(CNN) -- A couple dozen nurses stood together on the hospital lawn in rural Randolph County, Georgia. They wore black T-shirts that read "Patterson Hospital 1948-2020" over their hearts. The phrase "We Gave All" was written across a broken heart on their tired backs.
Many had spent their entire careers at the 25-bed critical care hospital, built more than seven decades ago by their grandparents and parents, who pooled their resources. It had recently been rebranded as Southwest Georgia Regional Medical Center, but many still called it by its original name, Patterson, for its beloved first doctor.
Yet in October, in the middle of a global pandemic, a maintenance crew hammered off the hospital's signs and hoisted a white plastic banner with glaring red letters.
"Effective October 22, 2020 HOSPITAL CLOSED. NO EMERGENCY SERVICES AVAILABLE AT THIS LOCATION. IN CASE OF EMERGENCY, CALL 911."
Early in the pandemic -- through April 2020 -- Randolph County had the state's highest rate of Covid-19 cases; going forward, the closest hospital would be at least a half-hour drive across the state line, in Alabama.
"It was a tough day for Randolph County, a tough day," said Steve Whatley, the mayor of the town of Cuthbert, where the hospital was located. "2020 was probably the most challenging year of my life here."
Patterson was one of 19 hospitals around the country that closed in 2020. It was the biggest loss of rural hospitals in a year since the University of North Carolina's Cecil G. Sheps Center for Health Services Research started keeping records in 2005. Two more have closed since the start of 2021.
'The nail in the coffin'
Even before the pandemic, rural hospitals faced significant financial uncertainty.
The pandemic has been what one health care leader called, "the nail in the coffin," after struggles decades in the making.
These communities are shrinking, and fewer patients means less money coming in to rural hospitals. Fewer patients with insurance typically means hospitals must cover a lot of uncompensated care. Even if a patient has Medicare or Medicaid, hospitals aren't paid as much as they would be with a privately insured patient; private insurers pay nearly double what Medicare pays for all hospital services.
And the type of care rural hospitals need to provide adds to their financial struggles. Generally, rural residents are older, have higher rates of chronic conditions and are more likely to have a disability, compared to urban populations, according to the US Centers for Disease Control and Prevention. They also have less access to primary care.
Due to longstanding health inequities, rural America tends to have a higher rate of smokers, people who are obese, and people with high blood pressure. The overall rate of drug overdoses in rural areas surpassed metropolitan areas over the last two decades.
"It's unfortunate, but these small towns are older, sicker, poorer," said Alan Morgan, the CEO of the National Rural Health Association. "You've got these populations clustered in these hundreds of small towns that are absolutely the wrong population to be together."
Before the pandemic, the budget for Randolph County's hospital could not be sustained by the sicker and poor patients it needed to serve.
This county in the heart of the historic Black Beltis one of the poorest in Georgia, according to Census figures. Kim Gilman, the last CEO for the Randolph County hospital, said about 20% of patients cared for there did not have coverage, public or private. in 2019, Gilman said the hospital provided $4.8 million in care to patients who qualified for free and discounted care, or patients who were unable to pay their bills.
"The experience of managing finances where services rendered are never paid for is very difficult," Gilman said.
Her hospital would get lump sum payments once or twice a year from Georgia's Indigent Care Trust Fund.
"Many years, we would watch our cash dwindle below comfort zones," Gilman said. "Once we'd receive such payments, we'd experience short periods of financial relief but never to the extent that we'd be able to address all financial needs or reinvest in our facilities and capital projects."
And then came Covid-19.
Rural hospitals like the one in Randolph County operate on razor thin margins and didn't have reserves to handle the pandemic's unplanned expenses.
They also couldn't make up for the significant loss of revenue from canceled appointments from early in the pandemic. A February report from The Chartis Center for Rural Health found 82% of the rural hospitals surveyed said suspension of outpatient services resulted in a loss of at least $5 million per month.
More than 180 rural hospitals have closed since 2005. Closures were already occurring at an accelerated rate over the last decade, and now 21 have shut down since the start of the pandemic.
They won't be the last.
Help could be on the way
Relief is coming, according to Tom Morris, the associate administrator for rural health policy in the Health Resources and Services Administration of the US Department of Health and Human Services.
To make up for lost revenue in the pandemic, hospitals got money from the 2020 CARES Act. Morris said rural providers can expect an influx of an additional $8.5 billion from the American Rescue Plan later this year.
In July, HHS also announced $398 million would also cover testing and Covid-19 mitigation.
If passed, the Rural Hospital Support Act under consideration with bipartisan backing in Congress could also bolster rural hospitals' budgets.
But money can't address every systemic problem.
"There's no silver bullet when it comes to addressing the challenges," Morris said. "But you know, I think there are things that are helping."
This help, though, comes too late for the 21 communities that lost hospitals during the pandemic. Their problems began long before Covid-19.
"We've been fighting the financial battle for 20 plus years," said Whatley, the mayor of Cuthbert, who had served on the local hospital authority since 1994. "I can easily say that the last 20 years have been very rough."
Studies show Medicaid expansion makes a difference for rural hospitals. A 2018 study found expansion was associated with a hospital's improved financial performance and a significantly lower likelihood of closure.
Georgia is one of 12 states that hasn't expanded Medicaid eligibility to most of its poor residents under the Affordable Care Act. Of the states on the list with the most rural hospital closures, including Texas, Tennessee and Georgia, none have expanded Medicaid.
Recently, the Biden administration offered financial incentives to states to expand, but Georgia Gov. Brian Kemp has so far not accepted the offer, forgoing $710 million.
At the closing of the hospital in Randolph County in October, Dr. A.S. Ghiathi, a physician who had cared for generations of residents, was asked by a crowd of reporters what would have saved it. He said it was simple: "Expansion of Medicaid."
Covid-19 was worse than they imagined
In Randolph County, the pandemic was too much for the fragile hospital, and the federal dollars came too late.
When Covid-19 took hold, so many hospital staff were taking care of family members or had their own illness that Phoebe Putney Health System, the group that managed the hospital, brought in extra staff to care for the residents of the nursing home attached to the hospital.
There was also an outbreak at the nursing home, according to Gilman, the former hospital CEO, so the hospital transferred its three acute care patients to make room for nursing home residents who weren't infected with the coronavirus.
Gilman said they had to divert ambulance traffic away from the emergency department because there was no way to admit patients with such limited staff. But they stayed open for walk-in patients and tested for Covid-19 "24/7 in our ED," Gilman said.
How they'd have enough PPE became an "hourly" discussion, she said.
Because of outdated HVAC units, they installed portable air chillers for dozens of small areas designed to filter airborne particles at the nursing home.
In the end, the hospital needed about $10 million for renovations and equipment that had "aged out," Gilman said. For a bigger hospital, $10 million may be easy to cover, but for the county that owned the hospital, it was too much.
The hospital authority's request for loans were denied. The decision to close the hospital was made, even as the county and the world wrestled with a fast-spreading novel virus.
"Covid-19 truly exposed our vulnerabilities as a rural hospital related to our minimal staffing structure, limited physicians, limited supplies on hand, and our aging facilities," Gilman said in an email. "We knew it was coming and were preparing but the reality of the virus and its impact were far worse than we could have imagined."
Not just inconvenient -- 'devastating'
Since October, Randolph County has tried to adapt, but it hasn't been easy.
As in many rural areas, there were few health care providers here before the hospital closed. Now, the closest ER is across the state line, in Alabama, about a 40-minute drive, and it's at least an hour to the closest in-state hospital and emergency department in Albany.
A convenient care clinic staffed by nurse practitioners has extended hours and is open seven days a week, but it doesn't have a doctor on staff.
"None of that replaces emergency room, but it does help," Whatley said.
Whatley said the closure has put pressure on EMS to pick up the slack. There are three ambulances to cover the county's 429 square miles, but only one that's fully staffed. If it makes a run, even for a less serious case, it cannot stop to pick up someone with an issue like a stroke. With additional travel time and paperwork, each run can now take hours.
People could drive to the hospital, but Randolph County has the highest percentage of households in the state without access to a vehicle, according to Census estimates. A 2021 US Government Accountability Office report on rural hospital closures found that when a local hospital closed, residents had to travel 20 miles farther for common services. For less common services, like alcohol or drug treatment, it was about 40 miles.
"That continues to be a challenge," Whatley said.
"It's not just inconvenient that our hospital closed, it's been devastating for a lot of people," said Willie Smith, a mortician in Cuthbert. "If someone has a stroke or a heart attack and they have to drive an hour, imagine what their chances are of surviving."
The town feels it for non-emergencies, too.
Smith said he hurt his knee moving a casket; the hospital was still open when he needed help with his injury, but by the time he needed physical therapy, it had closed and he regularly had to drive an hour away.
For Sandra Willis, not having a hospital meant her brother didn't have the family support he needed after a stroke.
The hospital and nursing home the ambulance took him to was more than an hour's drive away. While there, he caught Covid-19.
For two months, the nursing home was supposed to help him with rehab, but she said they didn't. She wasn't able to be there to advocate for him, and felt helpless.
"They never once got him out of bed, and they used up all his insurance," Willis said. "When his insurance was gone, they were glad to let me come get him."
'We're gonna do the best we can'
It's too soon to know what the overall health impact of 2020's rural hospital closures will have on communities, but a 2019 University of Kentucky study found an increase in mortality when rural residents have to go farther for emergency care.
When Randolph's two neighboring counties, Calhoun and Stewart, lost hospitals in 2013, there was a serious drop in the number of people who sought out emergency room care anywhere, according to Georgia records. ER visits decreased by 35% in those counties after the hospitals closed, cutting ER visits from a combined 4,808 visits in 2012 to 3,120 in 2013. White residents saw a 24% drop in visits -- from 1,354 to 1,003 -- while the decrease was even more substantial among Black residents, falling 40% from 3,454 to 2,087. It's unlikely people in these counties suddenly got healthier, and more likely means fewer people got medical attention.
At the October closing ceremony at the hospital in Randolph County in October, firefighters, ambulance drivers, politicians and neighbors came to surprise the staff and show their gratitude.
There were tears and prayers, and then the mayor stood among the crowd and made a solemn promise to all those who had gathered on the lawn.
"We're gonna do the best we can with what we got, from here forth out. We will provide all the sustainable medical services we can sustain," Whatley told the crowd.
As Whatley made that promise, the ambulance crew got a call. As they left the ceremony, the ambulance driver said into the mic on her shoulder they'd be on their way.
But as the crowd watched them leave, someone said quietly it would probably take a while.
™ & © 2021 Cable News Network, Inc., a WarnerMedia Company. All rights reserved.