About two years ago, Elise Severe was getting her middle daughter, Maddie, ready for kindergarten, brushing her hair, when Maddie said she didn’t feel well.
“Then her head tilted back, and you could see her eyes go back, and all of the color just went away,” Severe said. “Her lips were dark gray.”
Severe gently laid her daughter on the ground and then realized she wasn’t breathing or responsive. Severe called 911.
The Severe family lives in Dayton, Washington, in the middle of the state’s wheat-growing Palouse region. Elise Severe grew up here; her parents are wheat farmers. Now, she and her husband, a wind engineer for Puget Sound Energy, live in town with their three daughters.
Their house is less than a mile from the Dayton General Hospital — so when Maddie lost consciousness, the ambulance was there within minutes. But when changes to the federal Medicaid program take effect in about a year, rural hospitals like Dayton General could face closures, leaving people to drive an hour or more to the next closest options.
Rural hospitals depend more on Medicaid income than urban hospitals, and many are already operating on the brink. That means when an estimated 300,000 Washington state residents lose their Medicaid health insurance, these hospitals could become insolvent.
For the Severes, the next closest emergency room is in Walla Walla, 45 minutes away.
“I can’t imagine having to put [Maddie] in the car and then drive for a very long distance, you know?” Severe said. “In these moments, you wish you could teleport and be there even quicker.”
The doctors at Dayton General told the Severes that Maddie had experienced a kind of seizure small children can get — and she’d be fine.
It’s not the only time the Severes have used Dayton General’s emergency room in recent years.
There was the time Maddie fell as she was getting out of the car. She split her head open and an ER doctor glued it back together.
Another time, the eldest daughter stepped into a grate on a swimming pool’s deck, shredding the skin on her leg, so she needed stitches. Another time, she was bitten by a dog.
The Severes said they’ve lost count of all their hospital visits, but estimate they’ve been dozens of times.
“I have a lot of feelings about the possibility of losing our hospital,” Elise Severe said. “It made me panic. It actually made me really mad. … It would ruin our community.”
When the federal government’s changes to Medicaid take effect, U.S. citizens will have to work at least 80 hours a month to keep their Medicaid coverage, and states will have to verify their work status.
In states that already have work requirements, people sometimes lose their coverage because they can’t work. Then there are others who don’t know about the work requirement or find the task of documenting their work too onerous.
Additionally, the changes will make many lawfully present immigrants, such as refugees, ineligible for Medicaid.
And if federal subsidies for people who buy health insurance on the state marketplace expire next year as planned, another 80,000 Washington state residents would no longer be able to afford their premiums.
“Roughly one in every 20 Washingtonians is going to lose their health coverage in the next few years,” said Emily Brice, co-executive director of Northwest Health Law Advocates.
Rural America is poorer, older, and sicker than more urban areas, which means rural hospitals like Dayton General rely more on income from Medicaid and Medicare.
“You'll have hospitals and other providers who are seeing an increase in uncompensated care, emergency room visits and the like,” Brice said.
If hospitals don’t have as many patients who can pay walking in the door, that won’t just affect people on Medicaid or those who’ve lost their health coverage. If hospitals have to shutter services or close their doors, it will affect everyone — including people like the Severes, who have health insurance through an employer.
There are other federal Medicaid changes that rural hospital administrators and advocates worry about, such as one that, starting in 2028, will reduce how much income rural hospitals receive when they serve Medicaid patients.
Federal lawmakers tried to address the possibility that rural hospitals could close by earmarking some money specifically for them.
“The program is woefully insufficient,” Brice said. “The most likely scenario is that Washington would probably get $100 million a year for five years, which is a drop in the bucket compared to the harm that's at stake.”
Dayton General has a grassy, sprawling campus, with dozens of services: an emergency room, behavioral health therapists, a dental clinic for Medicaid recipients, a trailer with an MRI machine, a physical therapy wing that includes a rehab pool for people with back injuries or recovering from surgery, a daycare and preschool, assisted living homes.
“It's not like a total closure of services,” said Shane McGuire, who’s been the CEO of Dayton General for almost a decade. “You're not going to be there one day and gone the next.”
“What's going to happen is you're going to unwind services to a point where you're no longer a resource for your community, and then you might close,” he said. “We're all going to fight like heck to try to prevent that from happening.”
Dayton General is already operating on the brink — it has 15 days cash on hand, when a financially healthy hospital should have 120 days.
“It's pretty challenging day to day to deal with the things coming at you,” McGuire said.
Rural hospitals are often more financially unstable than urban hospitals because they serve many fewer patients. An emergency room, for example, needs to have doctors, nurses, other staff, and equipment available at all times for anyone who comes through the door. If few patients come in, the hospital still must pay for all of those salaries and equipment, without much income.
McGuire is currently running numbers on which services his hospital should cut, if it comes down to that, he added.
“I don’t sleep well at night,” he said, his voice breaking. “I worry — I worry about our patients and our organization.”
Just the day before his interview with KUOW, McGuire said, two trauma cases came into the hospital — one from a car crash, and one involving a tractor.
“We provided life-saving interventions, and we were able to get them out of here on a helicopter,” McGuire said. “And you just can't help but worry about, ‘What if we're not here?’”
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