SOUTH RENOVO, Pa. — Up Route 120 in north-central Pennsylvania, in an old logging town amid a seemingly endless swath of state forests pocked with hunting camps and one-lane bridges, sits one of the most isolated hospitals in the state.
Bucktail Medical Center, a one-story building on the outskirts of town, doubles as the local nursing home. It has two emergency-room bays, 21 acute-care beds, one physician on hand at any given time, and an ever-precarious bottom line. At a larger hospital, the nursing director's list of duties would employ five people. Officials here are still saving up to buy their first CT scanner.
"If changes are made to the way Medicaid is funded in the states — if critical-access hospitals are now back to serving higher numbers of uninsured patients, if they have to go back to providing uncompensated care — that is a death knell to their bottom line," said Lisa Davis, the director of the state Office of Rural Health.
In deeply red Clinton County, support for President Trump is unwavering. But in this community of 1,200 people on the Susquehanna River, patience with Congress is running thin. With 100 employees, Bucktail is the largest employer in the western end of the county and functions equally as a community center. It's where snakebites are treated, overdoses reversed, heart attacks, and strokes stabilized.
"There's nothing more important than the hospital," South Renovo Mayor Bob Cozzi said last week. "Nothing."
Bucktail is one of 15 hospitals in the state whose size and location designate them "critical-access hospitals." The next-closest hospital, in Lock Haven, is a 40-minute drive down winding Allegheny Mountain roads.
Bucktail had cycled through four CEOs in one year and defaulted on a bank loan by the time Tim Reeves took the job there in 2014, and declared bankruptcy shortly after. State officials say he's worked diligently to bring the hospital back from the brink, which is now close to breaking even.
"His leadership has been pretty remarkable," said Larry Baronner, the rural health systems manager at the state's Office of Rural Health.
But finances are still precarious. Last year, with Medicaid reimbursement funds frozen by the state budget impasse, the hospital nearly closed.
"With the remoteness of the community, any service we start to cut back has a larger effect on the population here," Reeves said in his office Tuesday, as the shift's doctor tended to the single patient in the emergency room and nursing-home residents wheeled through the hallways. "If we go to 12-hour days instead of 24, there are people who are either going to have a worse outcome, or they're not going to make that trip down the road [to the next-closest hospital]."
The Republican proposals to repeal or replace the Affordable Care Act have at times seemed to change by the hour. Late last week, Senate Majority Leader Mitch McConnell (R., Ky.) said he hoped to bring the latest plan to a vote this week, but it was unclear if it had support to pass. One controversial provision would roll back the expansion of Medicaid under Obamacare — a step that helped hundreds of thousands of Pennsylvanians get health-care coverage.
Sen. Bob Casey (D., Pa.), one of the critics of the GOP bills, said facilities like Bucktail would be "crushed" by the proposed changes.
"People who use critical-access hospitals don't have big-time lobbyists to make their case, but they are our neighbors, too, and their well-being should matter," Casey said in an email. "Would any of the Senators and Representatives voting for this bill endanger the only hospital in the community where their family lived?"
His Republican counterpart in the state, Sen. Pat Toomey, has been among the most vocal advocates for the changes. Toomey insists the plans, which he helped draft, would not cut Medicaid but just slow its growth.
"These are cuts in the rate of growth," he said in an appearance on Morning Joe last Monday. "The rural hospitals are going to be able to manage this."
Clinton County's poverty rate is 16.4 percent, above the state average, 13.5 percent. In Renovo, most residents drive out of town for work, to jobs in the gas industry, at the local prison, or a nearby bottled-water company.
About 90 minutes north in Tioga County is Soldiers & Sailors Memorial Hospital. The Wellsboro facility, part of the larger University of Pittsburgh medical system, downsized last year to become a critical-access hospital.
The resulting boost in federal reimbursement dollars — Medicare spending is reimbursed at 101 percent for critical-access hospitals — has given the hospital more financial flexibility, officials there say.
Soldiers & Sailors' facilities are still a far cry from Bucktail — there's an oncology ward, an intensive-care unit, operating theaters, and a pulmonary clinic. But other specialists are still a longer drive away.
The Medicaid rolls in Tioga County swelled more than anywhere else in the state after Gov. Wolf accepted the expanded Medicaid funding in 2015. Doctors at Soldiers & Sailors say they now see people whose chronic conditions went untreated while they were uninsured.
In the cancer ward, said unit supervisor Sabrina Scharborough, some young patients without insurance will still show up worried less about their illness than about the medical bills they might leave behind.
County Commissioner Erick Coolidge, who sat on the local health system's board for years, said he's worried about cuts, but sympathetic to small business owners' concerns about paying for health-care, too.
"Toomey is saying [the Affordable Care Act] is unsustainable," said Coolidge, a fellow Republican. "Then let's start looking at what will make it sustainable. To the everyday citizen, they're expecting us to manage money and provide services in as uninterrupted a manner as possible."
For many patients in Clinton County, Bucktail serves as a stopping-over point: the emergency room where they're stabilized before they're taken by ambulance or airlift to better-equipped hospitals.
Cozzi, whose house on the Susquehanna is a 10-minute walk from the hospital, said doctors there brought him back to life twice after heart attacks, and treated him for anaphylactic shock caused by an adverse reaction to a medication.
Across the river, Frank Campbell, a retired Air Force veteran, recalled the morning he and his wife found their daughter, pregnant with her first child, writhing in pain on the bathroom floor. She had gone into labor prematurely, and gave birth a few minutes after arriving at Bucktail. Mother and child were stabilized, packed into an ambulance, and whisked to Lock Haven.
"Without that hospital, there'd be a lot of people who wouldn't be here. At least one of my grandchildren would not be alive," Campbell said. "And there are low-income people here, that without that hospital, there would be no place to go."
Campbell and his wife, Patty, who said she worked at Bucktail for 20 years, voted for Hillary Clinton. Most of their neighbors went for Trump.
"There's a lot of people who wanted things to be stirred up," Campbell said.
Some voted for Trump because of his campaign rhetoric on health care: Yes, he'd promised to repeal the Affordable Care Act. But he also said the replacement plan would ensure "insurance for everybody."
"I just felt he would be more fair and do a better job with health care — make it affordable for families so that everybody would be covered," said Charlene Clarey, 54, of South Renovo.
Born and raised in the community, Clarey has insurance through her husband, a welder. Her sister, she said, who has diabetes, had only just been approved for Medicaid; she had been paying for insulin out-of-pocket.
Clarey said she had been "somewhat" following the health-care debate in Congress. "I know it would be too hard to do," she said, but she hoped Congress would offer coverage to all, with payments based on income, "so they can afford it."
She, like Cozzi, was waiting to see what Congress would do.
"They're working on it," Cozzi said. He noted McConnell last week ordered his colleagues to skip their August recess "to come up with something."
On Tuesday, Reeves, Bucktail's CEO, walked through the hospital's hallways, greeting every nursing-home resident by name, talking about his hopes for Bucktail — installing that CT scanner, maybe getting a visiting oncologist to stop by, holding more health-care education classes for the community.
And he is waiting to see what makes it through Congress.
"We're sitting right at that zero mark," Reeves said. "And we can only lose so much money for so long."