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This story was originally published by Stateline, an initiative of The Pew Charitable Trusts.

BOWIE — After sitting empty and exposed to thieves and vandals for more than two years, the one-story hospital that served Bowie for more than five decades is close to making a comeback — of sorts.

Reflecting the struggles facing hospitals throughout rural America, Bowie Memorial Hospital has closed twice since 2015, the first time when citizens refused a tax-supported bailout, and again in 2020, after a failed reopening.

Now, this north central Texas community of about 5,000 people is partnering with a hospital system in Jacksboro, about 30 miles away, to revive the brown brick building on Greenwood Avenue as a round-the-clock emergency and observation center. Bowie residents who’ve had to go to other towns for emergency care eagerly await its scaled-down reopening.

“We need a medical facility in our community above all,” 84-year-old Mildred McCraw said at a recent public meeting to discuss the plan, declaring herself “very ashamed” at the absence of a hospital.

The model taking shaping in Bowie exemplifies an emerging idea for rescuing hundreds of failing rural hospitals — just as federal dollars that have helped many hospitals stave off collapse during the COVID-19 pandemic are rapidly drying up.

The goal of the federal Rural Emergency Hospital program, approved by Congress in 2020 and launched in January, is to preserve at least some health care services in rural communities that can’t support a full-fledged hospital. The program provides higher Medicare payments and other dollars to small rural hospitals that shed inpatient services and instead staff a round-the-clock emergency department and provide observation care.

Because Bowie Memorial Hospital closed before the Rural Emergency Hospital program launched, it isn’t eligible to participate. However, the town’s pursuit of the same strategy independently makes it a case study for how the program might play out elsewhere.

Other hospitals across Texas are considering changing their model under the Rural Emergency Hospital program, as are hundreds of failing hospitals in other states, said Michael Topchik, who heads the Chicago-based Chartis Center for Rural Health, a consulting and research firm.

The revamped facilities will transfer people who need inpatient care to full-service hospitals nearby. But for many rural communities, the conversions to fewer services will be a bitter pill to swallow.

In Lock Haven, Pennsylvania, officials at UPMC Hospital say scaling back to an emergency department is “the best model of care to meet the needs of this community.” But Mayor Joel Long worries the absence of a full-scale local hospital could endanger the roughly 8,000 residents of Lock Haven.

“That travel time [to a full-scale hospital] could make all the difference in the world to one of our citizens,” he told Stateline. “You know — whether they survive or not.”

Shuttered hospitals, vanishing services

Health experts have long described the continuing closures of rural hospitals as a crisis brought on by a host of factors, including declining rural economies, shrinking populations, shortages of doctors and nurses, mounting operating costs and cuts in Medicare and Medicaid reimbursements.

Texas often is described as the epicenter of the rural hospital crisis, leading the nation with 26 temporary or permanent closures since the beginning of 2010. But many states are struggling with the problem.

In a study the Chartis Center recently presented to political officials and health experts in Washington, D.C., the organization reported that 143 rural hospitals have closed over the past 13 years, and another 453 are vulnerable to closure. Moreover, costly services such as obstetrics and chemotherapy “continue to vanish at an alarming rate,” the report said.

At least 43% of the nation’s rural hospitals are in the red, but in states such as Texas that haven’t expanded Medicaid under the Affordable Care Act, more than half of rural hospitals are losing money, according to the report.

In Hamlin, a West Texas community of about 2,200 people, a notice on the website of the Hamlin Medical Clinic advises that, “Emergency Room and Inpatient Services have been permanently discontinued.” Hamlin closed its hospital nearly four years ago, converting it into a walk-in clinic headed by Tonia Cook, a 46-year-old nurse practitioner who lives in Abilene.

“It’s a dwindling town,” Cook said. “We’ve lost a lot of businesses. We have an aging population. We have a lot of unfunded patients.”

The Chartis Center study noted that the expiration of COVID-19-related aid has exacerbated the economic pressures driving hospital closures. “As we move into a post-pandemic era, the long-term stability of the rural health safety net is strained,” the study states.

Sharp decline in Bowie

Bowie’s experience illustrates what it’s like for a rural community to struggle to rescue a troubled hospital and then try to limp along without it. “It stresses any community the size of ours to not have a local hospital,” Mayor Gaylynn Burris said.

Named after Texas folk hero James Bowie, the community was founded in the 1880s and developed into a regional commercial center for farmers and ranchers. Its largest tourist attraction is a giant 20-foot-long Bowie knife, paid for by local donations, which is listed in the Guinness Book of World Records.

Lynn Heller, 74, served two stints as administrator of Bowie Memorial Hospital. During his second tenure in 2015, the hospital was hopelessly in the red. The only way to keep it open, Heller believed, was to form a hospital district to raise taxes and pay off the debt. But voters rejected the idea, as they had a similar proposal four years earlier.

Two weeks after the 2015 election, the hospital closed. Heller and City Manager Bert Cunningham said some residents who voted against authorizing the taxing district regretted their action and called city hall to try to change their vote. One of Heller’s friends moved his family to Florida because of his wife’s medical needs.

“As far as I’m concerned, it had a very negative impact on the community,” he said.

The Hashmi Group, a family medical group from the Dallas-Fort Worth area, bought and reopened Bowie Memorial in 2017, but it closed again in 2020, leaving the building at the mercy of looters and vandals who stripped it of copper and used fire extinguishers to mar the walls and floors.

Janis Crawley, executive director of the Bowie Economic Development Corp., said the closure resulted in the loss of 474 jobs, including the hospital workforce and other jobs connected to the hospital. It took about five years for the community to recover from a 43% drop in sales tax revenue.

Crawley’s core mission in recruiting businesses to Bowie has also become much harder without being able to cite a functioning hospital as one of the attributes.

“It’s difficult because … one of the main things that people ask about when they’re moving to a community is, ‘Where’s the nearest hospital?’” Crawley said.

Bowie has two clinics, but the nearest hospital is 21 miles away, in Nocona. Crawley said she points out to prospective business recruits that driving there or to another nearby hospital on an open Texas highway can take less time than traveling a shorter distance in a congested metropolitan area. But to Bowie residents, having to travel so far is a hassle and can be life-threatening.

“It’s a big inconvenience,” said Chantel Housour, who runs an embroidery and apparel store, recalling when she dealt with persistent severe migraines that required treatment at a hospital. “My only option was to go to the emergency room, so that means I’d go to either Decatur or Nocona because nothing was here.”

Bowie Fire Chief Doug Page said his four-person department transports nearly 2,000 patients a year to one of the out-of-the-town hospitals. “It’s not great,” he said, “especially a town of 5,000 people, and you’re a long way from emergency medical care. You have clinics in town, but they’re not set up for critical patients, so we have to intervene.”

Earlier this month, 31 residents showed up at the Bowie Community Center, within walking distance of the giant Bowie knife, for a presentation by Frank C. Beaman, the man in charge of the hospital’s transformation.

“You’ve got to feel for the community,” Beaman said in an interview afterward. “Any community that loses a hospital … it’s just devastating.”

Although the timetable has been delayed by construction setbacks related to supply chain shortages and other issues, Beaman said he is hopeful the facility can open sometime around summer. Crawley said the residents of Bowie will be happy whenever the doors swing open.

“They’re excited about it,” said the economic director. “No. 1, it’s going to bring back jobs. No. 2, it’s going to bring back the life to an entire block that has sat empty.”