On a Friday afternoon in late March, some of the most powerful people in Wellington, Kansas, crowded into the office of physician Faustino Naldoza. The civic leaders, were trying to prevail upon state Sen. Larry Alley to side with them in a vote the following week. The state legislature would be deciding on whether to overturn a veto by Gov. Sam Brownback of an expansion of the state health care program called KanCare — otherwise known, unfortunately for its prospects, as Medicaid.

Kansas had long rejected the expansion of Medicaid authorized by the Affordable Care Act until, that is, President Barack Obama left office, and the legislature voted to accept the federal money. The expansion was a lifeline to towns like Wellington. Across Kansas and throughout much of the rural U.S., small hospitals have been closing. In 2017, Wellington’s Sumner Regional Medical Center joined a growing list of more than 600 rural hospitals that, according to 2016 report by health analytics firm iVantage, are at risk of shuttering, potentially leveling blows to local economies and leaving residents without nearby emergency services and accessible routine care.

Rick Schon at the Chamber of Commerce meeting that takes place each week with residents and local business owners to assess the health of business in town and local events. Wellington, KS. July 20, 2017.

Rick Schon at the Chamber of Commerce meeting that takes place each week with residents and local business owners to assess the health of business in town and local events in Wellington, Kan., July 20, 2017.

Photo: Alex Thompson

Clifford Bickel sits in front of his house. He rarely travels anywhere because he requires an oxygen tank to breathe after smoking cigarettes for much of his life. Wellington, KS. July 17, 2017.

Clifford Bickel sits in front of his house. He rarely travels anywhere because he requires an oxygen tank to breathe after smoking cigarettes for much of his life. Wellington, Kan. July 17, 2017.

Photo: Alex Thompson

Expanding Medicaid, according to Sumner Regional officials, would bring in an extra $750,000 a year, enough to keep it afloat. Alley had nonetheless voted against the expansion, but it passed without him. Then Brownback vetoed the bill, and Alley’s vote became necessary to override the veto.

In Naldoza’s office, according to an account in Sumner Newscow, a local news site, and interviews by The Intercept, town leaders brought every argument they had to bear on Alley.

Wellington’s mayor Shelley Hansel recalled an injury to her young son, wondering if he would have even survived if the facility hadn’t been so close by. J.C. Long, president of the town’s Bank of Commerce and a former firebrand Republican lawmaker, told Alley that “good policy should trump good politics.” From his perspective as a banker, a struggling hospital was better than no hospital —and if the hospital closed, the community would suffer through job losses (Sumner employs 130 people, according to Stacy Davis, executive director of economic development for Sumner County).

Earlier in the day, officials from GKN Aerospace Precision Machining, one of the town’s leading employers, explained that their workplace insurance premiums would jump, because insurers don’t look kindly on factories with no emergency room anywhere nearby. What’s more, recruitment is difficult in towns without hospitals, they said, so without a hospital in Wellington, the company would consider moving elsewhere.

That Monday, the House fell three votes short of the number needed to override, so the Senate never even needed to vote.

Seth pushes his son, Owen, in the backyard. Seth takes Owen and his younger brother into Wichita to receive pediatric care. Many in Wellington attribute Sumner Regional Medical Center's financial trouble to the fact that many of the town's residents choose to receive medical care elsewhere. Wellington, KS. July 16, 2017.

Seth Henton pushes his son, Owen, in the backyard. Henton takes his children into Wichita to receive pediatric care. Many residents in Wellington attribute Sumner Regional Medical Center’s financial trouble to the fact that many of the town’s residents choose to receive medical care elsewhere. Wellington, Kan., July 16, 2017.

Photo: Alex Thompson

Jason takes a break from trimming bushes on his property. When I asked him about the problems with the local hospital, he simply replied "we're keeping it alive." There is currently a half-cent sales tax in the city of Wellington whose funds are used to support the city-owned hospital and keep it open. Wellington, KS. July 16, 2017.

Jason takes a break from trimming bushes on his property in Wellington, Kan., on July 16. When asked about the problems with the local hospital, he simply replied, “We’re keeping it alive.”

Photo: Alex Thompson

The looming closure of Sumner Regional Medical Center stands as a potential disaster for many Sumner County residents.

Tagging clothes for her volunteer post at the Presbyterian Church thrift shop on a summer afternoon, Betty Farley expressed her fear that the closure could have a lasting impact on the community. But for the nearby hospital, the mother would not have been able to deal with her daughter’s treatment that has required both emergent and routine care over the last 15 years. The nearest hospital would now be 30 minutes away. For residents caught in a medical emergency, this could mean a costly ride in an ambulance or worse, not receiving that care in time.

The reflection from a thrift shop in downtown. Wellington, KS. July 17, 2017.
Betty Farley tags new items at the Presbyterian Church thrift shop in downtown. Like many, she fears that losing the hospital could hurt the town.

Left: The reflection from a thrift shop in downtown. Wellington, Kan. July 17, 2017. Right: Betty Farley tags new items at the Presbyterian Church thrift shop in downtown Wellington, Kan., on July 17, 2017.Photos: Alex Thompson

To understand the magnitude of a local hospital closure, you only need turn to nearby Independence, Kansas, which lost its hospital two years ago.

When her son’s finger was severed in a home accident, Rhonda Graven, a resident of Independence and at the time uninsured, was forced to make a drastic decision. She had her son Justin airlifted to Wichita but, when he arrived, doctors there refused to operate on him without a signature from his parents, who were a 90-minute drive away (they could not accompany Justin in the helicopter). The effort proved fruitless; Graven attributes the lapse in time from the accident to surgery as the reason why doctors could not reattach the finger.

“It’s a traumatic thing,” Graven said. “When your son wakes up and he’s 12 years old and you have to tell him they couldn’t attach it, it’s devastating.”

Rhonda Graven, owner of the Affordable Furniture Depot in Downtown Independence, received healthcare for the first time when the Affordable Care Act was passed in 2010. Before then, her family had no insurance and when her son nearly cut off his finger and was forced to be air lifted to the hospital in Coffeyville, they were stuck with a bill that exceeded $40,000. The bill was forgiven after she applied for a financial hardship waiver. She worries if the Affordable Care Act is repealed she will lose her health insurance. Independence, KS. July 18, 2017.

Rhonda Graven, owner of the Affordable Furniture Depot in downtown Independence, Kan., photographed on July 18, received health care for the first time when the Affordable Care Act was passed in 2010, but worries that if the ACA is repealed, she will lose her health insurance.

Photo: Alex Thompson

Then came the bills. Graven, who owns a furniture depot in Independence, is still dealing with the fallout more than a decade later. Without insurance, her son’s procedure was billed at nearly $40,000 — more than their combined annual income. After filing a hardship waiver that covered $26,000 of the total, the Gravens paid off the balance on their credit cards. But even those payments were too much to keep up with, and Rhonda Graven’s credit rating has not since recovered.

Wheelchairs in the lobby of Sumner Regional Medical Center. For the past few years, this hospital has struggled to remain open. The city has instilled  a half-cent sales tax whose proceeds go directly to the hospital to help it stay open. Wellington, KS. July 20, 2017.
Vernon outside of his apartment. Because he is on disability as a result of the stroke and two heart attacks he’s suffered, he receives Medicaid from the state which is the only way for him to receive any type of health insurance. His doctor was previously based in Independence but moved to Bartlesville, Oklahoma which is one hour south. Independence, KS. July 18, 2017.

Left: Wheelchairs in the lobby of Sumner Regional Medical Center in Wellington, Kan., on July 20, 2017. For the past few years, this hospital has struggled to remain open. The city has instilled a half-cent sales tax, with proceeds going directly to the hospital to help it stay open. Right: Vernon outside of his apartment in Independence, Kan., on July 18, 2017. Because he is on disability benefits — as a result of a stroke and two heart attacks — Vernon receives Medicaid from the state, his only path to being insured. His doctor was previously based in Independence but moved to Bartlesville, Oklah., which is one hour south.Photos: Alex Thompson

With more than a fifth of Independence residents living below the poverty level, paying for health insurance quickly falls off the list of priorities. Heath Welton — a cowboy, Army veteran, and physician’s assistant in nearby Coffeyville — knows this too well. He said it costs him $2,000 per year in tax penalties for leaving his family of four uninsured —but that’s cheaper than spending $7,200 a year on insurance

Welton has the luxury of being able to attend to some of his family’s medical needs himself, but many of his neighbors are not so lucky. When he is not working at the clinic, herding cattle, or working on the ranch, he makes house calls for uninsured members of the community, sometimes trading services for chickens and eggs.

Heath Welton and Mike Wilson watch as a neighbor bales hay. Because of how spread out each house is from the other, communities like Tyro which sits just outside of Independence, often come together and help each other as much as possible. Heath is a Physicians Assistant and makes frequent house calls to those nearby to offer medical services to a largely uninsured population. Tyro, KS. July 19, 2017.

Heath Welton and Mike Wilson watch as a neighbor bales hay in Tyro, Kan., on July 19. Communities like Tyro — which sits just outside of Independence — often come together and help each other as much as possible. Welton is a physician’s assistant and makes frequent house calls to those nearby to offer medical services to a largely uninsured population.

Photo: Alex Thompson

Longhorn Bulls in a field north of downtown Wellington. When Wellington was just beginning they created the Chisholm Trail which brought Longhorn Bulls through the city and helped build it's local economy. Wellington, KS. July 17, 2017.

Longhorn bulls in a field north of downtown Wellington. While the town was first building its economy, a group of men cut away part of the existing Chisholm Trail, diverting the cattle drivers to their town. This brought cattle through the city and was an important factor in the development of the town’s early economy.

Photo: Alex Thompson

Tim Hay, the Fire Chief for the city of Wellington, stands in the emergency response bay. If the hospital in Wellington closes, Chief Hay will be forced to hire more people for EMS, since the nearest hospital is in Wichita which would add more than 40 minutes to each emergency response. The annual cost of expanding emergency services would be $875,000, which would see the city raise taxes even more in order to support it. Wellington, KS. July 17, 2017.

Tim Hay, Wellington’s fire and EMS chief, stands in the emergency response bay on July 17. If the hospital in Wellington closes, Hay will need to hire more EMS staff, because the nearest hospital would be in Wichita — adding more than 40 minutes to each emergency response, he says.

Photo: Alex Thompson

In Wellington, the community’s emergency response teams know the financial burden of the hospital closure will go well beyond chickens and eggs, bracing for the impact of increased demand for emergency services.

Sumner County EMS already responds to more than 1,300 calls per year, according to Fire and EMS Chief Tim Hay, a number that is rising steadily year to year. If the local hospital closes, the total time for ambulance trips to Wichita would be two hours — an extended trip time that requires extended staffing. According to a fact sheet prepared by the EMS team laying out contingencies to deal with closing Sumner Regional, Hay estimates that hiring emergency responders, purchasing ambulances, and creating a larger station to accommodate staff would increase annual spending by close to $1 million.

The cost to Sumner County as a whole will be especially difficult to bear because the closure of the hospital could incur a $6 million hit to the retail economy, according to Davis, the economic development director.

Jeff Hill, owner of Frazer's clothing store in downtown Wellington. He's afraid that if the hospital closes it will impact his business because there will be fewer people with money to spend. Wellington, KS. July 20, 2017.
Clothes hang to dry on a tree. Wellington, KS. July 16, 2017.

Left: Jeff Hill, owner of Frazer's clothing store in downtown Wellington, Kan., is afraid that if the hospital closes it will impact his business, because there will be fewer people with money to spend. Right: Clothes hang to dry on a tree in Wellington.Photos: Alex Thompson

Wellington residents have consistently voted to tax themselves — 63.6 percent of voters approved a one-cent sales-tax increase in November 2014 — to keep the hospital open. The funds from the tax directly benefit the Sumner Regional Medical Center, but they have not proved to be enough.

For Wellington farmers, who, along with their food processing counterparts make up almost 50 percent of the local economy, skipping town is not an option. “We can’t just pick and up go,” said Bob White, whose family’s wheat farm dates back to 1902.  In a late-morning drive toward White’s farm this summer, speeding down gravel roads through the sea of Kansas wheat to his farm just outside of Wellington, he mused on the issue of universal access to health care. “Most people around here know how much it costs, but they don’t understand the value of it.”

The real problem for Wellington, however, is momentum. The impending closure of Sumner Regional coupled with consistent population decline — meaning even fewer tax-paying residents — could trigger further dislocations, causing further economic woes.

Steve Champagne feeds cats outside of Sumner Regional Medical Center. Steve believes the hospital will be fine as long as it's able to diversify it's services but believes the doctors want it to close so they can open their own clinics in town and make more money. Wellington, KS. July 17, 2017.

Steve Champagne feeds cats outside of Sumner Regional Medical Center in Wellington on July 17. He said he believes the hospital will be fine as long as it’s able to diversify its services.

Photo: Alex Thompson

Federal funding can help close the gap in financing for local hospitals that rural communities like Sumner County must contend with. That’s why local leaders in Wellington took such drastic action trying to convince Larry Alley to vote to override Brownback’s veto of expanding Medicaid; the Kansas Hospital Association estimates the state lost nearly $1.8 billion in federal funding due to the expansion effort’s failure. In turn, the debate about expanding Medicaid and local hospital closures is percolating into national politics.

In an April special election for Kansas’s 4th Congressional District, Democrat James Thompson came close to beating the Republican candidate in a district that the GOP — including President Donald Trump — routinely wins by 50 or more percentage points. In his bid to run again in 2018, Thompson’s strategy is to have liberal Wichita push him over the top, but he needs to perform decently in surrounding rural areas, like Sumner County. He sees a political opportunity in Republicans’ failure to expand Medicaid. In the April special election vote, which came just a week after the failure to override Brownback’s veto of Medicaid expansion, the likely death knell of Sumner Regional, Thompson exceeded expectations in Sumner County, cutting Trump’s 50-point margin in half.

“When I go out to the rural areas now, the things they’re talking about are how these policies are really starting to affect them. The failure to expand Medicaid is hurting rural hospitals in particular,” Thompson told The Intercept. “The people out there realize that. The hospital is the lifeblood of the community.”

Correction: Oct. 1, 2017, 2:56 p.m.
An earlier version of this story incorrectly stated that GKN officials were present at the meeting between Alley and town leaders. They had met with Alley earlier in the day.