Comanche County Medical Center is a 38-bed rural-Texas acute care hospital./Comanche County Medical Center

Rural hospitals provide emergency and routine care for millions of people in Texas. But over the past few decades, their doors have been closing. The Affordable Care Act was supposed to help financially-strained rural hospitals stay open – but it doesn’t look like there will be much relief for those in Texas.

The KERA radio story.

Hospitals in rural areas were relatively healthy up until the 1980s. But in that decade, and the one that followed, over 400 rural hospitals closed throughout the country.

David Lee, government affairs manager for the National Rural Health Association, says following the collapse, Congress essentially put rural hospitals on life support – funneling money through increased Medicare reimbursements for newly-designated critical access hospitals to slow the tide of closures.

Lee fears rural hospitals are in jeopardy again.

The Affordable Care Act’s Impact

In Texas, rural hospitals treat 15 percent of the population, but cover 85 percent of the state (see below for 10 facts on rural hospitals in Texas). In rural areas, patients are generally older, less healthy, and have less access to insurance.

Dr. Howard Dickey is a family practice doctor at Comanche Community Clinic in west central Texas.

Lauren Silverman/KERA News

Dr. Howard Dickey is a family practice doctor at Comanche Community Clinic in west-central Texas.

The Affordable Care Act was supposed to benefit both rural hospitals and rural patients – by providing access to insurance for folks in small towns the idea was that hospitals would recoup costs they spend on indigent care. But some people aren’t so sure it’ll work out that way.

Dr. Howard Dickey is a family medicine doctor in west-central Texas at Comanche County Community Clinic – one of Texas’ so-called critical access hospitals.

“I would hope that [Obamacare] would be favorable,” he says, “but I may end up working somewhere else when it’s all said and done.”

One of the reasons Obamacare may not benefit rural hospitals in Texas is because Governor Rick Perry decided not to expand Medicaid in the state. That means poor people who end up using the emergency room still won’t have any type of insurance to help cover the cost of their care.

[More from KERA News: Stuck In The Doughnut Hole: Living Without Insurance, Subsidies Or Medicaid]

The emergency evacuation helicopter at Comanche Community Clinic takes patients to larger hospitals in Fort Worth and Abilene, TX.

Lauren Silverman/KERA News

The emergency evacuation helicopter at Comanche Community Clinic takes patients to larger hospitals in Fort Worth and Abilene, TX.

Critical access hospitals rely more heavily on Medicaid and Medicare reimbursements than their urban counterparts. Without the chance for additional Medicaid money, and decreasing Medicare reimbursements, Dickey says his clinic’s tight budget might snap.

To make matters worse, the basic care and emergency services rural hospitals provide — like delivering babies — don’t bring in as much money as specialty operations like cardiac surgeries. But Dickey says that doesn’t mean the services aren’t important.

“Although we have helicopters and ambulances that can get a patient somewhere quick,” Dickey says, “a lot of times in trauma and real sick patient situations have to do it ourselves.”

Which might work in individual cases, but in the long run, Dickey and doctors across rural Texas aren’t sure trying to go it alone will be enough.

10 Things to Know About Texas Rural Hospitals – Prepared by the Texas Organization of Rural and Community Hospitals (TORCH) 

1. There are 183 rural hospitals in Texas out of 580 total licensed hospitals.*

2. Texas rural hospitals provide access to routine and emergency health care for 15 percent of the state’s population, but cover 85 percent of the state’s geography.

3. Texas has 80 Critical Access Hospitals (CAH) – a special Medicare designation for certain small rural hospitals with 25-or-less beds and at least 35 miles from another hospital (some exceptions on mileage separation). CAHs receive special reimbursement consideration from Medicare so they can remain financially viable even with lower patient volume

4. There are areas in Texas that are more than 100 miles away from the nearest hospital.

5. Texas rural hospitals are straining under the current reimbursement system having to layoff personnel and eliminate positions – 28 rural hospitals report 252 positions eliminated in the last few months.

6. Rural hospitals often cannot provide more profitable advanced services and medical procedures.

7. Rural hospitals treat older and poorer patients providing a higher percentage of Medicare and Medicaid services than urban hospitals – both of which often pay less than private insurance.

8. Rural areas in Texas have the highest levels of uninsured – some as high as 50 percent – while the Texas average is 26 percent. (14 of the 15 highest uninsured level counties in the country are Texas rural counties).

9. Rural hospitals comprise two percent of the overall Texas Medicaid budget and less than five percent of all Texas hospital related Medicaid payments.

10. More than 80 hospitals closed in Texas during the 1980s and 1990s, most of them were rural.

* (Using a definition of “rural” as a county population of 75,000 and less; and larger counties but in a city of 25,000 and less).