Serving Barnwell County and it's neighbors since 1852
Kathy Corley remembers the day that Barnwell’s Southern Palmetto Hospital closed. It was an ordinary weekday in January 2016, and she and her colleagues were given 48 hours’ notice that the hospital would stop serving patients. Shock quickly consumed Corley and the hospital staff. After 26 years of working alongside local health care workers — with yearly Christmas parties and the occasional cookout in between — the hospital had grown to be the center of Corley’s life.
“It was like losing your best friend,” said Corley, a nurse of 50 years who settled in rural Barnwell in 1990 after working in large urban hospitals. Her husband, Ed Corley, was also a volunteer at the hospital. “You’ve been there for all those years, you’ve taken care of patients, you’ve made lifelong friendships with the employees that are there. Some of those people I’ll never see again.”
Kathy Corley, a retired nurse who moved to Barnwell in 1990, worked at Barnwell's Southern Palmetto Hospital until it closed in 2016.
Corley and the 90 full-time and 28 part-time health care workers who lost their jobs during the closure were displaced across the regional health care workforce. Corley went on to work at a medical practice in nearby Aiken, working through the pandemic before eventually retiring in 2022. Without a local hospital, EMS drive times spiked as the nearest hospitals were at least a 30-minute drive for first responders until the Barnwell-Bamberg Emergency Medical Center opened in 2019; even a one-minute increase in the length of EMS drives can increase a patient's risk of mortality, according to the Medical Journal of Surgery (Barnwell County’s struggle with EMS services has been previously reported by The People-Sentinel).
But the story of Southern Palmetto’s closure is a microcosm of a national issue. In recent years, as rural hospitals across the United States have closed or downsized, rural health care workers have carried the weight of an increasingly strained industry. The structure of the United States’ health care payment system, several health care policy experts told The People-Sentinel, has created a national situation in which the cost of delivering health care in rural communities eclipses payments.
Despite these adversities, community stakeholders and health care workers have begun filling in the cracks and, in some cases, expanding local health care access through deep local ties and relationships. The story of modern health care in Barnwell and Allendale counties is one of grief and loss, as well as love and resilience.
The closure of rural hospitals
The need for health care in rural America is increasing, and increasing fast.
Rural communities are older and face higher rates of gun violence and deaths of despair (a term used to describe deaths from suicide, alcohol and opioids), according to the American Journal of Preventive Medicine. Even before the pandemic, life expectancy for rural Americans was declining, while life expectancy for urban Americans was increasing. Rural Americans also face unique vulnerabilities to the public health effects of pollution, climate change and other environmental issues. In Barnwell and Allendale, the Savannah River Site’s (SRS) legacy of pollution has left many local workers with lifelong work-related ailments, as previously reported by The People-Sentinel and other regional news publications.
Yet, despite this need, small rural hospitals have been closing at a rapid pace since the beginning of the 21st century. Between 2005 and 2019, 150 rural hospitals across America closed, four of which were in South Carolina, according to a report by the Center for Healthcare Quality and Payment Reform (CHQPR). Even more alarming, the CHQPR has concluded that nine additional rural hospitals in South Carolina are at risk of closure, with six of them considered to be at immediate risk.
The closure of Barnwell's Southern Palmetto Hospital was part of a national trend of rural hospital closures as a result of the corporatization of health insurance.
When the Southern Palmetto Hospital closed its doors in 2016, CEO Michael Patterson stated that the facility had lost $2.5 million due to a “low patient census and uncompensated care.” In 2018, the hospital was sold to Baptist Gardens, a Long Beach, California based religious non-profit, and now sits empty, with the growing cracks in its parking lot becoming a garden for weeds.
Just four years prior, Bamberg County’s hospital closed in April 2012 after declaring bankruptcy and similarly citing millions of dollars in losses. Suddenly, 350 rural health care workers had lost their jobs. After multiple attempts to re-open the hospital failed, Bamberg County’s 15,683 residents faced the long EMS drive that their neighbors in Barnwell County would four years later.
A money problem
Although the population decline of rural America has contributed to the falling number of rural hospitals, payment models for health care have been the largest factor locally and nationally, the CHQPR report found. The financial structure of the American health care system relies on a complicated blend of public funding, for-profit insurers, and direct payments from patients. For hospitals, this means that income is derived from a variety of payers such as Medicaid, Medicare, Medicare Advantage (a privatized version of Medicare), payments from for-profit insurance companies, and medical debt.
With each different payment source comes a different challenge for both rural patients and rural hospital administrators trying to collect payments on services. Medical debt — a multi-billion dollar industry run by debt collectors and private equity firms — is highest among patients in the southeast, according to the Consumer Financial Protection Bureau. Publicly funded programs like Medicare and Medicaid typically reimburse hospitals for services close to the full cost, however, the for-profit payers who insure the majority of rural patients frequently fight or delay the reimbursement claims by rural hospitals.
"It's getting tougher and tougher, and it's not getting easier," Lari Gooding, CEO of the Allendale County Hospital.
“Everything is micromanaged, not by government, but by private payers,” said Lari Gooding, chief executive officer of the Allendale County Hospital. Having worked in local health care for over 20 years, Gooding remembers when he was able to get paid for nearly every hospital visit. “It’s tougher and tougher, and it’s not getting easier.”
Lari Gooding, chief executive officer of the Allendale County Hospital, said that as a rural hospital administrator, his team has to frequently fight with payers.
On average, the CHQPR’s research found, for-profit insurers are responsible for 50 percent of the losses taken by rural hospitals at risk of closing. “The private insurance plans are the ones that are causing the problem,” said Harold Miller, president of the CHQPR. “If that health plan doesn’t pay enough to support the care, then the hospital is losing a lot of money on a significant proportion of its patients and it has no way to make it up.”
This creates a lose-lose scenario for rural hospitals, which provide unconditional care to their communities but receive conditional payment for their services; the more patients they receive, the larger their losses.
“The hospital is putting itself out of business under the current system,” Miller said. “An analogy for this is fire departments. We don’t pay fire departments by the fire. We pay fire departments to be there.”
Regardless of how hospital directors like Gooding set their rates, private health insurance payers will only pay a fixed amount for a procedure. Since small rural hospitals have less administrative staffing and resources than larger urban hospitals, fighting with private insurers for reimbursement is more of a challenge, Miller pointed out.
“We don’t have a lot of negotiating power with payers,” Gooding said. “We’re forced to accept what we can get, and that’s tough. … We take care of patients whether they can pay us or not and that’s where we really struggle.”
The situation is made even more difficult for Gooding and CEOs of other small hospitals in South Carolina by the state’s refusal to expand Medicaid, a decision made in 2012 by then-governor Nikki Haley. In 2019, the state’s former Medicaid program head said “several hundred” elderly and poor people likely died as a result of the decision. The expansion of Medicaid using federal dollars, Gooding said, quickly “became political,” at a detriment to hospitals and their patients.
The majority of losses that rural hospitals take are from private payers, who spend tens of millions on campaign contributions. Between 1998 and 2023, the health care industry spent over $5.8 billion on lobbying, reaching record levels during the 2022 election cycle. According to campaign contribution disclosures, the top three campaign contributors in the insurance industry during the 2024 election cycle have been health insurance companies, with tens of millions already spent.
The majority of losses that rural hospitals take are from private payers, which have spent tens of millions on campaign contributions, including to Allendale, Barnwell and Bamberg counties' congressmen.
Campaign contribution disclosures show that Allendale, Barnwell and Bamberg counties' congressmen — representatives Jim Clyburn and Joe Wilson, and senators Tim Scott and Lindsey Graham — have each taken thousands from the private health insurance companies. Scott and Graham did not respond to requests for comment.
Throughout his political career, Wilson has taken $20,500 from United Healthcare, $77,500 from Blue Cross/Blue Shield South Carolina and $5,000 from Humana, private health insurers. “Supporting programs focused on addressing the health care needs of those living in the rural areas of South Carolina is critical,” Wilson said in a statement. “Campaign donations have not and do not impact my policy decisions.”
Clyburn has received $40,500 from UnitedHealthCare, $14,500 from Blue Cross/Blue Shield South Carolina, $13,000 from Humana and $7,500 from Cigna, also a private insurance company.
“I recognize the serious challenges facing rural health care providers and am committed to finding solutions that provide every community with access to quality care,” Clyburn said in a statement. “Throughout my career, I’ve worked tirelessly to support rural hospitals and community health centers across the lowcountry.” Clyburn noted that he was the only member of the South Carolina House delegation to support the American Rescue Plan Act of 2021, which provided $6.2 million in Emergency Rural Health Care Grants through the United States Department of Agriculture to his district, which includes Allendale County. Clyburn did not address the money he takes from private insurers responsible for the crisis in his statement.
The rural health care workforce
The decline of rural hospitals in the United States has occurred concurrent to a growing shortage of nurses and health care workers, particularly in South Carolina, which has one of the lowest patient-to-nurse ratios in the country.
In March 2020, as the COVID-19 pandemic began straining health care systems around the world, Congress passed the Provider Relief Fund, a $135 billion attempt to backstop health care providers by preventing uncompensated losses. This allowed local providers like Low Country Health Care System (LCHCS) to hire additional staff, according to Jennifer Rahn, M.D., chief medical officer of LCHCS. But in 2023, as Congress allowed these programs to expire, an additional burden was placed back onto the rural health care system.
“Covid burned us out and changed the way we do a lot of things,” said Dr. Ashley Barnes, the chief executive officer of LCHCS. “That little bit of funding to help us get through covid is gone and now our expenses are a lot higher.”
Larger, urban hospitals have dedicated administrative teams fighting with private insurance companies to collect payments for treatments, Miller said. But at rural hospitals, a lack of staffing makes the fight to collect payment an uphill battle. Although nurses and physicians do not typically deal with insurers, some will call insurers on the phone to argue for their patients over denied coverage.
"I'm gonna fight for my patients," said Jennifer Rahn, chief medical officer of Low County Health Care System.
“If they say no, we’re not gonna go along with that,” Rahn said, noting that her team cares for the patient’s well-being both physically and financially. “I’m gonna fight for my patients.”
Having to fight with insurers in addition to providing care, Corley said, was one of the additional stressors of being a nurse, a profession that 100,000 people have left since the pandemic, according to the National Council of State Boards of Nursing (NCSBN).
“You’d think that insurance would pay for this stuff but now it doesn’t do that,” Corley said. “It infuriates me to think that some office worker in an insurance company now tells a doctor that he can’t have treatment done on his patient.”
For many health care workers, the stress of the COVID-19 pandemic was their final straw, according to Maryann Alexander, the chief officer of nursing regulation at the NCSBN.
“Covid was no doubt a major stressor on the workforce,” said Alexander. “Burnout issues increased tremendously. That burnout is not ending.”
Alexander said the story of nurses choosing to retire as a result of pandemic-related burnout was a common workforce phenomenon.
“It just got too much,” Corley said as one of the reasons she decided to retire. “We never got to sit down all day. … My husband would have to help me get out of the car after work because I was so stiff. Half of the time we didn’t get lunch because we were working.”
"There were nights when we walked out and everybody was in tears," said Becky Rowell, the director of nursing at the Allendale County Hospital.
Among rural nurses that remain in the workforce, rates of trauma and post-traumatic stress disorders are higher, surveys by the National Institutes of Health show.
“There were nights when we walked out and everybody was in tears,” said Becky Rowell, the director of nursing at the Allendale County Hospital, who recalled working 18-hour shifts during the pandemic. “We had patients that were dying here and their families could not be with them. It was quite traumatic for the nursing staff. We hope to never, ever see anything like that again.”
Becky Rowell, the Director of Nursing at the Allendale County Hospital, said the pandemic took a toll on many nurses in the hospital, which saw three staff members die of COVID-19.
Out of a small staff of 17, the Allendale County Hospital has multiple openings for Certified Nursing Assistants (CNA) and Registered Nurses (RN). Many of the staff at the Allendale County Hospital, Gooding said, take on multiple roles.
In addition to confronting a nursing shortage, turnover and a lack of overall workforce stability has impacted Allendale County Hospital. “What I would like to have is a good quality physician that’s not going to be here for two or three years and leave,” said Gooding. “Those are things that really create frustration for residents in the community: Turnover for physicians.”
"As a rural hospital, we're competing with larger systems," said Lari Gooding, chief executive officer of the Allendale County Hospital.
Competing with larger hospital system salaries complicates hiring new physicians, Gooding added. “If I don’t pay at least close to what they’re paying, then I’m gonna lose my nursing staff or I’m not going to be able to recruit new nursing staff. As a small rural hospital, we’re competing with larger systems.”
Longer-serving physicians, Gooding and Barnes told The People-Sentinel, help to deepen trust with the community and hold a wealth of knowledge specific to their patients.
“A lot of people in our rural communities, especially people of color, have a different level of trust for our health care professionals,” said Teshieka Curtis-Pugh, executive director of the South Carolina Nurses Association. “We’ve lost people who are the fabric of those communities.”
During the peak of the pandemic, multiple staff members at the Allendale County Hospital died from COVID-19, including a beloved worker who got COVID-19 from a patient.
“Everybody just loved her,” said April Long, a nurse at the Allendale County Hospital. “You would hear her singing the gospel to the patients that were dying of Covid. Any room she went in she spread joy. It impacted all of us around here, because she was the kind that would keep you level and grounded. But out of that you form a bond, and it’s a bond that cannot be broken.”
Creating solutions
Despite working within a system that is increasingly abandoning rural health care and its workforce, Barnwell and Allendale’s health care systems have recently begun expanding.
At the Allendale County Hospital, which the National Rural Health Association ranked as one of the top 20 rural hospitals in America, Gooding has been focused on diversifying revenue streams as a path to financial sustainability. After the only Walgreens in Allendale closed in early 2023, Gooding renovated a space in the hospital and opened what is now the only retail pharmacy in the county.
“It’s unusual for the hospital to be a retail pharmacy in general, but we are the only retail pharmacy in Allendale right now,” Gooding said. On August 10, Gooding also announced the opening of Allendale County Hospital Advanced Wound Care, a specialized outpatient wound treatment center. “Our dedicated clinical staff understands the totality of the patient from a perspective of wound healing. The goal is to treat not only the wound, but the underlying cause of the wound.”
The institutionalization of telehealth during the pandemic has also created new opportunities for rural providers. “Some of the ways the pandemic changed the way we do things was good, we do a lot more telehealth now,” Barnes said. The expansion of rural telehealth has allowed rural health care providers to learn new ways to provide the same care, Rahn said.
In 2023, South Carolina’s legislature began addressing the nursing shortage. The state strengthened the South Carolina Office for Healthcare Workforce (SCOHW), budgeting $500,000 for forming a workforce unit dedicated to identifying trends and nuances in health care workforce data. As expected, the SCOHW has found that nurses migrated from the state’s rural areas to its urban areas.
“People like to think in terms of shortage or surplus, but the issue is really more nuanced,” said Katie Gaul, the director of the SCOHW. “Our group here likes to think more in terms of maldistribution. There’s definitely a disparity between rural and urban in terms of the number of providers and other health professionals we have.”
Like many centers for rural healthcare, the Allendale County Hospital has experienced high turnover in its workforce, which competes with larger hospitals that can afford to pay higher wages.
But the SCOHW uncovered another issue: South Carolina also has an accompanying shortage of health care educators in nursing schools, creating classroom challenges for incoming nurses. During the 2022-23 legislative session, the state allocated $10 million toward nursing educators as well as another $10 million for tuition reimbursement for nursing students.
“It’s harder and harder to find nursing educators,” said April Wolfe, a clinical instructor in the Department of Nursing at the University of South Carolina (USC) Salkehatchie, whose campuses are in Walterboro and Allendale. “Nurse educators don’t get paid much. The numbers are not where we want them to be.”
Wolfe has been one of the leaders of USC Salkehatchie’s Rural Nursing Initiative, which partners resources across the USC system to offer four-year nursing bachelor’s degrees programs. The Rural Nursing Initiative also has a simulation lab for prospective nurses to gain on-the-job experience. Wolfe and others in nursing education are hoping to increase “home grown nurses”; nurses who work in the communities where they were raised.
The state and federal government have used taxpayer dollars to backstop some aspects of rural health care; in 2019, the Bamberg-Barnwell Emergency Center was opened with a $3.6 million Transformation Fund Grant from the state of South Carolina.
Yet, Miller notes that larger, upstream changes must be made to support rural health care and hospitals.
“The challenge in rural communities is that it costs more to deliver care,” Miller said. “Most of the food that people are eating in urban areas is coming from rural areas and if you don't have health care in rural areas to support the people who work on farms and ranches, you don’t have food.”
The growing lack of appreciation of rural communities was a concern for Dr. Dean Koukos, a local physician who died in February. For 20 years, Koukos would make a four-hour round trip each day from Bluffton, South Carolina to work at LCHCS in Barnwell and saw thousands of patients in the community.
Dale Koukus (left) sits with a former patient of her late husband, Dr. Dean Koukus, a physician who served thousands of patients in the Barnwell region.
Dale Koukos, Dr. Koukos’ widow, believes her husband’s local legacy highlighted a growing divide in American health care. The rise of specialization in medical fields, as opposed to community-based care, was one of Dr. Koukos' concerns. Prior to moving to South Carolina, Koukos worked in Pittsburgh, a Pennsylvania city known for its high number of medical colleges and institutions.
"He was giving care to people who appreciated it and respected him," said Dale Koukus, the widow of the late Dr. Dean Koukus, who served thousands of patients in Barnwell County.
“I can’t even tell you how much less money he made here,” said Dale Koukos, noting her late husband’s frustration with the corporatization of health care. “I would ask him ‘Why are you taking that position? You won’t make anything.’ It was because he likes these people. They’re salt of the earth, they work for a living. He was giving care to people who appreciated it and respected him.”
Every rural health care worker and provider interviewed by The People-Sentinel said that building trust between community health care providers and the rural communities they serve has been the path to local sustainability and resilience.
“One night we admitted a patient and she had cardiac arrest and her husband was sitting in the chair while I started CPR on her,” said Corley, the now-retired nurse. “We got her right back and she stills sees me today and says thank you. That’s what you remember; coming into work and it feeling like home.”
Elijah de Castro is a Report for America corps member who writes about rural communities like Allendale and Barnwell counties for The People-Sentinel. Your donation to match our RFA grant helps keep Elijah writing stories like this one; please consider making a tax-deductible gift of any amount today.
