By Misty Williams

Pam Renshaw doesn't know how long she lay unconscious amid the flames. Twenty seconds? Thirty? Long enough, at least, for the fire to sear nearly half of her body before Renshaw's boyfriend found her pinned under the four-wheeler that had flipped into a pile of burning trash. Billy Chavis lifted Renshaw into his truck and floored it toward downtown Folkston.

But he wasn't headed to Charlton Memorial Hospital in Folkston. There is no Charlton Memorial. It had closed 45 days before Renshaw's accident.

"I didn't know where to go," Chavis recalled. His girlfriend lay on the seat in shock, burned so badly that Chavis didn't know whether she would live or die. "It was just a lost feeling. I thought I was losing her."

Seven other rural hospitals have closed since 2001, and dozens more are hemorrhaging money at an alarming rate _ ultimately threatening access to critical health care for nearly 1 in 10 Georgians.

Of Georgia's 61 remaining rural hospitals, nearly two-thirds lost money in the year for which they most recently reported results, an Atlanta Journal-Constitution investigation has found. Twenty-one suffered budget shortfalls _ many in the millions of dollars _ for at least five years in a row, according to an AJC analysis of the latest hospital financial data from the state. Another 17 ended four of the five years in the red.

Only seven made a profit each year.

Rural hospitals have long struggled financially. But threats to their survival have intensified in recent years _ falling patient volumes, aging populations, payment cuts by government programs and commercial insurers alike, large numbers of uninsured and new regulations created by the Affordable Care Act. Some run nursing homes, primary care clinics or other more profitable operations that help make up for some of the losses. Many don't.

The demographics and economics of many rural areas can no longer support hospitals, said Jimmy Lewis, CEO of HomeTown Health, a network of rural Georgia hospitals. People tend to be older, sicker and poorer than in urban regions.

"We're approaching Third World care in the state of Georgia," Lewis said. "The future has pain in it; there's just no way around it."

Georgia lawmakers, hospital executives and community leaders are scrambling for ways to stem the financial bloodletting. But the truth is that some hospitals are simply beyond saving.

People, inevitably, will die.


Buren Jones didn't have to die.

The 52-year-old suffered a heart attack about a month after his local hospital, Stewart-Webster Hospital, closed in March 2013.

Normally, an ambulance could have reached him in five to seven minutes, said Sybil Ammons, coroner in Stewart County and former director of nursing at the shuttered hospital. But the area's two ambulances were already driving patients to other hospitals 20-plus miles away. The family knew CPR, but it wasn't enough.

"Our ambulances are tied up consistently," Ammons said. "They could have saved him. I truly believe he would have had a chance."

Another man who was stabbed and died would have had a much better chance at survival, she said. Yet another who suffered a stroke perhaps wouldn't have as severe permanent damage if he'd received help sooner, Ammons said.

"It's really scary," she said. "What's going to happen to us?"

The farther ambulances are forced to travel to get to an emergency department, the more precious minutes are lost from the critical "golden hour" immediately after a heart attack or stroke.

The poor and elderly often suffer the most when hospitals die. Most don't have cars or the money to pay someone else what Ammons calls a "ridiculous" price to transport them. Others can't take time off from work to travel to another town for care. Their diabetes and other chronic conditions go untreated, inevitably becoming more severe and costly.

Surrounding hospitals are forced to shoulder a bigger burden of uninsured patients _ threatening their own financial stability. Even patients who do have insurance face higher deductibles and often can't pay their bills. New rules created by the Affordable Care Act penalize hospitals, rural and urban alike, for too many avoidable "readmissions": patients who must go back into the hospital within 30 days of discharge.

The health law is also reducing support to hospitals under the assumption that they will have more paying patients under Medicaid expansion. But Georgia has rejected expansion.

Some counties can afford to subsidize their hospitals to keep them open; many cannot.

"We don't have $500 million in a pot that we can pull out," said state Sen. David Lucas, D-Macon. "We just can't build hospitals; there's just no way. These folks are being left without health care."

Nationwide, three rural hospitals closed in 2010, according to a report from the University of North Carolina. Fourteen closed last year. Many closures have been in the South in recent years, including Texas with eight, Alabama with five and Tennessee with three, the study shows.

(c)2015 The Atlanta Journal-Constitution