19 min readTHURSDAY, JANUARY 8, 1 P.M.: Snow starts falling as Brian Lopez, MD, exits Mineral Community Hospital. It’s been snowing on and off for two days in northwest Montana, turning the roads to black ice by dawn and messy slush by midmorning. But these flakes are different: fat and dense, the sort that pile up quickly. They accumulate on the shoulders of the bright orange down jacket he threw on his 6'3" frame and settle on top of his close-cut dark hair as he walks from the main building to the old assisted-living quarters, which once housed senior citizens. MCH had to close the facility back in 2017 when it started losing money—the kind of sacrifice that many rural hospitals are increasingly facing in order to prioritize more essential forms of care. Today, the building houses the maintenance office and the training room, where physicians can practice the kinds of complex medical scenarios that Dr. Lopez, 37, knows he might see today as this storm intensifies.
He’s the only doctor on shift in the hospital, serving a county with roughly 5,000 residents as well as all the people traveling on the adjacent four-lane Highway 90. Mineral County is shaped like the rivers that carve through it, long and skinny. The town of Superior, where the hospital is located, lies in the middle, tucked into a high, tight valley with timbered mountains rising on three sides. Reaching the county’s most remote areas means 45 minutes of winding up the highway to Lookout Pass, on the Montana-Idaho border, a spot that receives significantly more snow than other passes in the region. One nurse calls the health care that MCH provides not just rural but “the brink of frontier.”
Thanks to the dangerous combination of the highway, the weather, and the rugged landscape, MCH sees an unusually high number of trauma patients, on top of the local residents it cares for. As a result, Dr. Lopez says, “we’re 45 minutes from chaos”—in the form of multi-vehicle accidents—“at any given point.”
At the same time, it’s a one-stop shop for health care in a county where most people wouldn’t make the nearly 60-mile drive to Missoula (pop. 78,204), the nearest city with a big hospital, for preventive or primary care, and where those who need urgent lifesaving care might not even survive the trip. It’s a potentially two-hour-plus ordeal on winter roads from the far edges of Mineral County, a drive that’s often out of the question for elderly folks—and not even an option for low-income people without vehicles in rural areas with no public transportation.
In the U.S., 35 percent of the nation’s 5,121 community hospitals are rural, defined as those outside a metropolitan area. In the last 10 years, more than a hundred rural hospitals have closed after losing the battle to find sufficient funding, robbing millions of Americans of care. Of the 1,797 rural hospitals that are left, a third are at risk of shutting down, which could be devastating to the 66.3 million people—20 percent of America’s population—who live in rural areas. It costs more to provide health care in rural areas than urban ones. And insurance plans, especially Medicaid and Medicare, which a high proportion of rural residents rely on, don’t pay enough to cover those costs.
Recent policies enacted by the Trump administration are likely to push these hospitals further into crisis. Trump’s One Big Beautiful Bill cut $1.1 trillion from Medicaid and the ACA marketplaces, which will result in roughly 15 million people losing the health coverage that helps pay rural hospital bills—and thus keeps their doors open—by 2034. Congress wrote the Rural Health Transformation Program into the bill to offset those cuts, but it allocates just $50 billion to the states over five years. That leaves states with less than half of what was stripped. And there’s little guarantee that the $50 billion, which comes with strings attached and tight timelines, will even make it to hospitals, throwing rural facilities into a volatile financial situation. In a state like Montana, where nearly half the population is rural, that dramatic shortfall could be the death knell for several hospitals—meaning that more people will suffer and die avoidable deaths without emergency services, inpatient care, or even the primary care that’s often provided by a rural hospital.
As Dr. Lopez steps back into the hospital wing at 2:30, the radio behind the nurses’ station pings the distinctive beeps that signal an ambulance call. Voices crackle over the air: An ambulance is inbound, bringing a local elderly man who’s broken his arm.
The fracture should be a fairly routine scenario. But Dr. Lopez knows that it doesn’t take much for things here to go from slow and routine to “full rodeo,” overwhelming a four-bed emergency room with a single doctor on hand—like that day last year when the ambulance brought in a woman in respiratory failure. Dr. Lopez intubated her, only to find that the rarely used ventilator wasn’t working. He had to assign a nurse to manually squeeze an air bag to keep the woman alive while he called Life Flight Network, an air ambulance service that transports patients via helicopter, to try to get her to Missoula. As they were telling him they couldn’t fly due to bad weather, a person suffering severe chest pain came in needing a time-sensitive workup for what was likely an imminent heart attack. In the middle of those two urgent situations, a third patient walked in who also had upper respiratory issues.
Today, the fracture patient approaches through the thickening snow, and Dr. Lopez waits to see whether the day remains “routine” or, as the storm bares its teeth, becomes routine chaos. Either way, he and MCH will respond with everything they have. Because that’s what rural hospitals do. If they can keep themselves from closing.
5 HOURS EARLIER
THURSDAY, 8 A.M.
THAT MORNING, HOURS before the fracture patient will arrive, Laurel Chambers greets me by the arced counter of the nurses’ station under the fluorescent lights of the hospital’s main entryway. Blonde, blue-eyed, and with a welcoming smile, Chambers radiates calm—a trait that’s served her well in weathering nearly everything that rural health care has thrown at her. She takes me down a hallway to her office—surprisingly comfortable for a hospital, with modest plush chairs and plants thriving in the light spilling in from the big windows—so we can talk away from the daily bustle.
Twenty-five years ago, she tells me, she started as a physician’s assistant; she’s now the CEO. She’s still a licensed PA and steps onto the floor to help if the hospital or clinic is overwhelmed or needs an extra hand. Stacy Conrow-Ververis pokes her head in and then sits down to join us; she’s worked here for 23 years, in human resources and accounts payable and now as CFO. The two grew up together in Superior, and they’ve seen the hospital through disaster more than once: extended times of stress when not receiving a Medicare reimbursement check meant they wouldn’t be able to make payroll for their employees; times when they were afraid to answer the phone in case it was a vendor on the line demanding a check the hospital couldn’t afford and threatening not to deliver crucial supplies.
They take turns recounting how they’ve taken out lines of credit for the hospital and worked to get local tax levies approved. They’ve gotten creative with fundraisers, like a golf tournament and a food booth at the local fair.
As Chambers absentmindedly squeezes a stress ball, she says that for 19 of her 25 years, the hospital teetered on the verge of closing. Even now, it’s a win when MCH has 120 days of operating funds on hand. Like many other rural hospitals, it survives on very thin margins, barely plus or minus 1 percent. Rural areas have more unemployment and lower incomes than urban ones, so MCH relies more on Medicaid and Medicare, which reimburse hospitals at cost or below it. As with many similar hospitals, it wouldn’t take much to push MCH over the brink. “Every rural hospital is on the edge of where one bad thing could take us [out],” Chambers says.
After nearly an hour, we get up and she shows me around, pointing out that the building is old, and so is most of the equipment. The cuts to Medicaid and the ACA—which Chambers calls “tumultuous and hard to navigate”—will, in combination with the skyrocketing cost of living, force people to choose between buying food and paying their medical bills. That would leave MCH short of cash. Chambers says she has so much trauma from the hospital barely making it for so many years that she often lies awake at night thinking of the very plausible scenarios that could easily line up, like holes in a pile of Swiss cheese, to spark unrecoverable catastrophe: If even a few patients are cut off from the insurance that pays MCH’s bills… if the generator, so ancient that the maintenance team can’t get parts for it anymore, gives out… if the pipes under the hospital that are rotting away need to be dug up entirely and replaced, but that money has already been budgeted to replace the outdated electrical panels… if the X-ray machine dies (buying a new one would eat up as much as $300,000)… “It’s staggering how much everything costs,” Chambers says.
But Chambers and Conrow-Ververis are determined to keep the doors open. The people who need this hospital are their families, friends, and neighbors. The community relies on it not just for health care; three weeks ago, when a storm took out power to the region for six days, locals crowded into the building just to get warm. At 90 employees, MCH is the biggest employer in the county. If the hospital closed—on top of the dire health impact for the thousands of patients who access MCH for care each year—dozens of families would likely have to leave to find new jobs. Close the hospital and the community itself hollows out.
“But we’re gritty and resilient. That’s what makes a rural hospital survive,” Chambers says as she leads me back to the main section of the hospital for a tour. Other than the small emergency room, which sees up to 15 patients per day, the hospital is divided into two wings with a total of 25 beds. One side is dedicated to inpatients, and since much of the county’s population is elderly, conditions like pneumonia, infections, and heart failure often land people in this wing. The other side is essentially a low-income nursing home, a greatly scaled-down version of the old assisted-living facility. The hospital also has a room for physical and occupational therapy, an imaging room, and a lab. Attached to the hospital is the clinic, which provides primary care and family medicine.
9:30 A.M.
DR LOPEZ’S LONG strides eat up the floor between the cramped, windowless office the physicians use as a home base and an inpatient room across the hall with an elderly woman whose case might not be so routine. There were some oddities in her lab tests and he’s heading to call a specialist at Community Medical Center in Missoula. He might need to send her there for care. But Montana has seen such a surge in population over the past few years that even its urban hospitals are strained. Taking on additional patients if more rural hospitals close will strain them further, meaning that city residents will begin feeling the effects of a health care system stretched too thin. Dr. Lopez might have to decide to treat the woman here.
This is just one of a thousand decisions, maybe more, that Dr. Lopez makes during any given 24-hour shift. (Hospital doctors here work from 8 a.m. to 8 a.m.) Some are high stakes, like when the weather is so bad that Life Flight can’t fly and he needs to figure out how to get someone all the way to Missoula, fast. Is one of Superior’s two ambulances available to go? What if the patient needs care the EMTs aren’t trained to give? That’s not unlikely: Here, as in many rural settings, the volunteer ambulance crews are basic EMTs, not paramedics. They can’t give medications. They can’t intubate a person who stops breathing. Which means that in some cases, Dr. Lopez has to decide if a nurse needs to go with the patient in the ambulance. Or if he needs to pull in Kirk Crews, MD, a local PCP who’s working in the clinic today, to cover the ER while he goes himself. Sometimes at the end of a shift, the “absolute decision fatigue is so real,” as he puts it, that he doesn’t even want to decide what to have for dinner when he gets home.
After talking with the specialist in Missoula, Dr. Lopez sits down with me in the shoebox physicians’ office. A whiteboard tracking the current inpatients takes up one wall, ’70s-style cabinets are crammed against one another, and a basic desk with a computer claims the rest of the space. We both barely fit in there. Dr. Lopez tells me he grew up in eastern New Mexico, the son of a police officer and a hospice care nurse. He’s always worked in rural medicine and says that while Mineral County is rural, there are levels to rural. When he trained on a reservation at a Navajo Area Indian Health Service (NAIHS) hospital, “we’d see people who’d been traveling for days to get to the ER,” he says. “I’ll never forget the man who cut his arm horribly with a chainsaw. He wrapped a towel around it, packed a backpack, and walked for 48 hours to get to us.”
Another day at NAIHS, a severe car accident brought in a woman with a massive brain bleed that needed an immediate burr hole—a small opening drilled into the skull to relieve pressure on the brain. The young doctor Dr. Lopez was working with had trained on that procedure but had never done it on a patient. He pulled Dr. Lopez into an office to refresh himself on the steps with a YouTube video. These are the things Dr. Lopez practices in the training room at MCH: spinal taps, draining fluid from lungs and bellies, intubations, emergency C-sections. There’s no labor and delivery service here, but he delivers a baby every now and then when a mother won’t make it to the city.
It’s the kind of medicine on the fly that most physicians don’t opt for—especially when the pay might not match the pressure it comes with. Dr. Lopez always steps up, even when he feels the pressure acutely.
There was a time when he was younger that the crazy unpredictability and way-out-of-the-comfort-zone aspect of this genre of medicine appealed to him. But now, he says, “I’ve been in more of those really sketchy situations where you have two people who are trying to die at the same time, and you can’t get a helicopter, and you only have one ambulance to take one of these people, and you’re having to try to call somebody in to ride an ambulance to go with that person. And you have families in the waiting room that are losing their minds because they don’t know what’s going on with their loved one. And you’re coordinating all this and on the phone trying to arrange transfer while simultaneously trying to be in the room managing medications and airways and procedures. I think I’ve been in enough of those scenarios that that part appeals to me less and less.” This is the type of winter day, with the roads a dangerous mess, that rural doctors could come to dread—but plow through anyway.
11 A.M.
THERE’S ONE MAJOR factor buffering Dr. Lopez from even more potential chaos: In the building that connects to the hospital and the emergency room, the clinic is in full swing with appointments and walk-ins for the primary and preventive care that keeps medical conditions from turning into emergencies and long-term serious illnesses. Rural populations are at greater risk of death from stroke, heart disease, and cancer. Obesity and diabetes are much more common. If MCH were forced to close its doors, Dr. Crews wouldn’t be able to catch and treat new-onset diabetes before it becomes an ICU stay, or diagnose and address blood clots before the patient ends up on a ventilator.
I catch Dr. Crews during a break in his schedule, and we retreat to a tiny waiting room in the main hospital, away from the clinic’s constant background noise of check-ins and ringing phones. It’s not even lunchtime, and Dr. Crews, who says he’s part of the last generation trained in true full-scope primary care, has already treated a parade of patients: orthopedic issues, atrial fibrillation, a joint injection, an emergency room follow-up, and anxiety and depression.
“The scope of primary care is not valued enough,” he says. Dr. Crews, 57, is broad-shouldered, a big man with a big presence, serious one moment and then cracking jokes the next. He grew up in the Bitterroot Valley, south of Missoula, and has been a family medicine doctor for most of his career. “I did orthopedics, psychiatry, and cardiology all in the same visit, and yet primary care continues to be undervalued when it comes to reimbursement from Medicare and Medicaid,” meaning these programs cover only 80 percent, or less, of the cost of primary care visits.
That puts patients on the hook for the rest—which they often can’t afford, leaving the provider with a shortfall. It also pushes doctors away from primary care, even though, as Dr. Crews points out, “If people know who their primary care doctor is, they live longer.” And not just because they get consistent preventive care. With adolescents, he says, you see them repeatedly for everything from sports physicals to ear infections to stitches, all of which builds a relationship. “Then they have the worst month of their life—that adds up to not being sure if they want to be around anymore. They know they can come to Dr. Crews and say, ‘Can I just talk to you alone for a while?’ And they get to dump their wheelbarrow of pain on me because they trust me, and they trust me because they know me.” Sometimes he saves lives just by talking to kids, other times by treating issues including depression or anxiety, he says. This kind of lifesaving isn’t rare: Suicide rates are much higher in rural areas—and in-person mental health services are practically nonexistent—making the primary and preventive care that Dr. Crews provides that much more critical.
1:30 P.M.
SINGING VOICES DRAW me down the hall toward the residents’ common room, past a wall painted with a bright mural. Chambers told me the painting will be the first of many; she’s read that color is supposed to be good for people suffering from dementia, which most of the current long-term residents are.
In the common room, the hospital’s 13 elderly long-term residents are seated around a long table. A group of volunteers from churches in the county have come for their weekly visit to sing hymns and pray. I flash back to something Chambers told me earlier, one of the reasons it can be hard to recruit doctors and nurses to rural locations: Other than a lot of bars and a lot of churches, there’s not much to do in small towns. Most rural hospitals see high staff turnover, and it can be especially difficult to recruit people for skilled positions like lab and X-ray technicians.
At 96, Dot Vining is still sharp enough to tease her daughter Lena Jordan, who’s come to visit. Vining has lived here for three years, since she and her daughter moved to Superior. Vining has “outlived her money,” Jordan says. If her mother weren’t on Medicaid, she probably wouldn’t be able to stay here, where she gets the medicine she needs, the hospital doctor on shift provides regular checkups as well as emergency care, and Jordan can easily visit at a moment’s notice.
This wing isn’t a moneymaker. Almost half of these folks aren’t able to pay their bills; they’re either waiting to be approved for Medicaid or their families left them here without knowing where else to turn and don’t return calls anymore about their unpaid balances. But MCH can’t—and won’t—turn them out. They have nowhere else safe to go. It’s the constant tension that most rural hospitals wrestle with: serving patients at the expense of their bottom line.
3:15 P.M.
AT THE NURSES’ station, the radio emits familiar beeps and Dr. Lopez, who was heading to the ER to care for the elderly man with the fracture, freezes. It’s another ambulance call. Voices, sounding muffled and far away under the radio static, convey slim details: two semitrucks, overturned at the top of Lookout Pass; traffic closed in both directions.
In remote areas like this, doctors and nurses have to be prepared for almost everything, ready to perform a wide array of emergency procedures they might need to execute only once every two or three years but without which many patients would likely die before making it to Missoula. Physicians call the first hour after a serious injury the “golden hour of trauma,” and it’s one of the areas where rural hospitals are crucial. MCH doesn’t have anesthesiologists or surgeons, but Dr. Lopez regularly performs lifesaving procedures for traffic accident injuries, heart attacks, gunshot wounds, strokes, and myriad other circumstances. It’s a precious breadth of skill and knowledge that’s disappearing along with rural hospitals in this country.
Dr. Lopez’s brain immediately kicks into high gear. He knows he has at least 45 minutes—the time it takes for the ambulance to get back to the hospital from the accident site—to prepare for whatever is coming. If he knows what’s coming, that is, assuming the radios work and the EMTs can give a report from the scene. This region is so mountainous that radios often don’t work. He might know there’s an ambulance headed his way, with no idea whether it’s bringing a scrape or several open head wounds, whether everyone walked away unscathed or suffered multiple severe injuries. That last scenario has happened more than once: ambulances screaming to the ER from car accidents with up to five people involved, and every staff member on call needs to come in.
Dr. Lopez inventories who he has on hand and who can do what he might need: Many of the staff at rural hospitals are trained for things outside their job descriptions, like MCH’s radiology technicians, who can bag patients manually and perform CPR. He mentally maps out how the ER is set up, which beds are better situated for trauma, and whether the fracture patient needs to be moved to make space.
He does a quick lap around the trauma room, ensuring everything he needs for ventilation is set up and ready—and that the ventilator is actually working. He checks that the chest tube tray is stocked, the crash cart is ready. He instructs the nurses to start their checklists for IVs and important medications.
He thinks through the decisions he may have to make. Life Flight won’t be able to fly in this storm, and if both of Superior’s two ambulances are engaged and another trauma patient comes into the ER, Dr. Lopez won’t be able to send the patient to a bigger hospital for specialized care if it’s needed. He’ll have to hold onto them here.
And then there’s nothing to do but treat the fracture. And wait.
5 P.M.
AS DR. LOPEZ prepares for the worst, Dr. Crews is ending his shift in the clinic. Over the course of the afternoon, he added a child with an ear infection, another with pneumonia, someone around college age with a skin infection from a piercing, a man with diabetes, two patients with anxiety and insomnia, and someone needing a shoulder-joint injection to his tally for the day.
Earlier, Dr. Crews told me he’s building a stone house in the mountains outside Missoula, the way Carl Jung built a castle to “help find himself.” There’s a downside to all that trust patients place in their primary care doctor. Dr. Crews felt it acutely when he ran his own private family medicine clinic for years, working every day and nearly always on call, feeling as if his job never ended.
“Medicine is…hard,” he says, and pauses for a moment, his eyes filling almost imperceptibly. “The more people trust you, the more they bring to you, and the more difficult each visit gets. You wouldn’t go to your mechanic with seven problems with your car and expect that they’re going to take care of all seven problems. But people do that to family doctors all day, every day, and the training hasn’t really sorted out how to help us work through that.”
But practicing at MCH for the past year, working from 8 a.m. to 5 p.m. two days per week, has saved him from burnout. “Their focus on excellence, on giving me the time to be excellent, allows me to feel excellent again,” he says. “I love being a rural family physician. It is mostly magic, and often really, really hard. I’m going to go home knowing that I help people and I just bumped the world one step closer to goodness.”
5:30 P.M.
THE SEMI DRIVERS turn out to be lucky. Very lucky. Only one is brought to the ER, and not even badly hurt. Dr. Lopez is shocked, given the “gnarly” photos of the wreck. Still, he starts on a CT scan and a thorough examination. “It’s not uncommon for people to not feel too bad while they’re amped up with all their adrenaline from a car wreck like that, and then over the course of the next couple hours to find out they actually do have something internally wrong,” he says.
10:30 P.M.
THE HOSPITAL IS quiet. The ER is empty; the long-term residents are tucked into their beds. Dr. Lopez is trying to snag some shut-eye in the little room below the clinic where the hospital doctors sleep. He knows to nap when he has the chance.
And yet he cannot sleep. There’s no sound save the train laboring by on its slow way up the steep pass, and yet he hears beeping all the time, the tone of the ambulance call. It’s always in the back of his head. He’s woken up from a dead sleep in his home, off shift, certain he’s heard it, certain he’s needed as a crisis erupts.
8:30 A.M.
DR. LOPEZ READIES himself to exit the hospital and head home to his wife and baby. There are some shifts when he feels, despite his best efforts, that he can’t make headway, that none of his patients are in a better position than they were when he assumed their care 24 hours before. But not this Friday.
He treated the 90-something-year-old man with the fracture, sending him to Missoula for surgery. Then the man will return to MCH to stay and recover until he’s in good enough shape to go home and live alone again—probably a couple of months, Dr. Lopez estimates. After he saw the truck driver, a woman came in who’d sliced her finger open chopping lettuce. At 1 a.m., one of the inpatients suddenly worsened. The treatments at Dr. Lopez’s disposal weren’t having any effect, and he raised the EMTs to take her to the ICU in Missoula.
“[Today] I feel like I actually helped, made some progress towards helping people get better,” he says. “A lot of days…are really hard. But I love working here.”
He walks out MCH’s doors beneath the snow-covered mountains. Uncertainty hangs heavy in the air over all rural hospitals. But Dr. Lopez does what he always does: rests, takes care of himself and his family, and comes back again next week.
Cassidy Randall writes on adventure, environment, and the West. Her latest book, the survival epic Thirty Below, won the Banff Mountain Grand Prize and the Banff Award in Mountain Literature. Her journalism has earned numerous awards and has appeared in Vanity Fair, Rolling Stone, National Geographic, New York Times, Men’s Journal, Politico, Outside, and Men’s Journal, among others. She’s also author of The Hard Parts, with Paralympian Oksana Masters. When she’s not hunched over her computer, she ski tours, mountain bikes, whitewater paddles, and does whatever else takes her outside.
