Low reimbursements, high numbers of uninsured patients and staffing shortages are affecting rural hospitals nationwide. But in Randolph County, Ga., access to critical lifesaving care has all but disappeared.

Cuthbert, the county seat, is situated 200 miles south of Atlanta. Its Southwest Georgia Regional Medical Center has served citizens there since 1947. The hospital was the anchor for a multi-service facility, including a doctor’s office and the Joe-Anne Burgin Health & Rehabilitation Center.

But during the COVID-19 pandemic, Southwest Georgia Regional struggled to manage the flow of infected patients — on top the confluence of other problems — and shuttered its doors Oct. 22, 2020.

That closure severed immediate access to an emergency room for 6,400 citizens in a county where the median income is $28,000 (well below Georgia’s $66,000) and more than 60% of the population is Black. In 2023, Randolph County ranked 155 out of Georgia’s 159 counties with regard to health outcomes. The failure of its health care system has made the community a poster child for the fragility of rural hospitals around the country — and a bellwether for how swiftly such crises can cascade across regions.

Steve Whatley is the former mayor of Cuthbert and serves on the board of the Hospital Authority of Randolph County. The board managed the hospital and currently manages the Burgin nursing home and the CareConnect urgent care clinic, which is still open. One of key benefits of the Cuthbert hospital and its emergency room, Whatley agreed, was that it served as a facility to stabilize individuals who needed critical care locally.

At the onset of the COVID-19 pandemic, Albany, Ga., was the epicenter of one of the highest test positivity and death rates of COVID-19 in the nation. Though nearly an hour away, Albany has strong commercial and community ties to Randolph County with many of the town’s residents traveling there 44 miles in either direction for work, entertainment and shopping.

As a result, the burgeoning pandemic put a strain on the county’s already struggling medical infrastructure.  At one point in April 2020, Randolph County had the highest number of infections per 100,000 residents among counties in the state, even higher than neighboring Dougherty County.

First challenges, then crises

In the years leading up to the pandemic, the Southwest Georgia Regional Medical Center already faced challenges. Although the hospital was owned by the Hospital Authority of Randolph County, it was managed by the Phoebe Putney Memorial Hospital in Albany.

One of the key challenges hospitals face today is generating sufficient revenue with high numbers of uninsured patients. In 2023, 19% of the county’s population under 65 is uninsured. Therefore, turning a profit is difficult for hospitals serving rural, isolated populations.

“We [the hospital administration] were writing off 67 cents of every dollar we charged,” Whatley said.

In March 2013, two hospitals closed in nearby Stewart and Calhoun counties, shifting those counties' populations to dependence upon Cuthbert for health care services as the only nearby facility. Already in the red, the Hospital Association of Randolph County also faced mounting costs of keeping the Southwest Georgia Regional Medical Center building up to date. In the summer of 2016, the air conditioning system stopped working, creating real risks for patients and staff.

“We got within two degrees of transferring all the patients out,” Whatley said, “because of heating and cooling problems.” They had to bring in a generator to keep patients in the hospital. It was clear that the building became substandard. The roof itself totaled over a million dollars to repair alone.” 

In 2018, a building rehabilitation estimate determined $10 million was needed to keep the facility at medical standard.

Whatley said it was difficult to find the money needed to rehabilitate the increasingly outdated facility. Before the pandemic, the hospital attempted to find funding from private banks, but was turned down. It also attempted partnerships with other regional hospitals but to no avail.

Shortly before the pandemic in early 2020, The Hospital Authority board decided at that point to close the hospital, but no firm date was set.

“It became apparent from all the feedback we were getting from other institutions that it was just not a viable model,” Whatley said. “What we were running was not going to survive.”


Next came COVID-19

The first reported Georgia death from COVID-19 was announced by Gov. Brian Kemp on March 12, 2020. Just a few weeks later, the Georgia Department of Public Health started publishing reports on long-term care facilities. In the April 8, 2020 report, Cuthbert’s Joe-Anne Burgin Center had 47 staff and residents with COVID-19 and four deaths. At that point, it was was the second highest of all of Georgia’s nursing homes for positive cases and the third highest death numbers behind nearby Terrell and Dougherty counties.

Nine days later, in the April 17 report, eight more people had died, totaling 11, now with 53 residents and 20 staff having COVID-19. Ten days later, on April 27, at least 14 out of 42 residents had died and over 80 staff and residents had been diagnosed with COVID-19.

Southwest Georgia Regional Medical Center attempted COVID-19 mitigation protocols to stem the tide. It separated all the COVID and non-COVID-19 patients, sending all non-COVID-19 patients to other facilities. The administration temporarily suspended the operations at the hospital because there were too few staff members to run it, but utilized the hospital to give nursing home patients extra space to deal with the virus. The emergency room was kept open.

Then the hospital converted the rooms for treating COVID-19 patients into zero pressure rooms by separating ventilation systems. The refit cost over $50,000 a month just to keep the “makeshift” ventilation systems stable. However, because a significant number of staff tested positive for COVID-19, there was a shortage of critical care.

Over half of the staff left the facility altogether by either resigning or working for other facilities. 

“We didn’t have enough staff to staff the hospital or the nursing home," Whatley said.

Brenda Wilburn worked as a rehabilitation assistant at the nursing home for 30 years. But at the onset of the pandemic, she realized she had to make the tough decision to leave.

“I had to turn in my resignation due to COVID because of preexisting illnesses and all, you know, my age and everything,” she said. “It was just too risky to continue, but, um, it really hurt me real bad to have to leave, because that's what I love to do, you know, and everything. And I miss it.”

Through a state program, several nurses were sent to keep the nursing home open. The National Guard was also sent in to do extensive cleaning in and around the facility.

Like many other communities around the nation, Cuthbert was blindsided by the sheer magnitude of the pandemic. And the overwhelming number of deaths and positive cases had a disastrous impact on the town.

Because the nursing home was such a significant income stream for the already struggling hospital, when COVID- 19 hit,  it crippled the facility's ability to stay afloat.

“For many years, the nursing home subsidized the hospital because it was still profitable,” Whatley said. “However, the losses incurred from the pandemic caused a significant strain on this relationship. Although some money came in from the CARES Act, the facility was hemorrhaging money.”

By the end of April 2020, Randolph County had 278 deaths per 100,000, which was the highest death rate of any non-metropolitan area county in the nation. At that point, tiny Cuthbert was a microcosm for the challenges facing rural communities, especially those of color, nationwide.

“It was devastating on our community,” Whatley said. “It was the most impactful thing in my lifetime I’ve ever been through.”

It was clear that the hospital, already struggling, would not be able to sustain for much longer.

“It was the proverbial straw that broke the camel’s back,” Whatley said.

Closure and questions

In October 2020, the Southwest Georgia Regional Medical Center closed, creating a significant ripple effect not just for Randolph County, but the other surrounding counties the facility served.

Now, if the citizens of Randolph County have a medical emergency, the only options require traveling an hour to either Columbus or Albany, or 25 minutes across state lines to Eufaula, Ala. For the Georgia facilities, an hour could mean life or death for those in critical need, but using the Alabama facility might provide challenges because of out-of-state insurance policies.

In addition, Randolph initially had only one ambulance serving the 6,000 residents, meaning that each emergency call could take over two hours before it could be used for another patient. In the height of an unstable pandemic, those were critical minutes.

One late evening, longtime Cuthbert resident Mary Kearney said was not feeling well, and she called her neighbor, Elvira Shorter, to assist her.

“I thought I was dying; I really did,” she said. “ I couldn't breathe. I couldn't taste anything. I couldn't swallow.”

She said the ambulance took her to Eufaula because it was closer than Albany or Columbus.

“I needed help,” she said. “And everybody that I needed at that time of the morning was not available.”

Eventually she received the care she needed in Eufaula, but if the hospital was open in Cuthbert, she would have avoided many negative aspects of that ordeal.

“We had nowhere to go quick enough,” she said. “At one time somebody could have gotten me in the car and got me right up there. We can't do that anymore. We don't have that service anymore. And I know it's supposed to be a small community, but most of our community is, what you say, older people, retired or just senior citizens. And we need service that we can depend on.”

Cuthbert became filled with stories of people simply trying to get access to necessary care. In those dark months of 2020, especially after the hospital closure, with many Cuthbert residents losing loved ones to the pandemic, residents were frustrated that they had been forgotten.

“I want the hospital to open back up and bring in some doctors and some nurses and some people who care,” Kearney said, “and make sure that they're concerned about the community.”

The town now had two ambulances, plus the urgent care clinic and the nursing home. But it simply wasn’t enough.


The face of health care in rural America

In an effort to bring attention to the need for additional health care facilities, Cuthbert became a stop for political candidates.

U.S. Sen. Jon Ossoff stopped off in December 2020 while campaigning in the runoff elections, and in March 2022, Stacey Abrams kicked off her gubernatorial campaign in the town.

In 2021, Ossoff kept his campaign promise and pushed for more funding for Cuthbert. He sent a letter to U.S. Health and Human Services Secretary Xavier Becerra and Agriculture Secretary Tom Vilsack to reopen the Southwest Georgia Regional Medical Center.

“Health care is a basic human right, and to make that a reality for all Georgians they must have reasonable access to care,” Ossoff wrote. “I urge you to make every federal resource swiftly available to reopen this hospital facility, including federal funding to address the hospital’s infrastructure needs. I would ask that you work personally with me, my staff, Mayor Whatley, and Cuthbert and surrounding communities to see it through.”

Bobby Jenkins is the current mayor of Cuthbert. He spent many years as the first African American superintendent of Randolph County Schools. Before becoming mayor, he was chairman of the Randolph County Democratic Committee. He believes specific state policy would have helped keep the hospital open.

“Of course, in the back of my head, I wonder what Medicaid expansion would have done to make this hospital more viable for a longer period of time,” he said, “ And no one has yet answered that for me. I will keep trying to get an answer, uh, as to, you know, what impact that would've had on keeping that hospital open.”

As of this date, Georgia is one of 10 states that has not adopted full Medicaid expansion. More than a million of the state’s citizens are uninsured. In July 2023, Georgia will implement a partial Medicaid expansion, with an 80 hours-a-month work or approved activity requirement for people between 19 and 64 years old. But the state will still cover far fewer people than full expansion under the Affordable Care Act , and therefore would not qualify for enhanced federal matching funds. 678,000 of Georgia’s residents who have no health care now would benefit from full expansion.

In 2021, over 12.3% of Georgia’s residents were uninsured. It’s predicted that by 2026, the uninsured rate in rural Georgia will reach 25%. Since many hospitals depend on a tenuous payer mix, Medicaid expansion would potentially open up a revenue stream to keep many of Georgia’s rural hospitals afloat.  Rural hospitals are 62% less likely to close in states that have fully expanded Medicaid compared to those that have. Without full expansion, Georgia is missing out on $3.5 billion of federal money.


Stemming the tide

Since 2010, nine rural hospitals have closed in Georgia.  

Mayor Jenkins reiterated the challenge that rural hospitals face, and the additional task of transportation for many rural patients.

“You don't have the patient census that some of the larger facilities do,” he said, “so you're already operating on a thin budget. But as I understand it, Medicaid expansion would've provided additional funds because No. 1, Medicaid expansion would've targeted low-income individuals. Those would've been the people who would've gotten insurance. And if I live in Cuthbert and I don't have transportation, if I need to go to the hospital or doctor, where am I going?”

African Americans have higher comorbidities than other ethnic groups and as a result, suffer from higher mortality rates. Hypertension, diabetes, kidney and heart disease are preexisting conditions that exacerbate the severity of COVID-19. Since Cuthbert’s citizens are over 60% African American, having no access to emergency treatment in the middle of a pandemic creates a double burden.

Jenkins draws a direct comparison with income and mortality as it affects rural citizens of Georgia.

“When you are in a low-income area and you are striving and working each day to keep a roof over your head and food on the table, health care doesn't become an issue till it's critical," he said. "And that's what happens. I think that's why mortality varies so much. The mortality rate is basically a function of the household income.”

In the months after the hospital’s closure, former Mayor Whatley said the Hospital Authority fielded offers from management companies nationwide, but none of the offers presented long-term solutions to the previous issues.

But there is something finally on the horizon to open the hospital back up. 

The Hospital Authority of Randolph County first applied for a $20 million USDA loan, as it now will cost $15 million to rehabilitate the facility, up $5 million from the estimate in 2018 given new equipment needs. They have also applied for $13 million through Congressional Discretionary Spending. They need a minimum of $20 million to get the hospital operating again.

This article was sponsored by the Fund for Investigative Journalism. Brad Bailey is originally from Moultrie, Ga., and is a graduate student at Harvard University.