There's a new morning ritual in Pinedale, Wyoming, a town of about 2,000 nestled against the Wind River Mountains.
Friends and neighbors in the oil- and gas-rich community "take their morning coffee and pull up" to watch workers building the county's first hospital, said Kari DeWitt, the project's public relations director.
"I think it's just gratitude," DeWitt said.
Sublette County is the only one in Wyoming -- where counties span thousands of square miles -- without a hospital. The 10-bed, 40,000-square-foot hospital, with a similarly sized attached long-term care facility, is slated to open by the summer of 2025.
DeWitt, who also is executive director of the Sublette County Health Foundation, has an office at the town's health clinic with a window view of the construction.
Pinedale's residents have good reason to be excited. New full-service hospitals with inpatient beds are rare in rural America, where declining population has spurred decades of downsizing and closures. Yet, a few communities in Wyoming and others in Kansas and are defying the trend.
"To be honest with you, it even seems strange to me," said Wyoming Hospital Association President Eric Boley. Small rural "hospitals are really struggling all across the country," he said.
There is no official tally of new hospitals being built in rural America, but industry experts such as Boley said they're rare. Typically, health-related construction projects in rural areas are for smaller urgent care centers or stand-alone emergency facilities or are replacements for old hospitals.
About half of rural hospitals lost money in the prior year, according to Chartis, a health analytics and consulting firm. And nearly 150 rural hospitals have closed or converted to smaller operations since 2010, according to data collected by the University of North Carolina's Cecil G. Sheps Center for Health Services Research.
To stem the tide of closures, Congress created a new rural emergency hospital designation that allowed struggling hospitals to close their inpatient units and provide only outpatient and emergency services. Since January 2023, when the program took effect, 32 of the more than 1,700 eligible rural hospitals -- from Georgia to New Mexico -- have joined the program, according to data from the Centers for Medicare & Medicaid Services.
Tony Breitlow is healthcare studio director for EUA (Eppstein Uhen Architects), which has extensive experience working for rural healthcare systems. Breitlow said his national architecture and engineering firm's work expands, replaces, or revamps older buildings, many of which were constructed during the middle of the last century.
The work, Breitlow said, is part of healthcare "systems figuring out how to remain robust and viable."
Freeman Health System, based in Joplin, Missouri, to build a new 50-bed hospital across the state line in Kansas. Paula Baker, Freeman's president and chief executive, said the system is building for patients in the southeastern corner of the state who travel 45 minutes or more to its bigger Joplin facilities for care.
Freeman's new hospital, with construction on the building expected to begin in the spring, will be less than 10 miles away from an older, 64-bed hospital that has existed for decades. Kansas is one of more than a dozen states with that would require health providers to obtain approval from the state before offering new services or building or expanding facilities.
Baker also said Freeman plans to operate emergency services and a small 10-bed outpost in Fort Scott, Kansas, opening early next year in a corner of a hospital that closed in late 2018. Residents there "cried, they cheered, they hugged me," Baker said, adding that the "level of appreciation and gratitude that they felt and they displayed was overwhelming to me."
Michael Topchik, executive director of the Chartis Center for Rural Health, said regional healthcare systems in the Upper Midwest have been particularly active in competing for patients by, among other things, building new hospitals.
And while private corporate money can drive construction, many rural hospital projects tap government programs, especially those supported by the U.S. Department of Agriculture (USDA), Topchik said. That, he said, "surprises a lot of people."
Since 2021, the USDA's rural Community Facilities Programs have awarded $2.24 billion in loans and grants to 68 rural hospitals for work that was not related to an emergency or disaster, according to data analyzed by KFF Health News and confirmed by the agency. The federal program is funded through what is often known as the farm bill, which faces a September congressional renewal deadline.
Nearly all the projects are replacements or expansions and updates of older facilities.
The USDA confirmed that three new or planned Wyoming hospitals received federal funding. Hospital projects in Riverton and Saratoga received loans of $37.2 million and $18.3 million, respectively. Pinedale's hospital received a $29.2 million loan from the agency.
Wyoming's new construction is rare in a state where more than 80% of rural hospitals reported losses in the third quarter of 2023, according to Chartis. The state association's Boley said he worries about several hospitals that have less than 10 days' cash on hand "day and night."
Pinedale's project loan was approved after the community submitted a feasibility study to the USDA that included local clinics and a long-term care facility. "It's pretty remote and right up in the mountains," Boley said.
Pinedale's DeWitt said the community was missing key services, such as blood transfusions, which are often necessary when there is a trauma like a car crash or if a pregnant woman faces severe complications. Local ambulances drove 94,000 miles last year, she said.
DeWitt began working to raise support for the new hospital after her own pregnancy-related trauma in 2014. She was bleeding heavily and arrived at the local health clinic believing it operated like a hospital.
"It was shocking to hear, 'No, we're not a hospital. We can't do blood transfusions. We're just going to have to pray you live for the next 45 minutes,'" DeWitt said.
DeWitt had to be airlifted to Idaho, where she delivered a few minutes after landing. When the hospital financing went on the ballot in 2020, DeWitt -- fully recovered, with healthy grade-schoolers at home -- began making five calls a night to rally support for a county tax increase to help fund the hospital.
"By improving healthcare, I think we improve everybody's chances of survival. You know, it's pretty basic," DeWitt said.
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