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TheAssociatedPress WARSAW, POLAND Polish surgeons say they have suc- cessfully performed a rare and extensive transplant of the throat area. Prof. Adam Maciejewski said Monday the 37-year-old patient suffered from ad- vanced cancer of the voice box, making it impossible for him to breathe, swal- low and speak. Other parts involved in the rare trans- plant included the wind- pipe, esophagus and thy- roid gland. The patient, identified only as Michal, appeared at the medical team's news conference at the Oncology Center in the southern town of Gliwice, and whispered thanks. The transplant, from a donor, took place on April 11. Maciejewski said recov- ery was satisfactory, and he added that two similar but less extensive transplants have been previously per- formed in the world. In 2013, his team did a life-saving transplant of al- most the entire face on an- other patient. INTERNATIONAL Polish doctors perform rare throat-area transplant By David A. Lieb The Associated Press OSCEOLA, MO. After 45 years of providing health care in rural Missouri, Sac- Osage Hospital is being sold piece by piece. Ceiling tiles are going for 25 cents, the room doors for an average of less than $4 each, the patient beds for $250 apiece. Soon, the rem- nants of the hospital that long symbolized the life- blood of Osceola, popula- tion 923, will be torn to the ground. Sac-Osage is one of a growing number of rural U.S. hospitals closing their doors, citing a complex combination of changing demographics, medical practices, management decisions and federal pol- icies that have put more fi- nancial pressure on facil- ities that sometimes aver- age only a few in-patients a day. "Money just kept drying up," said Chris Smiley, a for- mer operating-room nurse who was the last chief ex- ecutive of Sac-Osage and is now overseeing its liquida- tion. Standing near the door- way of a room stripped of its cabinets and sinks, Smi- ley stared down a hospital hallway where a man was carting off $1 boxes of un- wanted items — pencils, plastic X-ray covers, a fish bowl, even a fly swatter. "It's sad to walk around here," she said, shaking her head. A total of 50 hospitals in the rural U.S. have closed since 2010, and the pace has been accelerating, with more closures in the past two years than in the previ- ous 10 years combined, ac- cording to the National Ru- ral Health Association. That could be just the beginning of what some health care analysts fear will be a crisis. An additional 283 ru- ral hospitals in 39 states are vulnerable to shutting down, and 35 percent of rural hospitals are operat- ing at a loss, according to iVantage Health Analytics, a firm based in Portland, Maine, that works with hos- pitals. Most of the rural hospi- tal closures so far have oc- curred in the South and Midwest. Of those at risk, nearly 70 percent are in states that have declined to expand Medicaid under the federal Affordable Care Act, although some experts are hesitant to draw a cause- and-effect correlation. In some cases, the shut- tered hospitals have been replaced by clinics offering urgent care and other out- patient services. The site of the old Sac- Osage Hospital, which closed in September, could eventually become part of a walk-in health clinic. But other closures have simply left a void. "When a hospital closes, the physicians leave. A lot of the health care infrastruc- ture leaves. Sometimes the local businesses will leave ... the schools suffer," said George Pink, deputy direc- tor of the Rural Health Re- search and Policy Analysis Center at the University of North Carolina. "There's a whole multiplier effect that really can devastate some towns." Big city hospitals have been closing at about the same rate as rural ones during the past five years, but an abundance of alter- natives in most major met- ropolitan areas typically re- duces the effect on patients. When a rural hospital closes, people might have to travel dozens of miles to reach the nearest hospital, an inconvenience that can sometimes be a matter of life or death. When 18-month-old Edith Gonzalez choked on a grape in August 2013, her parents rushed to Shelby Regional Medical Center in their hometown of Cen- ter, Texas, unaware that the hospital had closed several weeks earlier. Their daugh- ter was dead by the time an ambulance brought her to the next nearest hospital, more than 45 minutes later. Kathy Hagler, whose family owns a local gro- cery store, helped Edith's relatives gather 1,500 pe- tition signatures pleading with state and local offi- cials to re-open the hospi- tal. But nothing has come of it. "I didn't want baby Edith to be forgotten," Ha- gler said, "because we had no hospital here, and that could have saved her life." In rural North Carolina last summer, 48-year-old Portia Gibbs died from car- diac arrest after waiting 90 minutes for a medical heli- copter to arrive. She could have been at a hospital in less than half that time, had not the Vidant Pungo Hos- pital in Belhaven closed just six days earlier. Her death prompted Bel- haven's mayor to walk 273 miles to the nation's capi- tal in an attempt to raise awareness about the plight of rural hospitals. Mayor Adam O'Neal plans to lead a similar march June 1 with support- ers from at least 41 states. The city now is trying to acquire the old hospital through eminent domain and is seeking $6 million in federal loans to re-open it. Since Gibbs' death, O'Neal said, several other people have died before they could make it to more distant hospitals, includ- ing a 16-year-old boy hurt in a farming accident in April. "We have people need- lessly dying," O'Neal said. Since Belhaven lost its hospital last July, rural hos- pitals also have shut down in other states, including Mississippi, Ohio, Tennes- see and Texas. Parkway Regional Hos- pital in Fulton, Kentucky, was pronounced closed at 11:59 p.m. on March 31 af- ter three decades in oper- ation. Interim chief executive Dana Lawrence said an- nual patient admissions had fallen by half since 2010, to an average of less than two a day. A steady decline in pop- ulation, a depressed local economy and changes in inpatient admission guide- lines were the prime fac- tors. Those same factors have played a role in numerous other hospitals closures. Rural areas tend to "have older, poorer, sicker popu- lations," said Michael Top- chik, senior vice president of iVantage. That means they often have a higher percentage of patients covered by Medi- care and Medicaid, govern- ment health care programs that pay a lower reimburse- ment rate than private-sec- tor insurers. Hospitals that rely heavily on those pro- grams have been partic- ularly hard hit by federal budget cuts and provisions in the 2010 federal health care law that reduced char- ity care reimbursements and linked a portion of hos- pitals' Medicare payments to quality standards and readmission rates. The effects of the fed- eral health care law were the prime factor leading East Texas Medical Center to close three of its 12 ru- ral hospitals last year, said Perry Henderson, the hos- pital system's senior vice president for affiliate oper- ations. "The small rural hospi- tals are the most brittle of the bunch," Henderson said. "When you began cutting on those reimbursements, it hits their margins and pretty quickly drives those hospitals to some pretty sig- nificant losses." The framers of the fed- eral health care law as- sumed the cuts would be offset as more patients be- came covered by private in- surance and Medicaid. But Texas, which has the na- tion's highest uninsured rate, is among 21 states mainly in the South and Great Plains that have de- clined to expand Medicaid eligibility. The trend also has reached into California, where the booming econ- omy along the coast con- trasts with Central Valley agricultural communities that have been devastated economically by years of drought. Many residents remain uninsured or have Medicaid. A hospital serving the farming community of Corcoran closed in 2013, leaving residents with a clinic but no emergency room or major medical ser- vice. Corcoran District Hos- pital buckled financially in part from treating resi- dents without adequate in- surance. In a second blow, a state prison within the city limits scaled back its contract with the hospi- tal, diminishing an impor- tant source of revenue, said Jerry Robertson, the mayor and a pharmacist. "If you have a heart at- tack, you have to travel 20 miles without dying," he said. At Sac-Osage, poor man- agement was among the reasons the rural Missouri hospital fell into financial ruin. Some of its doctors, for example, were never ap- proved to be paid by partic- ular insurance companies. And it lost what some staff estimate was $1.5 million to $2 million be- cause the clinic failed to send out thousands of bills to insurers and patients since 2012. One local doctor made a last-ditch effort to buy Sac- Osage for $150,000. But the hospital board rejected his proposal as too vague and too late, deciding instead to close the facility and use part of its continuing tax revenue to pay for an am- bulance service run by a hospital in a larger town 35 miles to the south. For state Rep. Warren Love, a local cattle rancher who tried to help save Osceola's hospital, its pass- ing now seems sort of inev- itable. "Everything has evolved to the big gets bigger and the littlest disappears," Love said, "and that's re- ally what's happened with these hospitals." Associated Press Writer Scott Smith in Fresno contributed to this report. HEALTH CARE Rural hospitals struggle to stay open, adapt to changes ASSOCIATEDPRESSPHOTOS Chris Smiley, the hospital's last chief executive, stands in the empty emergency room of Sac-Osage Hospital in Osceola, Mo.. A er 45years of providing health care in rural western Missouri, Sac-Osage Hospital is being sold piece by piece. Closed and out of service, the entrance to Sac-Osage Hospital stands empty in Osceola, Mo. Chris Smiley, the hospital's last chief executive, checks on how to remove a plaque from the wall of Sac-Osage Hospital in Osceola, Mo. RANDAL S. ELLOWAY DDS IMPLANT DENTISTRY 2426 SO. 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