Dr. Max Self grabs a sanitary wipe and cleans off the small flashlight in his hands. More than 20 years as a family doctor in rural Fort Scott, Kan., has taught him a few tricks for dealing with little kids: "I've got my flashlight. See? Look, you want to hold it?"

Two-year-old Taelyn's brown eyes grow round, and her tiny hand reaches out. But, first, Self makes sure the little girl opens her mouth wide, and he peers down. Behind him sits another staff member — a medical scribe. The scribe gives the doctor the ability to "focus on people," rather than toggling between a computer screen and the patient. It's a new perk Self didn't have when he worked at Mercy Hospital.

That beloved hospital closed one year ago, and in the passing months, the small town's anger and fear evolved into grief, nervousness and — lately — pragmatic hope. Most of the handful of physicians in town stayed, taking jobs at a regional federally qualified health care center that took over much of the clinic work from Mercy. The emergency department, after closing for 18 days, was reopened, at least for now, and is run by a hospital 30 miles south.

It's not "all gloom and doom," insurance agent Don Doherty said during the town's weekly Chamber of Commerce coffee on Dec. 12. "Although we all wish we had a hospital — no doubt about it."

Nationwide, death rates have been higher in rural America compared with rates in urban areas since the 1980s, and the gap continues to widen. More rural residents live with chronic conditions, like diabetes, that affect their daily lives, and a higher percentage of residents are older. Rates of smoking and premature births are relatively high, and people often die younger than the national average.

Since 2010, 120 rural hospitals have closed across the U.S. — 19 in this year alone, according to data from the University of North Carolina's Cecil G. Sheps Center for Health Services Research. A national analysis of Medicare cost reports found that 21% of the nation's remaining rural hospitals are at high risk of closing.

"Frankly, it's not getting better," said Dr. Daniel DeBehnke, the study's co-author and a managing director with Navigant's health care practice.

A year ago, after Mercy gave Fort Scott a 90-day notice that it would close, City Manager Dave Martin said the betrayal felt by city leaders led to calls with lawyers and other health care systems about taking over the facility. Now Martin has realized "we will not have — [nor] do we need — a hospital."

But if not a hospital to care for rural communities like Fort Scott, with its 7,800 residents, what is needed? The answers to that question play out every day here and could hold lessons for the rest of the country.

"You will be taken care of"

Self has cared for his share of struggling patients in this town, where 1 in 4 children live in poverty and its main corridor — U.S. 69 — is lined with fast-food restaurants. But Fort Scott is "not far off" from what it needs to be healthy.

Sure, residents have to travel south 30 miles to Pittsburg, Kan., or north 90 miles to the Kansas City, Kan., area to be hospitalized. But "you will be taken care of," Self says.

The doctor's new employer is Community Health Center of Southeast Kansas, which, as a federally qualified health center, gets a higher level of government reimbursement for Medicare and Medicaid patients than Mercy did, says Jason Wesco, executive vice president at CHC.

The center can also gain grants to take care of the uninsured, which is important in states like Kansas that did not expand Medicaid, though Wesco says it has not received any grants for taking care of patients in Fort Scott.

Wesco estimates that 90% to 95% of the health care offered before the hospital closed is still available locally. And services have been added, including a much-needed therapist on-site for behavioral health and telehealth access to a psychiatrist and substance abuse services.

"Drive up there, go into the parking lot, you're like, 'There's a lot of people here,' " Wesco says. CHC's Fort Scott facilities have filled more prescriptions and done more mammograms in a month than the hospital "ever did," he says.

Local residents such as 28-year-old Eliza Oliver, whose daughter, Taelyn, easily passed her annual wellness check with Self, says it's much less expensive to get care and prescriptions at the new health center. That part is great, Oliver says. But she still worries about the future of emergency care in town and about whether women will be able to get to a place where they can safely deliver their babies.

Another Catholic hospital chain, Ascension Via Christi, which has a facility 30 miles away in Pittsburg, Kan., stepped in at the last minute to operate Mercy's old emergency room, signing a two-year agreement. This was vital: While much of the rest of Mercy Hospital Fort Scott had been underused and patient rooms sat empty, the ER handled nearly 9,000 people the year before it closed.

And Mercy Hospital delivered more than 230 babies between July 2017 and June 2018. A few months ago — after the hospital closed — Oliver drove a friend who was in labor across the Kansas-Missouri border more than 20 miles to deliver. "We had to jet over there," Oliver says, "and even though we made it in time, it's nerve-wracking."

Not having a community hospital does require a new mindset. The community still has an obstetrician, but doctors send patients out of town to have their babies. By June 2019, Ascension's Fort Scott ER staff had delivered three babies for expectant mothers who weren't able to get to a hospital in time.

Randy Cason, president at Ascension's Pittsburg hospital, drove to Fort Scott to tell the weekly Chamber of Commerce coffee gathering that doctors needed to "counsel and educate" mothers that it's no longer a 10-minute drive to the hospital.

Sherise Beckham, a former Mercy dietitian, was anxious and on bed rest this spring while awaiting her baby. "You're on a two-lane highway. A lot of times you get behind a semi, behind a tractor," Beckham says and laughs. "Sometimes, you are lucky if you have cell service."

Beckham's delivery did not go as planned. After driving to Ascension's Pittsburg hospital to meet her family doctor, she had an unexpected cesarean section, and the baby, whose heart rate dropped dramatically, was transferred to a neonatal intensive care unit an hour away from home in Joplin, Mo. Now, eight months later, the baby is healthy, though he continues to see a physical therapist who monitors his developmental progress.

Recent research by Katy Backes Kozhimannil, an associate professor at the University of Minnesota's School of Public Health, found that rural residents have a 9% greater chance of dying or suffering complications such as heart failure, stroke and the need for blood transfusions during childbirth, compared with nonrural residents.

Federal policymakers have said they want to do better. President Trump's administration this year set new Medicare payment policies that included more telehealth services and that changed some payments for rural hospitals. Seema Verma, the administrator for the Centers for Medicare & Medicaid Services, also promised a new rural health payment model, and "A lot of people are waiting with bated breath," says George Pink, a senior research fellow at UNC's Sheps Center.

CMS declined to comment on the timing of the proposal.

Congress, too, has made overtures to passing legislation. Maggie Elehwany, the lead federal lobbyist for the National Rural Health Association, says the Affordable Care Act's promise that hospitals would have more insured patients and less bad debt "never really unfolded in rural America." The 14 states that have not adopted Medicaid expansion are largely rural; many are in the South, where the greatest number of hospitals have closed.

Signs of change

Catholic nuns founded the Fort Scott hospital more than a century ago, and 89-year-old Fred Campbell still recalls a mantra etched in stone over the entrance of one old Mercy hospital building: "Dedicated to suffering humanity."

"We always felt that," Campbell says. "Come hell or high water, you're gonna be with us and you're not going to abandon us."

But exactly a year ago, the hospital's then-owner, St. Louis-based Mercy — a major health care conglomerate with more than 40 hospitals — declared it no longer financially viable.

Within weeks of Mercy's closing, a newly built $9 million grocery store closed. A few weeks later, the cancer center closed, and by October, the town's dialysis center had closed too. John Leatherman, a professor in the department of agricultural economics at Kansas State University, says there's no doubt that Bourbon County took "a big hit" when the hospital was shuttered.

Roxine Poznich lost her income when her job at Mercy ended. After more than 20 years at the hospital, the 73-year-old says she now finds herself paying for groceries with her credit card — even though she is unsure whether she can pay the bill at the end of the month. "I'm scared," Poznich says.

But Rachel Pruitt, Fort Scott's economic development director, says the loss of the hospital has not affected the city's sales tax revenue. Manufacturers like the community's largest employer, Peerless Architectural Windows and Doors, with its 400 jobs, continue to expand — just down the road from where Mercy's 177,000-square-foot hospital building still stands.

City leaders say that, ideally, the community would "right-size" its health care. That would include keeping the current outpatient clinics that provide primary care and an emergency department and also adding some inpatient beds that would allow residents with short-term hospitalization to stay local. Pruitt says there has even been talk of adding a wound center that could treat injuries among the town's industrial workers.

And though the mostly empty Mercy Hospital building feels like a white elephant, that, too, may soon change: Mercy recently announced it would donate land in a repurposed corner of its property to the Community Health Center.

Health center leaders have hired an architect for a new building that will probably be about 30,000 square feet. Wellness care, imaging, walk-in care, a women's health center, dental care and expanded primary and specialty care would be available there.

ER operator Ascension declined requests for interviews, but spokeswoman Michelle Kennedy says the Pittsburg leadership team is "working on plans related to our presence in Fort Scott in the near future," but could not release details. City leaders say they are confident an ER will remain.

Meanwhile, Mercy Hospital Fort Scott's former president, Reta Baker, has moved closer to her new job with CHC, at its headquarters in Pittsburg, Kan. Some residents of Fort Scott denounced her when the hospital closed.

Baker, who started her career as a nurse at Fort Scott's hospital in 1981 and grew up nearby, says she continues to "be engaged in a lot of conversations" about the community's future. The next year will have growing pains, she says, but she believes the health care needed for residents is there.

"Now, we need to cement it," she says.

This is the fifth installment in KHN's yearlong series No Mercy, which follows how the closure of a beloved rural hospital disrupts a community's health care, economy and equilibrium. Coming in 2020, a podcast from KHN with more voices and stories from Fort Scott, Kan.

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.