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 1s list of duties would employ five people. Officials here are still saving up to buy their first CT scanner.

And as the GOP's health-care bill winds its way through Congress, the staff is watching with bated breath. Like many other rural hospitals known as "critical-access hospitals," it relies heavily on federal funding from Medicaid and Medicare reimbursements - for Bucktail, which has a $6 million operating budget, it's nearly 80 percent of its revenue. 

"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.

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. 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, as the shift's doctor tended to the single patient in the emergency room and nursing-home residents wheeled through the hallways.

Many in north-central Pennsylvania 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."

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.

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 system1s board for years, said he's worried about cuts, but sympathetic to small business owners' concerns about paying for health-care, too.

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. South Renovo mayor Bob 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. "There's nothing more important here than the hospital," he said. "Nothing." "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." That same day, Reeves, Bucktail's CEO, walked through the hospital's hallways, greeting every nursing-home resident by name. And waited to see what makes it through Congress. "We're sitting right at that zero mark," he said. "And we can only lose so much money for so long."

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