The state is a poster child for how rural areas are suffering disproportionately amid the pandemic in the worst public health crisis in a century.

A graveyard outside the shuttered Haywood County Community Hospital in Brownsville, Tenn. on Feb. 7, 2022. | Photographs by Rory Doyle for POLITICO

By the time Covid-19 hit Haywood County, it was too late to prepare.

The rural county in the Tennessee delta, near the Mississippi River, had its health care system ground down in the years leading up to the pandemic: Ever since the 84-year-old Haywood County Community Hospital closed its doors in 2014, the numbers of doctors and other health care professionals dwindled. Residents who once were on a first-name basis with their care professionals were left to book appointments at facilities miles from where they’d raised their families and grown older.

Haywood County — with its flat land and fertile soil, generations of proud farmers but low per capita income of about $22,000 — is something of a poster child for rural America. It’s also a prime example of the decline of rural health care — and how rural areas are suffering disproportionately in the worst public health crisis in a century.

Some of the biggest disparities in the Covid-19 crisis aren’t just among red states and blue states, or Black, white and Latino populations; they’re between rural and urban communities.

Kyle Kopec, the director of government affairs for local health care company Braden Health, looks at an old photo of the Haywood County Community Hospital he found in a storage shed. The hospital had been gradually shrinking for years before closing completely in 2014.

Of the 50 counties with the highest Covid deaths per capita, 24 are within 40 miles of a hospital that has closed, according to a POLITICO analysis in late January. Nearly all 50 counties were in rural areas. Rural hospital closures have been accelerating, with 181 since 2005 — and over half of those happening since 2015, according to data from the University of North Carolina. But that may be just the beginning. Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health care advisory firms.

Those closures caused shortages of beds, ventilators and medical staff, and left behind patients with high and rising levels of diabetes and hypertension. Now, those communities often also have high rates of unvaccinated people — and that may well be related: In the communities where health resources disappear, so too does confidence in the medical system. Trusted sources of information go elsewhere.

The closure of Haywood County Community Hospital in Brownsville left local resident Jack Pettigrew with a 35-minute trip to the nearest emergency room, thinking Covid-19 was going to kill him.

“Honest to goodness, when we were backing out of the driveway that day, I had the strangest feeling that I wouldn’t be coming home,” he said, recalling how he worried about the long trek to the emergency room.

Pettigrew, who retired in 2020 after practicing medicine in Brownsville for 37 years, had spent his career treating a population that watched Haywood County Community Hospital shrink over the years until it finally closed entirely in 2014 — like six others in western Tennessee that closed in the same timeframe. Stories of people dying because they couldn’t get care fast enough started popping up everywhere after the closure. Underlying conditions became a bigger problem.

Jack Pettigrew stands for a portrait inside the Haywood County Community Hospital, which is now being remodeled, on Feb. 7.

“We would constantly make appointments for people for mammograms or diagnostic tests or whatever, and, you know, two weeks later, we’d get a note that the patient never showed,” recalled Pettigrew. “And you never know whether you missed a breast cancer or whatever because they just didn’t go.”

“In the case of Covid, we faced some of the same challenges,” Pettigrew said. “In our rural area, there are a lot of people that don’t even have transportation, so they rely on somebody else to take them places, bring them back. If they don’t have something like that, a lot of times, they just kind of ignore their situation, and it gets worse and worse and worse until they’ve gone beyond the point of return. And I suspect there were a lot of people that got Covid that didn’t do anything about it until they got extremely sick and then, unfortunately, a lot of them didn’t pull through it.”

Haywood County, tinted blue in most elections, has a middling vaccination rate by national standards, but it was still higher than surrounding counties. Nonetheless, the number of people who died of Covid in Haywood County is in the 97th percentile nationally — well above many nearby counties. Overall, rural communities have seen almost twice as many deaths per capita as metropolitan ones.

Pettigrew survived his own bout with Covid-19, after a harrowing experience at the nearest hospital, in Jackson, Tenn., where doctors and nurses were frantically battling Covid surges that led steady streams of patients from communities across western Tennessee that had lost their own hospitals.

Pettigrew’s sense of dread deepened as he heard codes called over the intercom, knowing many of them meant people were dying all around him. He texted his son, asking him to call when he was alone. Pettigrew didn’t want his wife to hear him tell his son about important documents and safe combinations, in case he died soon.

Haywood County — with its flat land and fertile soil, generations of proud farmers but low per capita income of about $22,000 — is something of a poster child for rural America. It’s also a prime example of the decline of rural health care — and how rural areas are suffering disproportionately in the worst public health crisis in a century.

After a day in the ER, he was finally moved to another room, where he would spend five days before returning home.

His outcome was better than many — not only because he survived Covid, but because he could get to a hospital, because he survived the trip there, because a bed was open at all. His wife, with Covid-19 and double pneumonia, would be turned away from the hospital. He wouldn’t even try to bring his dad, who was in his 90s and would eventually die from the virus.

“We knew they basically weren’t going to keep him or do much for him because they were basically hospitalizing people that were in an age group that would possibly survive and then be back into a normal life,” Pettigrew said.

In rural hospitals in western Tennessee, people would wait days in emergency room hallways, hoping for a bed to open up — even if the bed were on the other side of the state. Nurses would have to hand-pump air into patients for hours with manual ventilators because of shortages. Other hospitals in West Tennessee would connect two patients to a single ventilator while their owner, Braden Health, tried to buy ventilators from a recently closed field hospital — but they had already been sold to another state. One hospital in the region, Houston County Community Hospital, moved 50 patients into a nearby gymnasium.

“It’s one of those ripple things, it’s touched most everybody,” Pettigrew said. “Most everybody knows one of those stories, and it’s really sad.”

Washington ignored years of signals that the South’s health care system was crumbling. When the pandemic began, it was too late to rebuild.

The rate of rural closures accelerated over the last decade, with 2020 setting a record — even as demand for their hospital services was growing to an all-time high.

In the last decade, 138 rural hospitals have either partially or completely closed, according to data from the University of North Carolina. Well over three times that many — 453 — are at risk of closure, according to a 2020 analysis from the Chartis Center for Rural Health. Of that group, 216 are at a high risk of closure.

Most rural hospitals close because of financial trouble, and many of them relied largely on government reimbursements — Medicare and Medicaid — to survive. If the government or private insurance reimbursements don’t cover the cost of a procedure, it can lead to losses and eventual closures.

Other analyses are even more pessimistic. Over 500 rural hospitals are at immediate risk of closure, according to a 2022 model from the Center for Healthcare Quality and Payment Reform.

In Tennessee, both models show, over half of remaining rural hospitals are at risk of closure — just like in other states across the South and Midwest.

Tennessee — and the entire Southeast — was nearing a crisis well before the pandemic, with hospitals operating above surge capacity even before the first infections were reported.

“We were down to a bare-bones number of hospital beds to support communities, and there was almost no slack in the system,” said Stephan Russ, the associate chief of staff at Vanderbilt University Medical Center.

“I don’t think many people realize how close to the edge we were,” he added.

Vanderbilt’s hospital was already getting calls from states hours away in 2018 and 2019. One of those calls, which Russ experienced himself as an emergency physician, came in 2018. A rural hospital in southern Alabama called Vanderbilt asking if they had a bed for a patient in his late 40s who required emergency surgery for a twisted intestine. The hospital had recently lost its only surgeon, so the relatively straightforward procedure had to be done elsewhere. They had called nearby hospitals, all of which were full.

When the patient arrived in Nashville, the swelling in his abdomen had cut off circulation to his legs. He was immediately sent to the operating room, where he died on the table.

“We have a residency program at Guyana, on the coast of South America,” Russ said. “These are the types of things that [I see] when I go down and work in Guyana. We see this for the Amerindian population that are coming out of the villages and need a canoe to get, you know, to a hospital. This isn’t the type of thing that we’re used to seeing in the United States.”

Tennessee lost over 1,200 staffed hospital beds between 2010 and 2020 despite a population that grew by over half a million, according to the American Hospital Directory and census data. Mississippi, with the most Covid-19 deaths per capita, lost over 1,100 beds over that decade. Alabama, second only to Mississippi in per-capita deaths from the virus, lost over 800.

Those beds would have been critical to statewide systems under the stress of the pandemic, according to doctors and hospital officials. Smaller hospitals often send their most serious patients to larger hospitals, usually in urban areas, for higher levels of specialized care. But large hospitals also send patients to smaller hospitals when they can get the same level of care — especially if staffed beds are in short supply. Without rural hospitals, urban centers were swamped with patients, making transfers more difficult and higher levels of care less accessible.

In Florida, where there have been fewer closures, Tallahassee Memorial Health was able to alleviate the crowding caused by Covid-19 by training staff at smaller hospitals to treat cases that would usually require a higher level of care. Nearby rural hospitals proved to be the key to treating patients through the pandemic.

A Haywood County ambulance moves through Brownsville on Feb. 7. Closures of rural hospitals in Tennessee and other states have placed a bigger burden on urban centers and made transfers more difficult.

“We need every single one of them,” Lauren Faison-Clark, administrator for regional development, population health and telemedicine at Tallahassee Memorial HealthCare, said of rural hospitals. “We don’t want everybody coming to Tallahassee for health care.”

If the region had seen significant closures leading up to 2020, Faison-Clark said, Tallahassee hospitals would have likely seen overflowing emergency rooms with beds in hallways and worse outcomes for many patients.

In Mississippi, where officials told drivers to be cautious on the road because of the extreme shortage of beds, closures did lead to a breakdown in levels of care.

“The entire system clogged up,” said Claude Brunson, executive director of the Mississippi State Medical Association. “Without a doubt, there are some patients who died because we did get bottlenecked and couldn’t establish a very good flow of care across the system — because we had lost the numbers of beds that we truly did need.”

In central Tennessee, transfers became such a critical issue that hospitals, including Vanderbilt’s, created a transfer coordination center to maximize the efficiency of the system. But not every state or region has even that advantage.

“We have gotten calls all summer long from Georgia, Alabama, Kentucky, Virginia, West Virginia,” Russ said of Vanderbilt. “Oftentimes, these are small rural hospitals that have called over 50 big hospitals in the Southeast trying to get care for their patient and have been unsuccessful.”

In Brownsville, Andrea Bond Johnson — who locally operates an insurance company and ran for the state house — saw the limits of the hospital system first-hand when her parents were ill and waiting for results from their Covid tests.

Her 86-year-old mother was getting weaker, having to take breaks to rest when walking between the bedroom and the kitchen.

“Annie, come here,” her mom yelled from her bedroom. “Something is wrong with my heart.”

Fearing a heart attack, Johnson called 911. Fortunately, they lived near the EMS facility in town. Even more important — and not always the case — there was an ambulance available.

Andrea Bond Johnson stands for a portrait in Brownsville, Tenn. on Feb. 7. “Really, our emergency room is in the back of an ambulance,” Johnson said.

When the hospital closed, Haywood County had been obliged to purchase new ambulances to carry patients over longer distances. Even with more crews and vehicles, call times were still much longer.

A crew arrived about 15 minutes after Johnson’s call, moving her mother to the back of the ambulance. But the paramedics didn’t rush her to the hospital. Instead, they began examining her as if she were in the emergency room already.

Johnson saw her mother slumped over while the paramedics worked to get readings.

“Honestly, it looked like my mom had passed away,” Johnson said.

Doctors in Brownsville are acutely aware of the “golden hour” of care, Pettigrew said. The care in the first hour of severe illness can often determine the outcome. Spending more than half of that hour driving to a hospital can prove to be fatal.

Johnson looked closer at her mother and saw faint breathing. The paramedics continued working for quite a while, Johnson said, before determining that her mother needed to be airlifted to Jackson’s hospital.

Johnson drove to the hospital, beating the helicopter. Her mother was held longer in the ambulance to try to stabilize her as much as possible before the trip.

“Really, our emergency room is in the back of an ambulance,” Johnson said, echoing a sentiment — and sometimes verbatim quote — from people across the South who’ve lost their hospitals.

Doctors and nurses at the closest open hospital to Brownsville, in Jackson, have been frantically battling Covid surges that led steady streams of patients from communities across western Tennessee that had lost their own hospitals. Haywood County EMS Director David Smith (left) and his team have become even more critical in providing the immediate care that can often determine patient outcomes.

Unable to get into the hospital because of Covid protocols, Johnson returned home to care for her 87-year-old father. It wasn’t long before his breathing became irregular. She called an ambulance again, which took him to Jackson’s hospital.

After he arrived — unable to walk, and with Parkinson’s Disease along with Covid-related pneumonia — Johnson got a call from the hospital. They said her dad had to go home.

“[Haywood County residents] filled up the Jackson hospital until they said, ‘Listen, we have no more beds. I’m sorry, we just cannot take care of you,’” she said.

Her father was sent to a skilled nursing facility in Dyersburg, a 50-minute drive away, where his wife would eventually join him. They stayed together in a Covid wing of that facility for weeks, celebrating their 59th wedding anniversary there.

Johnson’s mother got worse, having to go back to a hospital — but Jackson’s was out of space. She went to the hospital in Dyersburg, but also short on beds, she had to stay in the emergency room overnight before she could get a room. After hours of Johnson driving and weeks of her parents resting, her mother and father recovered.

“It would have made a tremendous difference if the hospital had been open,” she said. “We were unable to take care of ourselves in our own community.”

Lisa Piercey, the health commissioner for the Tennessee Department of Health, was regularly checking metrics on how the state’s 95 counties were performing through the pandemic. Urban areas were regularly the best performers — with high vaccination levels and low Covid-19 mortality rates — but so were rural areas that had open hospitals and clinics.

“I would say, ‘Oh my goodness, why is this little rural county on this list of high vaccination rates?’” she said. Trust in the system would turn out to be a key to success.

“The population there didn’t necessarily put that much credibility in what I say or what the governor had to say, but if their local hospital and their local doctors did that ... they would go there, and their vaccination rates were higher,” Piercey said.

Large hospitals across the South, trying to reach the unvaccinated, would partner with rural hospitals to convince more people to get the shot. Without smaller facilities with roots in a community, however, vaccine hesitancy gained a foothold.

A vehicle drives past a vaccine sign at the Haywood County Health Department on Feb. 7. According to data from the state, just under 60 percent of Haywood County residents have received at least one dose of a Covid-19 vaccine.

Hospital closures have led to fewer vaccinations of all kinds for some communities — not just shots for Covid-19. In the years after Haywood County’s hospital closed, flu vaccinations dropped almost 10 percent in the county, according to data from the University of Wisconsin.

“It’s almost like they’ve been forgotten,” said David Sudduth, executive director of Healthy Me-Healthy SC, a program to improve health care for people in rural South Carolina.

That separation was a key contributor to vaccine hesitancy in some communities, the Mississippi State Medical Association found in a local study.

“The number-one priority is [the unvaccinated] wanted to get information from someone they trusted, and the number-one trusted person for those folks and their families is their primary care physician,” Brunson, president of the MSMA, said. “The primary care physicians would be in the rural hospital there ... and probably has a clinic outside that’s closely associated with that hospital. And so by not having the rural hospital, you lose that connection between that community and the health care professional that would have been there.”

Hospital closures also led to more underlying conditions in communities, doctors and health care experts across the South said — and those illnesses compounded Covid’s danger. Haywood County’s hospital closure was followed by a spike in chronic illness and underlying conditions. The premature death rate had ticked up to its highest level in well over a decade in the years after the closure. The rate of obesity had risen to its highest recorded level, as did deaths from heart diseases. Brownsville’s city government started programs trying to get underlying conditions under control, promoting healthier diets and exercise.

The same was true in rural areas across the South.

“Any of us who practice medicine — we know that if we talked to a patient that we’ve been taking care of them and their family for a long period of time, they’ll do something because they trust us,” said Mississippi’s Brunson.

When the pandemic is over, the impacts of rural hospital closures and a weakened health care infrastructure will remain. Through the pandemic, people have become even less connected to their doctors, underlying conditions have gone untreated, and the opioid epidemic has accelerated.

Most rural hospitals close because of financial trouble, and many of them relied largely on government reimbursements — Medicare and Medicaid — to survive. If the government or private insurance reimbursements don’t cover the cost of a procedure, it can lead to losses and eventual closures. Hospitals that aren’t part of a large system have almost no bargaining power with private insurers, they say, which can exclude the facility from their network entirely.

And without larger systems, which can both bargain for better pricing and also have departments dedicated to filing for maximum reimbursements, many rural centers find it increasingly hard to survive.

That’s why the Centers for Medicare and Medicaid Services has implemented payment structures that are supposed to aid rural hospitals — including a coming payment structure intended to benefit rural emergency rooms. Some states put their own funding into rural hospitals to stop the financial bleeding, others hired consultants and created task forces to find out what was going wrong.

But the solutions that had been proposed up to 2020 had either had limited impact or never passed at all.

When the pandemic hit, conversations about those solutions, once mostly out of the news cycle, became urgent. Constituent calls started pouring in.

Older folks in Brownsville remember when Haywood Community Hospital was a model of quality. After being closed for eight years, the hospital is currently under construction ahead of a full reopening slated for this summer.

“One of the big issues we had when Covid first started was people couldn’t get an ambulance to come to their house, so they were just dying,” said a legislative aide working for a member of Congress from a rural state.

All of the staff shortages, sustained losses in revenue and declining access to health care seemed to come to a head when deaths from the pandemic started adding up.

“It’s kind of the perfect storm,” the aide said. “We were shit out of luck.”

Rural doctors had been sounding the alarm for decades, trying to get state and federal action. Pettigrew, from his office in Haywood County, had worked to get the attention of legislators in the late 1980s and early 1990s.

“I tried my best to get someone from Washington to send down somebody — a representative — and just spend a week in my clinic before they made decisions on how they wanted to change the health care delivery,” he said. “Because so many people just have no idea what it’s really like in areas like this.”

These efforts continued for years, even with large hospitals joining the effort.

“I was meeting with people from Deloitte and others, trying to get attention to this,” Russ, asssociate chief of staff at Vanderbilt University Medical Center, said. “In 2018, there were days where, at least from a transfer perspective, it didn’t appear that we had more than a handful of open ICU beds in the entire Southeast.”

Sen. Susan Collins (R-Maine) has long been concerned about rural hospital closures, but it was only after systemwide failures that the problem could begin to be seriously addressed, she said.

“This is a moment of action, and I think if you look at the flurry of activity prompted by the pandemic, that that becomes evident,” she told POLITICO.

Updates to health requirements that she and other lawmakers have been working on for a decade, for instance, are now finally law after the pandemic pushed Congress to act. The Paycheck Protection Program and Provider Relief Fund offered most rural facilities more government support than they had ever seen. Broadband expansion and updated telehealth regulations will offer new opportunities for care in many areas, and several bills have been introduced to boost the workforce in rural health care. Behavioral health and addiction treatment have also come into the spotlight, with new measures to bring care to rural Americans.

The reopening of the Haywood County Community Hospital in Brownsville seemed far-fetched to many amid the sea of closures — even to the town’s mayor, Bill Rawls (top left). ““It was just a never-ending, bottomless pit of issues that put people’s lives in jeopardy,” Rawls said.

“At least the pandemic has allowed us to make some changes — whether it’s reimbursement or telemedicine or allowing others than physicians to prescribe home health care — that we had not been successful in getting through before,” Collins said.

Emergency federal funding for hospitals during the pandemic meant rural closures fell to an all-time low in 2021 — after being at an all-time high in 2020, with 19 closures in a single year. But that money will eventually run out, leaving rural providers to navigate the patchwork of adjustments state and federal lawmakers have made to try to stop the financial losses.

“We always had a Band-Aid on [the rural health care crisis],” one aide who works on health care legislation said.

There are some policies aimed at tackling the closures in a new way. CMS is working to create a payment system that would incentivize hospitals facing closure to at least continue offering emergency services.

A few months ago, Collins visited the Maine Medical Center in Portland, where the staff and facilities were overwhelmed. In the Covid wing, many patients would not survive, she said. Most of them were from rural Maine, far beyond the reaches of Portland.

“You see the patients literally in the hallways — and I saw that even at Maine Medical Center, but it’s more prevalent at the rural hospitals where all the ICU beds are filled,” Collins said. “There was one rural hospital that was putting Covid patients in the areas that were for obstetrics, and they were just hoping that there wouldn’t be any moms coming in to give birth.”

Older folks in Brownsville remember when Haywood Community Hospital was a model of quality. The hospital had at one time attracted specialists from Memphis, who would perform delicate surgeries in Brownsville. Other rural hospitals in West Tennessee also had specialized care, from orthopedic surgery to coronary care units.

Even as such specialized care was pared down over the years, the hospital’s essential services saved lives and supported the health of the community. In 2013, exactly one year before the hospital closed, a baby in Brownsville had a severe allergic reaction — Clayton Pinner was rushed to the local hospital and eventually transported to Memphis.

“The doctors just kept saying if we had not gotten in there so quickly, he certainly would not have lived,” said Natalie Pinner, Clayton’s mother.

But even while doctors and nurses were saving people like Pinner, the hospital was losing money — a good year was when it was only $300,000 in the red, said Michael Banks, who was on the community’s advisory board for the hospital before it closed — and instrumental in its reopening.

“We struggled, I mean we were turning into your typical Delta town,” he said.

Top: Clayton and Natalie Pinner pose for a portrait in their home in Brownsville, Tenn. Left: Natalie holds a photo from the hospital on from the day she offered to have a cell transplant for Clayton. Right: Clayton and Natalie play football together after school.

After the closure, Haywood County didn’t have a working emergency room to stabilize patients before moving them to larger facilities, much less any specialists. A resident had a heart attack soon after the closure, and without facilities to get him immediate treatment, he died.

The hospital was there for the Pinners in 2013, but it was not in 2018, when Clayton was diagnosed with a rare form of leukemia. During the first wave of Covid, doctors at St. Jude Children’s Research Hospital were concerned there wouldn’t be enough hospital beds to go around for at-risk children in rural areas, like Clayton.

“With all of the hospital closures in the surrounding counties, the ER that we had been sent to in Jackson was just overworked,” Pinner said.

Pinner and her husband checked the number of hospital beds available in West Tennessee every day, and deciding it was too dangerous to be far from St. Jude, they moved to Memphis.

When the pandemic is over, the impacts of hospital closures and a weakened health care infrastructure will remain. Through the pandemic, people have become even less connected to their doctors, underlying conditions have gone untreated, and the opioid epidemic has accelerated.

Even if hospitals had no more Covid cases to take on, many rural states would have a hard time keeping up with demand.

Braden Health, the company reopening the Haywood County Community Hospital, is betting that many — if not most — of these closures didn’t have to happen at all. They have begun opening hospitals in the South — including a few in western Tennessee — with the belief that they could be financially sustainable.

Kyle Kopec, the director of government affairs for the company, said that some of these hospitals could have been kept open through the pandemic if they had the precise knowledge of what is sustainable in a rural setting — and if the American reimbursement system took smaller, rural hospitals into account. Even though some policies are changing, experts and hospital operators say it’s likely too little, too late.

Kyle Kopec stands amongst the Haywood County Community Hospital construction on Feb. 7. Kopec and Braden Health are betting that many — if not most — of these hospital closures didn’t have to happen at all.

Braden Health, even while opening Haywood County’s hospital and others, estimates the worst is yet to come for rural health care. More than a decade’s worth of closures could be possible in the next few years, some projections warn.

“Your hospital is essentially an oil tanker in the middle of the ocean, and it’s on fire. It’s sinking and has no lifeboats, and if you don’t figure it out, you’re going down with the ship,” Kopec said.

The reopening of the Haywood County Community Hospital in Brownsville seemed far-fetched amid the sea of closures — even to the town’s mayor, Bill Rawls.

“It was just a never-ending, bottomless pit of issues that put people’s lives in jeopardy. At the end of that pit was somebody’s life,” he said. “It’s just a blessing from God, Dr. Braden and his group.”

Morning light casts on a mural inside the Haywood County Community Hospital on Feb. 8.

But for now, Haywood County continues to hold out hope that a new hospital — slated to fully reopen this summer, with limited services returning sooner — could change the outlook on their health. Braden Health and local doctors hope to reestablish a deeper connection between the community and health care workers, and many residents are more excited about the acute care, mental health care and diagnostics coming to them than the $5.6 billion Ford plant being built a few minutes away.

“We need quality health care to be available to everybody. It should be a right, not a privilege. And we just saw that right taken from us,” Rawls said. “People didn’t realize how much they needed until it was gone. It’s like you don’t miss the water until the well runs dry.”