyers said.

To limit what they spend out-of-pocket, traditional Medicare enrollees typically sign up for supplemental insurance, such as employer coverage or a private Medigap policy. If they are low-income, Medicaid may provide that supplemental coverage.

But, Meyers said, there’s a catch: While beneficiaries who enrolled first in traditional Medicare are guaranteed to qualify for a Medigap policy without pricing based on their medical history, Medigap insurers can deny coverage to beneficiaries transferring from Medicare Advantage plans or base their prices on medical underwriting.

Only four states — Connecticut, Maine, Massachusetts, and New York — prohibit insurers from denying a Medigap policy if the enrollee has preexisting conditions such as diabetes or heart disease.

Paul Ginsburg is a former commissioner on the Medicare Payment Advisory Commission, also known as MedPAC. It’s a legislative branch agency that advises Congress on the Medicare program. He said the inability of enrollees to easily switch between Medicare Advantage and traditional Medicare during open enrollment periods is “a real concern in our system; it shouldn’t be that way.”

The federal government offers specific enrollment periods every year for switching plans. During Medicare’s open enrollment period, from Oct. 15 to Dec. 7, enrollees can switch out of their private plans to traditional, government-administered Medicare.

Medicare Advantage enrollees can also switch plans or transfer to traditional Medicare during another open enrollment period, from Jan. 1 to March 31.

“There are a lot of people that say, ‘Hey, I’d love to come back, but I can’t get Medigap anymore, or I’ll have to just pay a lot more,’” said Ginsburg, who is now a professor of health policy at the University of Southern California.

Timmins is one of those people. The retired veterinarian lives in a rural community on Whidbey Island just north of Seattle. It’s a rugged, idyllic landscape and a popular place for second homes, hiking, and the arts. But it’s also a bit remote.

While it’s typically harder to find doctors in rural areas, Timmins said he believes his Premera Blue Cross plan made it more challenging to get care for a variety of reasons, including the difficulty of finding and getting in to see specialists.

Nearly half of Medicare Advantage plan directories contained inaccurate information on what providers were available, according to the most recent federal review. Beginning in 2024, new or expanding Medicare Advantage plans must demonstrate compliance with federal network expectations or their applications could be denied.

Amanda Lansford, a Premera Blue Cross spokesperson, declined to comment on Timmins’ case. She said the plan meets federal network adequacy requirements as well as travel time and distance standards “to ensure members are not experiencing undue burdens when seeking care.”

Traditional Medicare allows beneficiaries to go to nearly any doctor or hospital in the U.S., and in most cases enrollees do not need approval to get services.

Timmins, who recently finished immunotherapy, said he doesn’t think he would be approved for a Medigap policy, “because of my health issue.” And if he were to get into one, Timmins said, it would likely be too expensive.

For now, Timmins said, he is staying with his Medicare Advantage plan.

“I’m getting older. More stuff is going to happen.”

There is also a chance, Timmins said, that his cancer could resurface: “I’m very aware of my mortality.”

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Determinar el tamaño de un bebé durante una visita obstétrica de 28 semanas es algo rutinario. Pero Magloire, médica de cabecera capacitada en obstetricia, sabe que encontrar el útero de la madre, y chequear al bebé, puede ser complicado para profesionales sin experiencia.

“A veces está, como, desviado”, explicó Magloire, mostrándole a un estudiante de medicina visitante cómo presionar con firmeza y completar el examen. Movió ligeramente el dedo para calcular la altura del feto: “Ahí está, justo aquí”.

Evans sonrió y luego dijo que Magloire la hizo sentir “cómoda”.

La joven de 21 años se había mudado recientemente de Louisiana al sureste de Georgia, dos estados donde persiste una elevada tasa de mortalidad materno-infantil. Ahora vive con su madre y su abuelo cerca de Cairo, una comunidad agrícola donde el hospital tiene una unidad de parto muy activa.

Magloire y otros médicos en la clínica local donde trabaja atienden cientos de partos cada año.

Escenas como la de Evans y Magloire se repiten regularmente en este rincón rural de Georgia a pesar de la sombría realidad que enfrentan madres y bebés en todo el país.

Las muertes maternas siguen aumentando, y las madres negras e indígenas son las que están en mayor riesgo.

El número de bebés que murieron antes de cumplir su primer año aumentó el año pasado; y más de la mitad de los condados rurales no tienen servicios hospitalarios para partos, lo que aumenta el tiempo que los futuros padres deben viajar al lugar de la atención, y, por ende, causa bajas en la atención prenatal.

Hay muchas razones por las cuales las unidades de trabajo de parto y parto cierran, incluidos los altos costos operativos, el declive demográfico, las bajas tasas de reembolso de Medicaid y la escasez de personal.

En la América rural, los médicos de familia todavía proporcionan la mayoría de la atención en estas áreas, pero pocos profesionales nuevos ofrecen atención obstétrica en áreas menos pobladas, en parte porque no quieren estar disponibles las 24 horas del día, los 7 días de la semana.

Ahora, con la pérdida de proveedores de atención médica en las zonas rurales, el gobierno federal está invirtiendo dólares y atención para aumentar el personal.

“Obviamente, la crisis está aquí”, dijo Hana Hinkle, directora ejecutiva de Rural Training Track Collaborative, que trabaja con más de 70 programas de capacitación con residencias en áreas rurales. Hinkle dijo que las subvenciones federales han impulsado estos programas en los últimos años.

En julio, el Departamento de Salud y Servicios Humanos (HHS) anunció una inversión de casi $11 millones en nuevos programas rurales, incluidas residencias de medicina familiar centradas en la capacitación obstétrica.

A nivel nacional, la disminución del número de médicos de atención primaria, tanto internistas como de familia, ha dificultado que los pacientes programen citas y, en algunos casos, encuentren un doctor.

En las áreas rurales, capacitar a estos médicos en obstetricia puede ser más díficil debido al bajo reembolso gubernamental y al aumento de los costos de responsabilidad médica, dijo Hinkle, quien también es decana adjunta de Profesiones de Salud Rural en la Facultad de Medicina de la Universidad de Illinois en Rockford.

En la década de 1980, aproximadamente el 43% de los médicos de cabecera que completaron sus residencias fueron capacitados en obstetricia. En 2021, la encuesta anual de perfiles de práctica de la Academia Americana de Médicos de Familia (AAFP) reveló que solo el 15% de los encuestados habían practicado obstetricia.

Sin embargo, los médicos de familia, que también brindan el espectro completo de servicios de atención primaria, son “el pilar de los partos rurales”, dijo Julie Wood, médica y vicepresidenta senior de investigación, ciencia y salud pública de la AAFP.

En una encuesta realizada con 216 hospitales rurales en 10 estados, los médicos de medicina familiar atendieron partos en el 67% de los hospitales, y en el 27% fueron los únicos que atendieron partos.

Los datos contabilizaron los bebés nacidos entre 2013 y 2017. Y, según los autores, si esos médicos de familia no hubieran estado allí, muchos pacientes habrían tenido que conducir un promedio de 86 millas de ida y vuelta para recibir atención.

Mark Deutchman, autor principal del informe, dijo que, metafóricamente, estuvo “de guardia durante 12 años” esperando que lo llamaran cuando trabajaba en un pueblo de 2,000 habitantes en el área rural del estado de Washington. Deutchman explicó que era uno de los dos únicos médicos locales que realizaban cesáreas.

Agregó que la mejor manera de asegurar que los médicos de medicina familiar puedan fortalecer las unidades obstétricas es garantizando que trabajen como parte de un equipo para evitar el agotamiento, y no como médicos solitarios que tienen que hacer todo.

Debe haber un grupo central de médicos, enfermeras y una administración hospitalaria solidaria para compartir la carga de trabajo “para que alguien no esté de guardia los 365 días del año”, dijo Deutchman, quien también es decano asociado de Salud Rural en la Escuela de Medicina de la Universidad de Colorado, en el Campus Médico Anschutz. Este otoño, la Facultad de Enfermería de la escuela recibió una subvención federal de $2 millones para capacitar a parteras para trabajar en áreas rurales de Colorado.

A nivel nacional, equipos de proveedores están asegurando que las unidades obstétricas rurales se mantengan ocupadas.

En Lakin, Kansas, Drew Miller trabaja con otros cinco médicos de medicina familiar y un asistente médico que completó una beca en obstetricia. Juntos, atienden los partos de alrededor de 340 bebés al año. Eran poco más de 100 anuales cuando Miller se mudó allí en 2010.

El boca a boca y el cierre de dos unidades obstétricas cercanas han aumentado el número de partos. Miller dijo que ha visto a amigos y colegas “de comunidades cercanas dejar de atender simplemente por agotamiento extremo”.

En Galesburg, Illinois, Annevay Conlee ha sido testigo del cierre de cuatro unidades obstétricas cercanas desde 2012, obligando a algunas embarazadas a conducir hasta una hora y media para sus citas médicas.

Conlee es médica familiar y directora médica que supervisa cuatro áreas rurales con un equipo de ginecólogos obstetras, médicos de cabecera y una enfermera partera. “Ya no tenemos la capacidad de estar de guardia 24/7”, dijo Conlee. “Tiene que haber un poco más de armonía al reclutar para realmente apoyar a un equipo de médicos y parteras”.

En Cairo, Magloire dijo que practicar obstetricia es “simplemente atención esencial”. De hecho, la atención prenatal representa solo una parte de las visitas en esta ciudad de unos 10,000 habitantes. En una mañana reciente, los pacientes de Magloire incluyeron a dos mujeres embarazadas, a una adolescente preocupada por un dolor de cadera y a una eufórica mujer de 47 años feliz por haber perdido peso.

Cairo Medical Care, una clínica independiente situada al otro lado de la calle del hospital Archbold Grady, de 60 camas, está en una comunidad conocida principalmente por sus cultivos de maníes y como el lugar de nacimiento de la leyenda del béisbol Jackie Robinson.

El centro de salud cuenta con seis médicos, de medicina familiar, como Magloire, y ginecólogos obstetras, que atienden a pacientes de los condados circundantes. Reciben a cerca de 300 bebés cada año.

Deanna Buckins, de 36 años y madre de cuatro niños, dijo que se sintió aliviada cuando encontró a “la Dra. Z” porque “cambió completamente nuestras vidas”.

“Realmente me escucha y acepta mis decisiones en lugar de imponerse”, dijo Buckins, con su hijo de 3 semanas en brazos, parto que Magloire asistió. Años atrás, Magloire ayudó a diagnosticar a uno de los hijos mayores de Buckins con autismo y creó un vínculo de confianza con la familia.

“Voy con uno de mis niños; pero antes de irnos, hemos hablado de cada uno de ellos y cómo les va, y, ya sabes, nos ponemos al día con la vida”, dijo Buckins.

Magloire creció en Tallahassee, Florida, e hizo su residencia en el área rural de Kansas. Dijo que el tamaño de Cairo le permite ver a los pacientes mientras crecen, y charlar con los niños cuando las madres o hermanos vienen a las citas.

“Es muy amigable”, dijo Evans sobre Magloire. Evans, quien tuvo a su primer hijo con un ginecólogo obstetra, dijo que estaba nerviosa por encontrar al médico adecuado. No le importaba el tipo de especialista que fuera su médico tanto como estar con “alguien a quien le importas”, dijo.

Como médica de atención primaria, Magloire puede cuidar de Evans y sus hijos durante muchos años más.

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Determining a baby’s size during a 28-week obstetrical visit is routine. But Magloire, a family physician trained in obstetrics, knows that finding the mother’s uterus and, thus, checking the baby, can be tricky for inexperienced doctors.

“Sometimes it’s, like, off to the side,” Magloire said, showing a visiting medical student how to press down firmly and complete the hands-on exam. She moved her finger slightly to calculate the fetus’s height: “There she is, right here.”

Evans smiled and later said Magloire made her “comfortable.”

The 21-year-old had recently relocated from Louisiana to southeastern Georgia, two states where both maternal and infant mortality are persistently high. She moved in with her mother and grandfather near Cairo, an agricultural community where the hospital has a busy labor and delivery unit. Magloire and other doctors at the local clinic where she works deliver hundreds of babies there each year.

Scenes like the one between Evans and Magloire regularly play out in this rural corner of Georgia despite grim realities mothers and babies face nationwide. Maternal deaths keep rising, with Black and Indigenous mothers most at risk; the number of babies who died before their 1st birthday climbed last year; and more than half of all rural counties in the United States have no hospital services for delivering babies, increasing travel time for parents-to-be and causing declines in prenatal care.

There are many reasons labor and delivery units close, including high operating costs, declining populations, low Medicaid reimbursement rates, and staffing shortages. Family medicine physicians still provide the majority of labor and delivery care in rural America, but few new doctors recruited to less populated areas offer obstetrics care, partly because they don’t want to be on call 24/7. Now, with rural America hemorrhaging health care providers, the federal government is investing dollars and attention to increase the ranks.

“Obviously the crisis is here,” said Hana Hinkle, executive director of the Rural Training Track Collaborative, which works with more than 70 rural residency training programs. Federal grants have boosted training programs in recent years, Hinkle said.

In July, the Department of Health and Human Services announced a nearly $11 million investment in new rural programs, including family medicine residencies that focus on obstetrical training.

Nationwide, a declining number of primary care doctors — internal and family medicine — has made it difficult for patients to book appointments and, in some cases, find a doctor at all. In rural America, training family medicine doctors in obstetrics can be more daunting because of low government reimbursement and increasing medical liability costs, said Hinkle, who is also assistant dean of Rural Health Professions at the University of Illinois College of Medicine in Rockford.

In the 1980s, about 43% of general family physicians who completed their residencies were trained in obstetrics. In 2021, the American Academy of Family Physicians’ annual practice profile survey found that 15% of respondents had practiced obstetrics.

Yet family doctors, who also provide the full spectrum of primary care services, are “the backbone of rural deliveries,” said Julie Wood, a doctor and senior vice president of research, science, and health of the public at the AAFP.

In a survey of 216 rural hospitals in 10 states, family practice doctors delivered babies in 67% of the hospitals, and at 27% of the hospitals they were the only ones who delivered babies. The data counted babies delivered from 2013 to 2017. And, the authors found, if those family physicians hadn’t been there, many patients would have driven an average of 86 miles round-trip for care.

Mark Deutchman, the report’s lead author, said he was “on call for 12 years” when he worked in a town of 2,000 residents in rural Washington. Clarifying that he was exaggerating, Deutchman explained that he was one of just two local doctors who performed cesarean sections. He said the best way to ensure family physicians can bolster obstetric units is to make sure they work as part of a team to prevent burnout, rather than as solo do-it-all doctors of old.

There needs to be a core group of physicians, nurses, and a supportive hospital administration to share the workload “so that somebody isn’t on call 365 days a year,” said Deutchman, who is also associate dean for rural health at the University of Colorado Anschutz Medical Campus School of Medicine. The school’s College of Nursing received a $2 million federal grant this fall to train midwives to work in rural areas of Colorado.

Nationwide, teams of providers are ensuring rural obstetric units stay busy. In Lakin, Kansas, Drew Miller works with five other family physicians and a physician assistant who has done an obstetrical fellowship. Together, they deliver about 340 babies a year, up from just over 100 annually when Miller first moved there in 2010. Word-of-mouth and two nearby obstetric unit closures have increased their deliveries. Miller said he has seen friends and partners “from surrounding communities stop delivering just from sheer burnout.”

In Galesburg, Illinois, Annevay Conlee has watched four nearby obstetric units close since 2012, forcing some pregnant people to drive up to an hour and a half for care. Conlee is a practicing family medicine doctor and medical director overseeing four rural areas with a team of OB-GYNs, family physicians, and a nurse-midwife. “There’s no longer the ability to be on 24/7 call for your women to deliver,” Conlee said. “There needs to be a little more harmony when recruiting in to really support a team of physicians and midwives.”

In Cairo, Magloire said practicing obstetrics is “just essential care.” In fact, pregnancy care represents just a slice of her patient visits in this Georgia town of about 10,000 people. On a recent morning, Magloire’s patients included two pregnant people as well as a teen concerned about hip pain and an ecstatic 47-year-old who celebrated losing weight.

Cairo Medical Care, an independent clinic situated across the street from the 60-bed Archbold Grady hospital, is in a community best known for its peanut crops and as the birthplace of baseball legend Jackie Robinson. The historical downtown has brick-accented streets and the oldest movie theater in Georgia, and a corner of the library is dedicated to local history.

The clinic’s six doctors, who are a mix of family medicine practitioners, like Magloire, and obstetrician-gynecologists, pull in patients from the surrounding counties and together deliver nearly 300 babies at the hospital each year.

Deanna Buckins, a 36-year-old mother of four boys, said she was relieved when she found “Dr. Z” because she “completely changed our lives.”

“She actually listens to me and accepts my decisions instead of pushing things upon me,” said Buckins, as she held her 3-week-old son, whom Magloire had delivered. Years earlier, Magloire helped diagnose one of Buckins’ older children with autism and built trust with the family.

“Say I go in with one kid; before we leave, we’ve talked about every single kid on how they’re doing and, you know, getting caught up with life,” Buckins said.

Magloire grew up in Tallahassee, Florida, and did her residency in rural Kansas. The smallness of Cairo, she said, allows her to see patients as they grow — chatting up the kids when the mothers or siblings come for appointments.

“She’s very friendly,” Evans said of Magloire. Evans, whose first child was delivered by an OB-GYN, said she was nervous about finding the right doctor. The kind of specialist her doctor was didn’t matter as much as being with “someone who cares,” she said.

As a primary care doctor, Magloire can care for Evans and her children for years to come.

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When several representatives from private health insurance companies called on him a few years ago to offer Medicare Advantage plan contracts so their enrollees could use his hospital, Bleak sent them away.

“Come back to the table with a better offer,” the chief executive recalled telling them. The representatives haven’t returned.

Battle Mountain is in north-central Nevada about a three-hour drive from Reno, and four hours from Salt Lake City. Bleak suspects insurance companies simply haven’t enrolled enough of the area’s seniors to need his hospital in their network.

Medicare Advantage insurers are private companies that contract with the federal government to provide Medicare benefits to seniors in place of traditional Medicare. The plans have become dubious payers for many large and small hospitals, which report the insurers are often slow to pay or don’t pay.

Private plans now cover more than half of all those eligible for Medicare. And while enrollment is highest in metropolitan areas, it has increased fourfold in rural areas since 2010. Meanwhile, more than 150 rural hospitals have closed since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. Largely rural states such as Texas, Tennessee, and Georgia have had the most closures.

Medicare Advantage growth has had an outsize impact on the finances of small, rural hospitals that Medicare has designated as “critical access.” Under the designation, government-administered Medicare pays extra to those hospitals to compensate for low patient volumes. Medicare Advantage plans, on the other hand, offer negotiated rates that hospital operators say often don’t match those of traditional Medicare.

“It’s happening across the country,” said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, whose members include small-town hospitals.

“Depending on the level of Medicare Advantage penetration in individual communities, some facilities are seeing a significant portion of their traditional Medicare patient or beneficiary move into Medicare Advantage,” Cochran-McClain said.

Kelly Adams is the CEO of Mesa View Regional Hospital, another rural hospital in Nevada. He said he applauds Battle Mountain’s Bleak for keeping Medicare Advantage plans out of his hospital “as long as he has.”

Mesa View, which is a little more than an hour’s drive east of Las Vegas, has a high percentage of patients enrolled in Medicare Advantage plans.

“Am I going to say I’m not going to take care of 40% of our patients at the hospital or the clinic?” Adams said, adding that it would be a “tough deal” to be forced to reject patients because they didn’t have traditional Medicare.

Mesa View has 21 Medicare Advantage contracts with multiple insurance companies. Adams said he has trouble getting the plans to pay for care the hospital has provided. They are either “slow pay or no pay,” he said.

In all, the plans owe Mesa View more than $800,000 for care already provided. Mesa View lost about $1.3 million taking care of patients, according to its most recent annual cost report.

NRHA’s Cochran-McClain said the growth in the plans also narrows options for patients because “the contracting that is happening under Medicare Advantage frequently has an influence on steering patients to specific types of providers.” If a hospital or provider does not contract with a Medicare Advantage plan, then a patient may have to pay for out-of-network care. That generally wouldn’t happen with traditional Medicare, which is widely accepted.

At Mesa View, patients must drive to Utah to find nursing homes and rehabilitation facilities covered by their Medicare Advantage plans.

“Our local nursing homes are not taking Medicare Advantage patients because they don’t get paid. But if you’re straight Medicare, they’d be happy to take that patient,” Adams said.

David Allen, a spokesperson for AHIP, an industry trade group formerly known as America’s Health Insurance Plans, declined to respond to Bleak’s and Adams’ specific concerns. Instead, he said enrollees are signing on because the plans “are more efficient, more cost-effective, and deliver better value than original Medicare.”

Centers for Medicare & Medicaid Services press secretary Sara Lonardo said CMS has acted to ensure “that private insurance companies are held accountable for providing quality coverage and care.”

The reach of private Medicare Advantage plans varies widely in rural areas, said Keith Mueller, director of the Rural Policy Research Institute at the University of Iowa College of Public Health. If recent trends continue, enrollment could tip to 50% of all rural Medicare beneficiaries in about three years — with some regions like the Upper Midwest already higher than 50% and others lower, such as Nevada and the Mountain States, but trending upward.

In June, a bipartisan group of Congress members, led by Sen. Sherrod Brown (D-Ohio), sent a letter urging federal agencies to do more to force Medicare Advantage insurers to pay health systems what they owe for patient care.

In an August response, CMS Administrator Chiquita Brooks-LaSure wrote that a final rule issued in April made “impactful changes” to speed up care and address concerns about prior authorization — when a hospital and patient must get advance permission for care to ensure it will be covered by an insurer. Brooks-LaSure noted another proposed rule that, once finalized, could mandate that insurers provide specific reasons for denying care within seven days.

Hospital operators Adams and Bleak also want more federal action, and fast.

Bleak at Battle Mountain said he knows Medicare Advantage plans will eventually move into his area and he will have to contract with them.

“The question is,” Bleak said, “how can we match the reimbursement so that we can sustain and keep our hospitals in these rural areas viable and strong?”

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A woman lifted a child from the back of an SUV and walked into the store. A dog barked from a black pickup truck before its owner returned with cases of soda. Another woman checked her hair in a convertible’s rearview mirror before shopping.

Each went right by a sign exclaiming “Quick, Easy Health Visits,” with an image of a mobile clinic.

Just after 10 a.m., registered nurse Kimberly French arrived to work at the DocGo mobile clinic parked in the store’s lot. She checked her schedule.

“We don’t have any appointments so far today, but that could change,” French said. “Last night we didn’t have any appointments and three or four people showed up all at one time.”

Dollar General, the nation’s largest retailer by number of stores, with more than 19,000, partnered with New York-based mobile medical services company DocGo to test whether they could draw more customers and tackle persistent health inequities.

Deploying mobile clinics to fill care gaps in underserved areas isn’t a new idea. But pairing them with Dollar General’s ubiquitous small-town presence has been heralded by investment analysts and some rural health experts as a way to ease the health care drought in rural America.

Dollar General’s latest annual report notes that about 80% of the company’s stores are in towns with populations of fewer than 20,000 — precisely where medical professionals are scarce.

Catering to those who want urgent or primary care, the mobile clinics take private insurance as well as Medicaid and Medicare. The company’s website says DocGo’s self-pay rates start at $69 for patients without insurance or who are out of network. DocGo officials said Tennessee patients may be charged different rates but declined to provide details.

On the ground in Tennessee, primary care doctors and patients are skeptical.

“Honestly, they don’t really grasp, I don’t think, what they’re getting into,” said Brent Staton, a family medicine doctor and the leader of the Cumberland Center for Healthcare Innovation, a statewide organization that helps small-town family care doctors coordinate care and negotiate with insurers, including Medicare.

Michelle Green manages the popular Sweet Charlotte grill about 10 miles south of Dollar General’s most rural test site. Green, who was handing out hamburgers and hand-cut fries during a Saturday rush, said she hadn’t heard of the mobile clinic. She said with a shrug that Dollar General and health care clinics “don’t go together.”

“I wouldn’t want to go to a health care clinic in a parking lot; that’s just me,” Green said, adding that someone might go if “you’re sick and you can’t go anywhere else.”

Bumps in the Road

The Clarksville-area pilot, which launched last fall, is in a federally designated primary care shortage area for low-income residents.

About 1,000 patients have been seen in the company’s clinics, either at Dollar General sites or community pop-up events, and some became repeat visitors, according to DocGo. Payment is taken outside on a mobile device and, once inside, patients meet with an on-site staff member, like French, and connect via telehealth on an iPad screen with a physician assistant or nurse practitioner.

The clinic rotates between three Dollar General pilot sites each week. The stores are in the Clarksville area and, early this summer, the van stopped going to the most rural site, near Cumberland Furnace, because of low utilization, according to company leaders. DocGo moved that location’s time slot to busy Fort Campbell Boulevard in Clarksville.

“We do try for months in a given area to see where it makes sense and where it doesn’t,” former DocGo CEO Anthony Capone said in a July interview. “Our goal is to align the supply we have with the demand of the local community.”

Capone, though, said he thought the pilot would work in rural areas when insurers are signed on to refer their members to the mobile clinic. DocGo recently announced a deal with Blue Cross Blue Shield of Tennessee.

Capone abruptly resigned on Sept. 15 after the Albany Times Union reported he lied about having a graduate degree.

Dollar General stores have a “tremendous opportunity” to have “a major impact on health there and really bond themselves as a member of the community,” said Tom Campanella, the healthcare executive-in-residence at Baldwin Wallace University, who has managed mobile clinics in rural places.

Near tiny Cumberland Furnace, south of Clarksville, William “Bubba” Murphy stopped on his way into a Dollar General, paused to wave and holler hello to friends getting out of their cars, and shared that multiple family members — his sister-in-law, nephew, and niece’s boyfriend — used and liked “the little clinic on wheels.”

“We don’t have to go to town and fight all that traffic,” he said. “They come to us. That’s a wonderful thing. It helps a lot of people.”

Over on busy Fort Campbell Boulevard in Clarksville, Marina Woolever, a mother of three, said she might use the clinic if she didn’t have insurance. Natural health professional Nichole Clemmer glanced toward the clinic and called it a “ploy” to make more money.

Jefferies lead equity analyst Corey Tarlowe, who follows discount retailers, said the clinics will help “democratize” access to health care and simultaneously boost traffic to Dollar General stores.

With its rapid growth in recent years, Dollar General has faced accusations that its stores kill off local grocery stores and other businesses, reduce employment, and contribute to the creation of food deserts. More recently, the U.S. Labor Department said the chain “continues to discount safety” for employees as it has piled up more than $21 million in federal fines.

Crystal Luce, senior director of public relations for Dollar General, said the company believes each new store provides “positive economic benefits,” including new jobs, low-cost products, and its literacy foundation. On the federal fines, Luce said Dollar General is “committed to providing a safe work environment for its associates and shopping experience for its customers.” The company declined to provide an interview.

The DocGo pilot, she wrote, is intended to “complement” the DG Wellbeing initiative, which is a corporatewide push. Dollar General wants to increase “access to basic health care products and, ultimately, services over time, particularly in rural America,” Luce wrote.

States away, DocGo is under fire for a no-bid contract to provide housing, busing, and other services for asylum-seekers in New York. State Attorney General Letitia James is investigating complaints levied by migrants under the company’s care. In August, DocGo officials said claims aired by sources in a New York Times article that first reported the problems were “not reflective of the overall scope and quality” of the services the company has provided.

The company’s pilot with Dollar General is “supported with funding from the state of Tennessee,” DocGo’s Capone said during the company’s first-quarter earnings call. The Dollar General partnership is cited in quarterly grant reports DocGo’s Rapid Reliable Testing LLC submitted to the state, according to records KFF Health News obtained through public information requests.

In the grant filing, DocGo listed Dollar General along with other organizations as “trusted messengers” in building vaccine awareness.

Dollar General declined to respond to a question about its involvement in the grant. Instead, Luce stated, “We continue to test and learn through the DocGo pilot.”

‘Relational Care’

The goal of the $2.4 million grant, funded by the Centers for Disease Control and Prevention and distributed by the Tennessee Department of Health, is to administer covid-19 vaccines. In a written response provided by DocGo’s marketing director, Amanda Shell Jennings, the company said, “Dollar General has no involvement with the TN Department of Health grant funding or allocations.”

The grant covers storage and maintenance of covid-19 vaccines on the DocGo mobile clinics, Jennings’ statement said, adding that, as of September, DocGo has held 41 vaccine events and provided 66 vaccines to rural Tennesseans.

Lulu West, 72, was visiting a friend at the Historic Cumberland Furnace Iron Museum when she stopped to consider the mobile clinic. West said she would rather go to her primary care doctor.

“When you say mobile clinic outside a Dollar General it just kind of has a connotation that you may not be comfortable with. You know what I mean?” she said.

That kind of response doesn’t surprise Carlo Pike, a doctor who for years has practiced family medicine in Clarksville. He said he’s not worried about the competition because providing primary care is about developing relationships.

“If I can do this relationship right,” Pike said, “maybe we can keep you from getting a [blood] sugar of 500 [mg/dL] or from Grandpa climbing up a ladder and trying to fix something he has no business with and falling off and breaking his leg.”

Staton said the Cumberland Center for Healthcare Innovation, his accountable care organization, has saved Medicare and Medicare Advantage companies more than $100 million by focusing on preventive care and reducing hospitalizations and emergency visits for patients.

“We’re just small rural primary care docs doing our jobs with a process that works,” Staton said. In another interview, Staton called it “relational care.”

DocGo surveyed its patients and found that 19% of them did not have a primary care physician or hadn’t seen theirs in more than a year. In the written responses Jennings provided, DocGo said it follows up with every patient after the initial visit, offers telemedicine support between visits, and provides ongoing preventive care on a regular schedule.

But despite its outreach, DocGo struggled to get a foothold in rural Cumberland Furnace.

Lottie Stokes, the president of the community center in Cumberland Furnace, said DocGo’s team had “called and asked to come down here.” Stokes said she would rather use the local emergency medical technicians and firefighters, who she knows are “legit.”

Her father-in-law, Bobby Stokes, who’s nearly 80 years old, said he used the mobile clinic before it moved locations.

His wife couldn’t breathe. They pulled into the parking lot and climbed onto the van.

“We wasn’t in there five minutes,” he said. “They done the blood pressure test and what they need to do and put her in the car and said, ‘Get her to the hospital, to the emergency room.’”

The DocGo staff, he said, did not ask for payment: “Nothing.”

“They were more concerned with her than they were with I guess getting their money,” he said, adding that his wife is doing well now. “They told me to get there, and I took them at their word. My car runs fast.”

KFF Health News correspondent Brett Kelman contributed to this report.

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The news came Sept. 27, three months after KFF Health News’ reporting raised questions about why a federal Health Resources and Services Administration program targeting rural maternal mortality hadn’t sent a grant to serve mothers in majority-Black rural communities.

Non-Hispanic Black women — regardless of income or education level — die of pregnancy-related causes at nearly three times the rate of non-Hispanic white women.

The Institute for the Advancement of Minority Health in Madison, Mississippi, was one of two winners in the latest round of an initiative administered by HRSA. Mary Hitchcock Memorial Hospital in Lebanon, New Hampshire, was the other winner, according to an agency announcement.

“Very happy to see Mississippi,” said Peiyin Hung, deputy director of the University of South Carolina’s Rural and Minority Health Research Center. Mississippi has the highest rate of maternal mortality in the U.S. and the highest proportion of Black births in the U.S., she said.

Hung, who is a member of the health equity advisory group for the maternal grant program, said the Mississippi nonprofit is an unusual awardee because it is not part of a larger health system.

In June, KFF Health News found that HRSA’s Rural Maternity and Obstetrics Management Strategies Program, or RMOMS, had failed to fund any sites in the Southeast, where the U.S. Census Bureau shows the largest concentration of predominantly Black rural communities. The program began four years ago and had budgeted nearly $32 million to provide access and care for thousands of mothers and babies nationwide — including Hispanic women along the Rio Grande and Indigenous mothers in Minnesota.

The rural Southeast was omitted despite a White House declaration to make Black maternal health a priority, and despite statistics showing America’s maternal mortality rate rising sharply in recent years.

Rep. Robin Kelly (D-Ill.) introduced the “CARE for Moms Act” in mid-September and — in response to KFF Health News’ reporting ― called for accountability and reporting requirements for maternal health grants under the Department of Health and Human Services.

“Where is the money going?” she said during a September press conference. “Is it going where it’s needed or is it going to bigger organizations who have the people who can write the grants?” She added that “maybe smaller areas or more rural areas” need it more.

HRSA spokesperson Martin Kramer declined to provide more information about the rural maternity grant awards and did not respond when asked about Kelly’s bill. The legislation also would establish regional “centers of excellence,” Kelly said, to address implicit bias and cultural competency in health care providers. She said the bill would also “build up the doula workforce” and establish a state-based perinatal quality collaborative to improve care nationwide.

In an interview with KFF Health News, Kelly, co-chair of the House Maternity Care Caucus and a congressional leader in expanding Medicaid for postpartum care, suggested the lack of grants to the predominantly Black rural South could be because of “implicit bias,” and she said her bill would help “get to the heart of the matter and get [the money] to the people that really need it.”

The roughly $2 million in new rural grants are part of nearly $90 million in maternal health funding announced in late September by HRSA, an agency within HHS.

The Mississippi-based Institute for the Advancement of Minority Health was created in 2019 to reduce health disparities through partnerships, according to federal filings. Chief executive Sandra Melvin confirmed in an email that this is the first time the institute has applied for the grant, but also noted that it has been working to reduce maternal and infant health disparities since 2019.

Work performed with the grant “will be successful,” she said, because the organization plans to take a community-based approach that includes partnering with health centers, hospitals, and a university.

In past years, the grant application process skewed toward large health systems because they “have much higher capacity to form a statewide network,” Hung said. That’s, in part, because grant winners were required to create a network of specific health care clinics, hospitals, and the state Medicaid office. In recent years, the agency has “become much more flexible,” Hung said.

The success of the Mississippi application is a “promising signal” for states that don’t have large rural health systems focusing on maternal care, said Hung, who hopes a South Carolina applicant receives a grant in the future.

In New Hampshire — where awardee Mary Hitchcock Memorial Hospital is part of the larger Dartmouth Health system in New England ― three rural hospital labor and delivery units have closed in recent years. The closures forced pregnant women to drive up to an hour and a half to appointments or delivery services, said Greg Norman, senior director of community health at Dartmouth Hitchcock Medical Center.

Its HRSA application included the North Country Maternity Network, a collaboration of hospitals and clinics created in late 2021, Norman said. The New Hampshire group did not win the federal maternity grant the first time it applied. But this time the network was more established , he said.

The money from the New Hampshire grant — up to $1 million a year for four years — will help create standardized medical and social screening for pregnant people. It will also pay for a shared high-risk coordinator and increased use of doulas and community health workers who could do home visits, he said.

The whole project, Norman said, is “a step in the direction of more equitable care.”

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The grant-funded initiative, administered by the Health Resources and Services Administration, began rolling out four years ago and, so far, has budgeted nearly $32 million to provide access and care for thousands of mothers and babies nationwide — for instance, Hispanic women along the Rio Grande or Indigenous mothers in Minnesota.

KFF Health News found that none of the sites funded by the agency serves mothers in the Southeast, where the U.S. Census Bureau shows the largest concentration of predominantly Black rural communities. That omission exists despite a White House declaration to make Black maternal health a priority and statistics showing America’s maternal mortality rate has risen sharply in recent years. Non-Hispanic Black women — regardless of income or education level — die at nearly three times the rate of non-Hispanic white women.

“There’s a responsibility to respond to the crisis in a way that is more intentional,” said Jamila Taylor, chief executive of the National WIC Association, a nonprofit advocacy group for the federal Special Supplemental Nutrition Program for Women, Infants, and Children.

“Why isn’t HRSA stepping up to the plate, especially with this rural moms’ program?” Taylor said. According to a 2021 analysis of federal data, Black women living in rural areas also are more likely to die or experience more severe health complications during delivery than white women living in rural areas.

Experts say the failure of HRSA’s Rural Maternity and Obstetrics Management Strategies Program, or RMOMS, to reach predominantly Black communities in the rural South reveals structural inequities and underinvestment in a region where health care resources are scarce and have deteriorated.

The steady closure of hospitals in the region and widespread medical staffing shortages have hindered the ability of cash-strapped agencies and care providers to provide more than essential services. Many “don’t have sufficient resources” to apply for the grants, said Peiyin Hung, deputy director of the University of South Carolina’s Rural and Minority Health Research Center. Hung is also a member of the health equity advisory group for the maternal grant program.

“RMOMS really means to invest in the most underserved and the most disadvantaged communities,” she said, but because the program demands applicants have a network of hospitals and other care providers, she said, “the odds are not there for them to even try.”

Hung said she favors basing the awards on need and not solely on the quality of an application.

Where the Help Is Going

The rural program launched in 2019 and has awarded 10 maternal health grants nationwide to bolster telehealth and create networks between hospitals and clinics. Despite the disruption of care due to the covid-19 pandemic, the program’s earliest grant winners helped more than 5,000 women get medical treatment and recorded a decrease in preterm births during the second year of implementation, the agency reported.

When KFF Health News first asked Tom Morris, associate administrator for rural health policy at HRSA, about the lack of grants in the rural South, he said the agency has an “objective review process” and regularly reviews the program to ensure it reaches the people who need it most.

“The rural rates of maternal mortality for African Americans is a real concern,” Morris said, adding, “I think you raised a good point there, and something we can focus on moving forward.”

So far, the maternal grants have gone to health care providers in Arkansas, Maine, Minnesota, New Mexico, South Dakota, Texas, Utah, and West Virginia, as well as two awards in Missouri.

Among the initial 2019 awardees, Texas reports that 91% of people it served were Hispanic; New Mexico reported 59% of recipients were Hispanic; and the Missouri project, which was in the southeastern part of the state known as the Bootheel, said 22% of beneficiaries were Black patients. In all cases, the majority were Medicaid enrollees. No data was available for other grant awardees. (Hispanic people can be of any race or combination of races.)

States across the rural Southeast have not expanded Medicaid coverage to larger numbers of lower-income residents, which often means lower shares of patients have health coverage.

Where Help Is Most Needed

The lack of Medicaid expansion in the region is "all the more reason funding should be going to these areas,” said the WIC association’s Taylor. She said the program’s failure to reach into the southeastern U.S. seems “incredibly odd.”

“The South is a hotbed — to be quite honest — of a whole host of chronic diseases and health challenges, particularly for people of color,” Taylor said.

Taylor, who previously worked on similar programs with community-based organizations while at the Century Foundation, said grant applications are often long and tedious and require intense data collection, adding to the “real challenges and barriers in the process of applying for the grants in the first place.”

Rep. Robin Kelly (D-Ill.), whose district spans rural and urban areas, said it is her experience that “some of the neediest places don’t apply for the grants because they don’t have the personnel.”

“There needs to be special outreach,” said Kelly, who created legislation in 2018 to extend postpartum care after hearing from a constituent. “We need to take the extra steps that mean saving women’s lives.”

Several current grant winners said the federal agency does provide extensive technical assistance and is responsive to questions and concerns — but they also described how difficult it was to win the grants, which amounted to $1 million or less for last year’s winners.

“It’s an intimidating grant to apply for,” said Johnna Nynas, an obstetrician and gynecologist who wrote the maternal grant application for Sanford Bemidji Medical Center in Minnesota.

“I don’t want to admit how much of my own personal time I dedicated to this grant, writing it,” she said. Sanford won the grant in 2021.

Unlike applicants from smaller, cash-strapped health organizations, Nynas was able to solicit help from the internal grant team at Sanford Health, which operates a regional system including a health plan as well as hospitals, clinics, and other facilities in the Dakotas, Iowa, and Minnesota.

Nynas said four hospitals in the remote region of northern Minnesota, where Bemidji is located, have closed their labor and delivery units in recent years, leaving residents — including a significant number of Indigenous women — to drive 60 miles or more one way for care.

Meeting an application requirement to create a network that includes specific health clinics as partners in the grant was “the biggest challenge,” Nynas said, adding “when you look at the map, those can be very difficult to find.”

Try, Try Again

In South Dakota, Avera Health’s application stalled for two years because of grant criteria requiring state Medicaid agencies to sign on as network partners, said Kimberlee McKay, an OB-GYN and the program director for the South Dakota grant. Avera Health spans Iowa, Minnesota, Nebraska, North Dakota, and South Dakota.

It wasn’t until the third round, McKay said, and after “the climate around maternal health had changed,” when the state Medicaid agency committed to fully partnering on the maternity care grant.

South Dakota voters adopted Medicaid expansion in late 2022 and will implement it this summer. Avera’s South Dakota program will use grant money to reach more than 10,000 pregnant patients in the eastern part of the state and the region’s tribal communities.

Among the previous grant winners, only the Texas winner is from a non-Medicaid expansion state. HRSA spokesperson Elana Ross said 10 of 38 applications won grants since 2019. She declined to release a list of unsuccessful applicants, citing privacy concerns.

Ross said the requirement to partner with Medicaid “increases the likelihood that the pool of applicants, if selected, will be able to sustain services at the end of federal funding.” Medicaid, she noted, pays for nearly half of all births nationally and a greater share of births in rural areas.

The goal for the grants is that applicants can keep the program operating even after several years of federal funding runs out, HRSA officials said.

Stoking Change

In May, after KFF Health News began reporting this article, the agency released a new call for applicants and relaxed requirements. Only two awards will be given, and the applications, which demand detailed network plans, are due July 7.

In an emailed statement released after announcing the more flexible expectations, Morris said the federal agency’s mission was to provide care for “the highest-need communities, and that means dedicating significant funds towards addressing the Black maternal health crisis.” The agency will no longer require state Medicaid programs to be partners on initial applications. It also loosened language about which clinics needed to be in the network.

And in perhaps the most significant shift, the agency said it will use newly created criteria to determine “areas of greatest need.” Alabama, Louisiana, and Mississippi all qualify as areas with shortages of maternity health care providers, according to the funding notice.

Kelly, who works on Congress’ bipartisan maternity care caucus, said of the lack of grants in the rural South: “Money matters, resources matter.”

Despite the government-wide focus on maternal care, it wasn’t clear whether the rural program would award new grants in 2023. In April, Morris told KFF Health News the agency was “trying to figure out if we have enough funding to support our existing grantees and do a new competition.”

The rural maternity program’s initial fiscal year 2023 budget was $8 million — down from $10.4 million the year before, according to the agency’s operating plan. The release of grants in May came after the federal agency found an additional $2.4 million in its internal budget.

Even so, Kelly said, she “would love to see more money being put toward it” as well as evaluations of “where the money is being spent and where the holes are.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“I tried to gut it out for three hours because of the insurance situation,” said Comfort, a retired teacher and American citizen who has Swiss insurance.

When the pain became unbearable, Comfort called his brother, who drove him and his wife, Nazuna, a few miles to the nearest emergency department, at the University of Pittsburgh Medical Center’s hospital in Williamsport, Pennsylvania.

Every bump of the drive was “like someone taking something and just jabbing it into my abdomen,” he said.

At the hospital, Nazuna Konishi Comfort handed over her husband’s Swiss insurance card, which confirmed coverage by Groupe Mutuel. Jay recalled the staff making copies of his insurance card and then treating his acute appendicitis. Doctors performed emergency surgery to remove the inflamed appendix.

Diagnostic tests confirmed he had a rare cancer, which doctors in Switzerland later removed with another surgery after he returned home. “It was a miracle,” Comfort said, adding that the cancer was completely removed.

After his appendectomy, Comfort recalled vomiting and then waiting in a recovery room. In all, he spent about 14 hours at UPMC Williamsport before being released. He attended his daughter’s wedding and, eventually, traveled back to Switzerland.

Then the bill came.

The Patient: Leslie “Jay” Comfort, 66, a retired educator who worked in Japan and Switzerland. Comfort pays a monthly fee and deductible for Switzerland’s mandatory basic health insurance, which he has with the Swiss-based Groupe Mutuel. His benefits — and the prices for procedures — are defined by the Swiss government.

Medical Service: Emergency laparoscopic appendectomy and diagnostic tests, which showed Comfort had a rare subtype of cancer called goblet cell adenocarcinoma.

Service Provider: University of Pittsburgh Medical Center Williamsport, which is about 3½ hours northeast of Pittsburgh. The UPMC health system is one of the state’s largest employers, with 40 hospitals.

Total Bill: $42,156.50, covering emergency surgery, scans, laboratory testing, and three hours in a recovery room. His insurer has said it will pay him about $8,184 (7,260.40 in Swiss francs), which is double the procedure’s price in Switzerland. This left him to cover the remaining roughly $34,000.

What Gives: Although Comfort has health coverage, his Swiss insurance had no contract with the U.S. hospital where he underwent emergency surgery — or with any other provider outside Switzerland.

With what is considered an excellent health system, Switzerland has the highest prices for medical care in Europe. As in the U.S., the country relies on private insurers and hospitals. But the cost of care in Switzerland is substantially lower than what is charged in the U.S., so the reimbursement his insurer offered is a fraction of what Comfort owes the U.S. hospital.

“I’m trying to do the right thing and say I’m willing to pay my responsibility,” he said.

Groupe Mutuel does not have agreements with foreign providers, such as UPMC, and does not deal with them directly, said Lisa Flückiger, a spokesperson for Groupe Mutuel. The insurer originally agreed to reimburse Comfort what would have been paid in Switzerland for the same treatment in a public hospital and then double that because it was an emergency in a foreign country — a total of 4,838 in Swiss francs, or about $5,460.

While helpful, Comfort said, that amount wouldn’t pay off the $42,156.50 he owes UPMC.

UPMC has expanded its reach throughout Pennsylvania and is now the largest provider of care in many parts of the state. In 2016, it purchased a smaller health system and now runs two major hospitals, UPMC Williamsport and UPMC Williamsport Divine Providence Campus.

Studies show that in areas where hospital consolidation is high, prices go up. Because there is less competition, hospitals have more power to charge what they want when patients have private insurance or are paying out-of-pocket.

In the U.S., the amounts charged for medical care are “all over the map,” said Johnathan Clarke, vice president of strategy and business development at Penfield Care, a medical cost-containment company in Canada. The company negotiates medical bills on behalf of individuals, including international visitors to the U.S., but is not involved in Comfort’s case.

Clarke said he would expect an appendectomy to be priced between $6,500 and $18,800, based on his analysis of Medicare payments in the Pittsburgh area. Healthcare Bluebook — which evaluates insurers’ claims data to provide cost estimates based on what insurers have paid, rather than what providers charge — says a fair price for a laparoscopic appendectomy in Williamsport is about $14,554.

Comfort said a “reasonable price estimate” based on his own internet research would be between $7,500 and $12,000.

Comfort’s care included an X-ray and an EKG, or electrocardiogram for his heart, because “there was no information relating to past medical/surgical history for this patient,” wrote Susan Manko, vice president of public relations at UPMC. The staff also conducted pathology work that identified cancer.

But those additional services did not fully explain the gap between cost estimates and what the hospital charged. For instance, UPMC charged $8,357 for Comfort’s three-hour stay in the recovery room.

Manko said Comfort’s total bill aligns with UPMC’s standard charges.

The cost disparities highlight the stark difference in international pricing. Cost estimates last year showed the average amount paid for an appendectomy in the U.S. was “nearly exactly double” that paid in Switzerland, said Christopher Watney, chief executive of the International Federation of Health Plans, an industry association whose members include health insurers on six continents.

Health care in Switzerland, though, is often expensive compared with other European countries, Watney said. The Swiss pay double for an appendectomy compared with Germans, and more than three times that of those in Spain, he said. Across the globe, Watney said, many countries include an overnight stay in the cost of an uncomplicated appendectomy in contrast to Comfort’s experience, which was billed as outpatient care.

Comfort, who has dual residency in Switzerland and Japan after nearly three decades working abroad, said he worked in the U.S. long enough to qualify for Social Security benefits and Medicare. He said he had previously tried to gain Medicare coverage at one point but still is not enrolled, after being transferred to a couple of offices and “playing phone tag.”

Still, unlike many patients dealing with a five-figure medical bill, Comfort said he is not concerned about UPMC harming his financial reputation. The health system doesn’t “seem to put bad marks against people’s credit record — and I don’t have credit in the United States. I’ve been out for 30 years.”

Manko confirmed that, saying UPMC reviewed and updated its collection policy last year; it states the health system will not engage in “extraordinary collection actions” such as lawsuits, liens on homes, arrests, or reporting to credit agencies.

She said the health system — which, as a nonprofit system, is tax-exempt — maintains a “robust financial assistance program” for patients unable to pay. But “to our knowledge” Comfort has not applied for financial assistance, Manko told KFF Health News.

The Resolution: Comfort said he spent months waiting for a bill and finally reached out to UPMC because, if the bill had arrived this year, he would have had to pay his insurance deductible again on top of the charges.

Comfort received a full UPMC bill six months after his surgery. Manko said there was “confusion” at the time of Comfort’s ER registration. Comfort’s wife provided the insurance information, she said, “but there was no documentation in the patients record for address, policy number or policy holder information.”

Once Comfort received his bill, he realized it was much higher than his Swiss insurance reimbursement and, frustrated, contacted KFF Health News.

Flückiger said the original payment amount Comfort’s insurer calculated was by episode and did not include the scan or laboratory costs. After receiving questions from a KFF Health News reporter, Groupe Mutuel “realized that we have not included the laboratory analysis and the CT scan,” which are not routinely part of an appendectomy, Flückiger wrote.

After KFF Health News provided a detailed summary of the UPMC bill, the insurer increased the amount it would pay Comfort. In all, the insurer said, Comfort should receive 7,260.40 in Swiss francs, or about $8,184.

Comfort still hopes to negotiate directly with UPMC to reduce what he owes.

“I don’t want to try to walk away, saying I don’t owe you anything,” Comfort said. “That’s not right. We’re moral people, you know. But if you’re going to try to gouge me and play the power trip and think you’re going to try to get everything you can out of me, I won’t play that game.”

The Takeaway: Though the Affordable Care Act was meant to provide insurance to more Americans and bring down the cost of care, hospital bills remain extraordinarily high and highly variable.

For a nonemergency, Comfort could have tried to compare prices at other hospitals. But most hospitals in the area where he fell ill are owned by UPMC. And an inflamed appendix can’t wait for comparison shopping.

Clarke, the cost-containment expert, said the “only thing” Comfort could have done differently was to purchase a travel health insurance policy before leaving Switzerland. While prices for health care in continental Europe are comparable to Switzerland, the high cost of care in the U.S. means Groupe Mutuel insurance is “insufficient.”

That is especially important for visitors to the U.S. since, as Robin Ingle, CEO of travel insurance company Ingle International, said: U.S. prices are “kind of crazy numbers.”

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).