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The death divide in Texas: What rural hospitals have learned during COVID-19

Recently released data by the Rural Policy Research Institute brings the problem facing such communities and hospitals into razor sharp focus.

DALLAS — To say it has been a difficult 18 months for hospitals throughout the state would be an understatement. But you cannot overstate the acute pain that’s been felt by rural Texas hospitals, who limped into the pandemic to begin with.

“There were 70 of them that had less than 30 days operating cash on hand when this thing started. And so, the simple fact of the matter is if it had not been for federal stimulus in 2020, and now some state funding in 2021, there are rural hospitals that survived that just wouldn't have made it otherwise,” John Henderson said on the most recent episode of Y’all-itics.

And experts like Henderson don’t even like to imagine how bad things might have gotten had more rural hospitals been forced to close. Henderson is President and CEO of the Texas Organization of Rural & Community Hospitals (TORCH), so he sees the struggles on a daily basis. He says the last rural hospital closure in Texas came in January 2020. Up until that point, two months before the state started shutting down for the pandemic, Texas led every state in rural hospital closures. Henderson says 26 locations closed in 22 communities in the ten years prior.

They know exactly what Henderson is talking about at the last independent hospital in northeast Texas, Titus Regional Medical Center in Mount Pleasant. CEO Terry Scoggin says that community’s fourth COVID surge started in August. And then came the hospital’s death crescendo.

“We saw 26 deaths in the month of September in this hospital. We've never seen that in the history, 70 years, of this hospital,” Scoggin said on Y’all-itics. “We’ve never seen that many deaths in this hospital, which takes a toll on the doctors and the nurses, the cleaning staff.”

And Scoggin says in rural communities like theirs, everybody knows somebody and in the middle of a pandemic that means you stay close to death and illness. And everyone has been impacted. Everyone.

“We heard stories of our friends and former employees that were here crying in our ICU because they knew it was could be the end for them. And during COVID, you were by yourself a lot. So, our team members and nurses had to step up and be that person next to their side,” said Scoggin.

Listen to the full episode of Y'all-itics:

And recently released data by the Rural Policy Research Institute brings the problem facing such communities and hospitals into razor sharp focus. It found that rural Texans are twice as likely to die of COVID than their urban counterparts. Both Henderson and Scoggin know the study well and have seen real world examples.

There have been three main issues contributing to this death divide in Texas. The first is vaccine hesitancy in rural communities. In Titus County, for example, the Texas Department of State Health Services says 53% of those aged 12 and older have received their first shot. That average is nearly 74% statewide.

And Scoggin says a second reason behind the death disparity is because rural Texans have more underlying health conditions, from heart disease to diabetes and obesity to smoking. Scoggin says that’s just rural America and even he’s had to think more about his own health.

“People don't seek medical care the same way that they do in a city. They may be farther away from it. They may not have the resources,” Scoggin said. “Some choose not to. And some just choose not to because we’re hard-headed.”

And that’s not to mention the rate of uninsured. Scoggin says Titus County has the highest uninsured rate in northeast Texas at 31% of adults and 13% of children. The Texas Comptroller’s Office says statewide, the share of Texans without health insurance is 18.4%, twice the national average of 9.2%. And the office says those numbers have gotten worse during the pandemic.

A third reason contributing to the death disparity is the very nature of what it means to be rural. Henderson says it’s important to remember that rural is not just a small version of urban. He says the state definition of rural in Texas is a county population of 60,000 or less. And by that criteria, he says there are currently 157 rural Texas hospitals (Texas has 254 total counties).

“But more than half of those don't deliver babies. More than half of those don't do surgery. And most like 75, 80% don't have an ICU bed. So, they're small. They're limited services. They all have an ER so that they can treat, you know, heat strokes and heart attacks. But when it comes to acute high-level illness or injury, most just aren't equipped to handle that,” Henderson told the Jasons.

But the hard-working, blue collar spirit of rural Texas has led to some breakthroughs in care and a possible blueprint for rural healthcare moving forward. When the pandemic first hit, nobody knew anything specific about the novel coronavirus, so at places like Titus Regional Medical Center, they had to become their own COVID experts, experience forged through loss and hardship.

Scoggin says doctors at Titus started using Regeneron monoclonal antibody treatment long before any former presidents or governors made it popular. And at one point, the hospital simply ran out of beds and had to send people home.

“And we sent EMS out there every day. We did a televisit in their houses,” said the CEO. “They actually recovered quicker at home than they did in the hospital. Because, I think, you're in your own bed, you have your own TV, nobody’s waking you up in the middle of the night.”

Both Scoggin and Henderson think virtual care from home has been a game changer and that rural hospitals will continue the practice well into the future. And Scoggin says they’ll study the results of those home and virtual visits to figure what how much of a difference they truly made.

Rural healthcare experts also say there may not be much more they can do to move the needle on vaccinations. But in some smaller communities, secret vaccinations are making a difference.

“What they've been telling them is we can keep a secret. And it's related to people in that community that got sick and passed away,” Henderson said. “But it's a weird dynamic when you're having to tell people to come in the back door of the clinic to get their shot and then still publicly speaking out against it.”

Henderson says these secret shots aren’t producing overwhelming numbers of newly vaccinated rural Texans. But he says it’s how you move the needle in rural communities. And that’s what he tells his hospitals in the TORCH network.

“And my advice to them, frankly, has been whatever it takes. I mean, we aren't trying to win a pride war. We're trying to keep people safe.”

As President and CEO of TORCH, Henderson recently testified before lawmakers in Austin who were deciding how to divide the $16 Billion they received in COVID relief funds from the federal government.

Henderson says rural hospitals will receive $75 Million.

“In rural hospitals we say we can make a meal out of crumbs. So half a million dollars to each of these hospitals is a big deal. Some of them literally think pay cycle to pay cycle, surviving. And this gives them breathing room to be able to meet that local need,” he said.


On top of everything else, rural hospitals are also dealing with a major nursing shortage. Hear about that impact on rural communities during the pandemic and how they’re trying to solve the problem in the latest episode of Y’all-itics. Cheers!

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