METALINE FALLS – Joyce Evans remembers when Metaline Falls buzzed with activity. Three mines and a cement plant filled the small town’s apartment complexes with families and the school system with children. At one point, Evans recalls, Metaline Falls had more than 700 residents. Now the census puts that number around 250.
Metaline Falls, Metaline and Ione are the three most northern towns in Washington’s Pend Oreille County, last stops before the Canadian border station at Nelway. Highway 31 snakes along the Pend Oreille River and then crosses it to enter Metaline Falls, over a bridge more iconic than the falls themselves, which disappeared when the Boundary Dam was erected.
Health care access in Pend Oreille County depends on where one lives. While the county boasts a strong public hospital district to the south, medical services wane as you head north.
In Newport in the southern part of the county, residents can access primary, emergency, surgery and even some specialist care in town, due to the robust systems supported by the public hospital district. Drive north for an hour, however, and health care options are sparse. Metaline Falls, Metaline and Ione residents can see a health care provider on some days in a community clinic in Ione.
As mines close and populations decline, the story of small-town economies here also are reflected in their health care system. In northern Pend Oreille County, residents want a doctor back in their community – a difficult position to fill these days, as rural health clinics struggle to recruit professionals to practice in remote Washington towns.
A history of health
Mining was not the safest job, and doctors stayed busy throughout the 20th century in Metaline Falls. To meet the need for health care, community members began thinking of ways to build a hospital as early as the 1940s.
The Metaline Falls Community Hospital Association formed as a nonprofit and started raising money to build a hospital in 1944. A decade later, with little progress made, community members opted for a more formal solution: They asked voters to form a hospital district, Pend Oreille County Hospital District 2.
Public hospital districts in the state of can levy taxes on property up to 50 cents per $1,000 of assessed value, as well as an additional levy up to 25 cents per $1,000 of assessed property value. If the district needs more funds, it can conduct a special election to collect more revenue. This enables communities to raise funds to care for their own by funding hospitals, clinics and care homes.
Voters easily approved funding to build a hospital in Metaline Falls in 1956, with support from community members in Metaline Falls, Metaline and Ione, which are all included in the geographical boundaries of the district.
Construction began, and the new Mount Linton Hospital in Metaline Falls opened to much fanfare two years later.
Evans gave birth to her son in that hospital, after walking there to see if she was in labor.
Nancy Kiss was a registered nurse in the 21-bed hospital, and her mother was the administrator at the time. They were busy, she said, and the hospital thrived in those days. From delivering babies to treating injuries, the hospital took care of the community and employed many of its residents who weren’t in the mines.
But as in many mining and rural towns across the country, the good economic times in Metaline Falls did not last.
In 1983, Mount Linton celebrated its 25th anniversary. A profile of administrator Roberta Garrett in the local paper said the hospital had 19 beds and 32 employees at the time. The hospital district had passed a second levy in 1982, Garrett said in the story, and while she didn’t see the need for another levy in the future, she admitted that there were financial concerns on a monthly basis. In the 1980s, 64% of patients seen at the hospital were Medicare or Medicaid patients.
Just five years later, in 1988, things got drastically worse when the last remaining physician in the region, Dr. Byron Hanson, moved away.
Without a physician in the area to refer patients, the hospital faced closure, and the Ione clinic would be staffed by a nurse practitioner only.
Hanson owned the clinic, and he sold it and most of the equipment to the still-active Metaline Falls Community Hospital Association. Meanwhile, the hospital district needed money, fast, because without referrals from a doctor, the hospital would be cut off from federal funding. Hospital personnel were laid off, and the hospital district commissioners attempted to levy funds to keep the lights on, in the hope that they could court a doctor back to the area. Voters rejected the levy three separate times in 1988 and 1989.
“When the government got involved and had all to do with Medicaid and HMOs (health maintenance organizations) … that’s when the little rural hospitals went kaput,” Evans said.
“They didn’t pay enough,” she said. “You were only allowed to be in the hospital for so many days, and we couldn’t afford to keep doctors.”
The district sold the hospital building, which was converted to a motel for awhile. Now its light blue and brick exterior is overrun with plants and greenery. Evans envisions the building as a nursing home.
After the hospital closed, the Metaline Falls Community Hospital Association actively funded a physician search, which by 1992 proved successful. A physician and a physician’s assistant staffed the Ione clinic in the early ’90s, archives show. In 1994, NEW Health, a group of federally qualified health centers, took over care at Selkirk Community Health Center, the clinic in Ione, leasing the space from the Metaline Falls Community Hospital Association. That lease agreement is still in place today.
This summer, history repeated itself.
As the last mine closed, save for a skeleton crew, the physician in the Ione clinic also packed up and left.
Now the Ione clinic is open four days a week, with a physician’s assistant and a nurse practitioner. Desiree Sweeney, CEO of NEW Health, which has several clinics and dental offices throughout the Tri-County region of Ferry, Stevens and Pend Oreille counties, said recruiting physicians to work in their remote locations is one of their biggest challenges.
“So, rural is very different. Even within rural, there’s layers of rural: rural, remote, frontier,” Sweeney said.
NEW Health hub clinic in Colville, for example, is considered rural, even though Colville is a commercial center with a critical access hospital. Compare that to the satellite clinic in Ione, where cell service is spotty. Even in Colville, though, NEW Health has struggled for almost a year to find a physician.
Currently, NEW Health is looking for two doctors. Ideally, one of those physicians could be in the Ione clinic a few days a week, Sweeney said. Recruiting for positions in remote locations is challenging for myriad reasons. From broadband to a potentially isolating environment, finding a good fit is essential to keeping health care practitioners happy and comfortable in their community. Sweeney said hiring for their “mission” is vital.
“The communities are very different. The patients have a unique perspective, and the providers have to match that,” she said.
Rural medicine practitioners face incredibly slow days as well as high-stakes days. When Hanson left Ione in 1988, he cited burnout, isolation and boredom as reasons for his move to the west side of the state to practice.
“Many times I wish I had someone to talk to,” he told The Spokesman-Review at the time.
Metaline Falls residents are pleased with the Ione clinic, and the majority of residents receive primary care there. Metaline Falls, Metaline and Ione together have about 900 residents, but approximately 1,200 patients were served at the Ione clinic in 2018. This means patients from unincorporated parts of the county seek care at Selkirk Community Health Center. Seventy-five percent of residents in Pend Oreille County live in unincorporated communities.
Fran Maxwell, who relocated to Metaline Falls two years ago, said the care has been excellent at the clinic in Ione. Patients in the Metaline-Ione community, who tend to be older, visit the clinic about four times a year on average, Sweeney estimates.
NEW Health does not have specific insurance provider data for the Ione clinic, but in their 11 clinics, 55% of their patients have Medicaid or Medicare, and 16% of their patients are uninsured. As a federally qualified health center, all patients are seen at the clinics regardless of their insurance status.
In Pend Oreille County, 63% of residents are on Medicare or Medicaid. More than a quarter of the population is over 65 years old.
Sweeney said her organization watches the school district numbers when it comes to looking at patient populations. The Selkirk School District, which has students from the three northernmost towns, has 287 enrolled students, which has held steady this year, The Miner newspaper reported this fall. The district has gone to a four-day school week to try to attract more teachers, too.
“We’re not seeing a huge pediatric population, and that’s what’s going to feed your pediatric, middle age and geriatric population, so we see a very heavy geriatric population,” Sweeney said. “They really rely on our clinic for a higher level of acuity than most clinicians are even trained for whether they are a physician or not, so that brings in the problem of recruiting.”
If a patient needs to see a physician or go to a hospital, they can go in one of two directions: Colville, about 50 miles west and over the Selkirk mountains, or down the river about an hour to Newport, where an independent hospital district continues to build up its health care infrastructure to serve the county as well as its largest town.
‘We can’t afford to lose this service’
Tom Wilbur, the CEO of Newport Hospital and Health Services, doesn’t mince words. He understands his industry, acknowledging that while many good ideas to coordinate care are admirable, they don’t make money. That hasn’t stopped Newport Hospital and Health Services and the public hospital district that runs it from providing care, despite rising costs, because as he says, “It’s the right thing to do.”
Newport Hospital and Health Services has a primary care clinic, emergency room, 24-bed critical access hospital and two assisted living facilities located in downtown Newport, which is adjacent to the Idaho border.
Wilbur and his team started to integrate behavioral and primary care long before state mandates took effect to do so. Care coordinators, who work to ensure that a person’s physical, mental and substance-related health needs are met, are available to patients inside the primary care clinic in Newport. They also go out in the community to follow up with them. It’s a model that provides better care for patients, but it’s not lucrative.
“Some of the stuff we’ve done historically, no one does. (On) care coordination, we are way, way far ahead,” Wilbur said. “As we go around to local communities, we have five to six care coordinators that work on different populations, different chronic diseases. We think we’ve made a difference.”
In a smaller health care ecosystem, care coordination can work to improve patient outcomes, but Wilbur noted that hospitals are not reimbursed based on making patients better.
“This is the whole dilemma we face: When we start this, if I get my care coordinators in there to go out to your home, get you to a subspecialist, you stay out of my emergency department and hospital and you stay relatively healthy. What did I do?” he said. “I just cut my reimbursement is what I did. So my revenue stream out of the ordinary course is now gone, but my client is better.”
Newport Hospital and Health Services is run by the Pend Oreille County Public Hospital District 1. Wilbur reports to the district’s five commissioners and, when necessary, makes budgetary requests to keep the hospital running.
Newport Hospital and Health has 13 physicians and five nurse practitioners or physician assistants. Wilbur said it has not been too difficult to recruit staff, especially with Newport’s proximity to Spokane.
“There’s a lot of people that want to get out of the urban grind, so we’re pretty close,” he said. “So in that regard it’s a blessing. The bane is what services should you provide or do you need to provide when you’re 45 minutes to an hour (from) downtown?”
Not all hospital districts in the state run hospitals, and state law gives the taxing authorities broad leeway to run health care-related programs. Nationally, rural hospitals are in a tough spot, and while no Washington state critical access hospitals have been forced to close in recent years, it’s not easy.
Jacqueline Barton True, interim executive director of the Association of Washington Public Hospital Districts, said Medicaid expansion and the public hospital district model have kept hospital doors open statewide.
“They are really able to use that levy to keep their doors open and make up that margin, and that’s true of over a dozen hospitals in the state,” she said. “They are covering their losses on the backs of that local tax base.”
In Newport, a bond issue went to the taxpayers in the hospital district in 2015 seeking more funds to build a new advanced care assisted living facility, convert the district’s old skilled nursing home to a better building and create a more affordable payment model for residents. The ballot measure failed the first time. A citizen’s committee put it on the ballot again in April, and it passed.
County commissioner Mike Manus said the bond had bipartisan support, noting that there is a sense in Newport and in the county as a whole that they need to take care of the generation that helped build and establish the community.
“It means families will stay here,” Manus said. “We can’t afford to lose this service.”
Two years after the bond passed, the new advanced care assisted living facility sparkles like a new hotel just a few blocks away from the hospital. In August, residents were wheeled down and across the street, in a kind of parade, with some holding handmade signs as they moved.
When the last part of the facility, opens, River Mountain Village Advanced Care Assisted Living will have the capacity to house 72 residents. Currently, it houses 44 residents, including those in the memory care wing. There are 10 spots open.
The old skilled nursing facility resembled a hospital wing. Its faint pink walls show their 1968 construction well. Rooms typically housed two to four residents, with a few lucky single bedroom suites. Hallway bathrooms had curtains because the doors could not close with wheelchair or walkers inside. The hospital district has yet to decide what to do with the old building.
Each section of River Mountain Village Advanced Care Assisted Living has its own full kitchen, dining area and living room-like common space. There is a sitting room with a television and tables for playing cards or games; and meals are served here for residents of each “neighborhood.” The wide halls are carpeted and well-lit, with high ceilings, and each room has its own bathroom. Some have showers, too.
Jenny Cooper, activities director at the facility, said conflicts among residents and noise have both gone down significantly since the move.
Barton True with the hospital district association said the opportunity for local input is an advantage of hospital districts.
“It allows them to retain that local community autonomy,” she said. “They still have a local board, but it allows them to figure out the right size of health care for them.”
Wilbur said having a board with invested community members has been awesome.
“My job is to make sure we have a plan, and my job is to make sure they’re educated on what the environment is, what’s going on in the world (of health care),” he said.
Jenny Smith, marketing and foundation director at Newport Health, said construction was paid for through $12.2 million in funds, $2.2 million from the district’s coffers and the approval of the $10 million bond, but Newport Hospital and Health Services won’t necessarily be making money on the new facility.
“We can afford to run the services and afford care, but I’m not sure we’ll make a profit,” she said.
Newport Hospital is a critical access hospital, meaning its reimbursement rates are cost-based, but when about 70 percent of its patients are on Medicaid or Medicare, finances are challenging. But Smith said accepting Medicaid, with no cap, is crucial to the care they provide.
“We do accept Medicaid, and we don’t have a cap on it,” Smith said. “We’re not going to do that.”
In rural areas of the state, where hospice care is essentially nonexistent, advanced and long-term care assisted living facilities fill this role. Newport’s new facility is also filling a countywide need. There are only two assisted living facilities in the county, Commissioner Manus said, and both are in Newport.
Flying for care
A line of maple trees, ablaze with the orange and reds of fall, surround a grassy field in Metaline, near the border patrol station. It is here that Evans envisions an assisted living facility. She is thinking about the future as she imagines having access to that kind of care here in the town she has lived in since 1944.
“If we can’t have a hospital here, we need a nursing home and assisted living, and I think the old project area in Metaline is a perfect spot for an assisted living,” she said. “And the old hospital would be great for a nursing home. Look how many people it would employ.”
Options for assisted living in the northern region are primarily in Colville or Newport. Providence closed its 40-bed long-term care unit in Chewelah this summer, forcing some residents to move to Spokane and others to the new Newport facility.
Living in rural parts of Washington state comes with a gamble that some residents prefer to take and others do not. Despite only having a clinic in northeast Pend Oreille County, residents there do have access to Life Flight, which can land in a field in Metaline Falls or at the small airport in Ione. Life Flight operates from the area critical access hospitals, too.
For Gladys Bishop, a resident of River Mountain Village, the combination of a critical access hospital ER, Life Flight and cardiologists in Spokane saved her life this September.
She wasn’t at the assisted living facility but was with her grandson coloring when, as she tells it, she started “speaking in tongues.” She was rushed by ambulance to the Newport hospital, where they determined she was having a heart attack, not a stroke.
Life Flight flew her to Spokane, where cardiologists treated her heart and got her back up to Newport, stable in less than a week.
The various health care systems coming together to save her life is indicative of how rural health care sectors must coordinate, with emergency services, critical access hospitals (and hospital districts) and the proximity to a larger medical hub like Spokane.
Life Flight bills a person’s health insurance plan to help cover costs, but not all insurance companies fully cover a flight, leaving a person liable to a very large medical bill. Life Flight offers memberships to avoid these types of bills, for a household at the cost of $65 a year or $1,100 for a lifetime membership.
Bishop had a Life Flight membership, which she was grateful for.
“Look at me: If it hadn’t been for Life Flight, I wouldn’t be here,” she said.
Providing primary care to residents living in far rural areas of the state is challenging, and the physicians NEW Health is seeking must be comfortable with not only living with spotty cell service but also being able to take anything that walks through the door.
Residents and care providers alike in the northeast part of the state hope that with both the Washington State School of Medicine and the University of Washington’s WWAMI School of Medicine program based in Spokane, more physicians will be going rural soon.
Sweeney said that rural physicians, even if they are general practice doctors, need a vast skill set and are able to deliver babies, treat lacerations and perform tracheotomies. With no emergency departments or urgent care clinics, communities often treat their clinics as one-stop shops out of necessity.
“When we have these satellite locations, it just magnifies an aging population, high acuity (cases). We have lots of lacerations,” Sweeney said. “People aren’t trained for that anymore. Health care has really changed.”
She hopes that with the potential for new residencies in rural areas, students will be trained in actual rural health care. Sweeney said sometimes potential physician candidates ask about how much they will be simply “air traffic controlling” or just referring patients out in NEW Health clinics.
“The West Coast still has the latitude for primary care physicians to perform more than what they do on the East Coast,” Sweeney said. “But then if you take it to the next level and go rural, you never know what you’re going to get.”
This story has been updated to correct the name of the dam on the Pend Oreille River that stopped the falls.
Local journalism is essential.
Give directly to The Spokesman-Review's Northwest Passages community forums series -- which helps to offset the costs of several reporter and editor positions at the newspaper -- by using the easy options below. Gifts processed in this system are not tax deductible, but are predominately used to help meet the local financial requirements needed to receive national matching-grant funds.
Subscribe to the Coronavirus newsletter
Get the day’s latest Coronavirus news delivered to your inbox by subscribing to our newsletter.