Corporate hospital chains closed rural emergency departments before the overdose wave that would need them arrived. Three people died in Mountainair, New Mexico on Wednesday, and the first responders who arrived to help them came home sick. The town has fewer than a thousand people. The mayor closed town hall Thursday because of the emotional toll. The substance that killed three and sickened more than a dozen responders has not been identified. New Mexico State Police said they believe it is transmitted through contact, not airborne, and that there is no public threat. The University of New Mexico Hospital in Albuquerque assessed and decontaminated nearly two dozen patients. Three symptomatic responders were monitored Wednesday evening.
Read the Mountainair story in the Wisconsin State Journal online Tuesday night at the bench. Recognized every piece of it — the volunteer firefighters, the town of fewer than a thousand, the mayor closing town hall because the weight landed, the hospital that used to be there and isn’t. Adams County lost its last inpatient psychiatric beds in 2019 when the regional hospital converted to outpatient-only behavioral health services and then closed those a year later. Mountainair doesn’t have a hospital at all. The nearest emergency department is in Albuquerque, ninety minutes west.
Antonette Alguire, a volunteer firefighter in Mountainair, told reporters she helped perform CPR on a woman outside the home and watched EMTs and firefighters develop symptoms as they worked — coughing, vomiting, dizziness. Alguire said she did not go inside and did not experience symptoms herself. What she said next is the sentence that does the work: “It’s getting to that point where we just have to live in fear, even saving lives.”
That is what happens when you strip the infrastructure from a community and then hand the community a national crisis to manage with what is left. Mountainair is managing an overdose epidemic in a state with the fourth-highest drug overdose death rate in the country — 775 deaths in 2024 per the Centers for Disease Control and Prevention. New Mexico’s overdose toll has been among the highest nationwide for years. Mountainair Mayor Peter Nieto called addiction and substance abuse “a statewide and national problem” and said lasting change requires family support, accountability, education, and individuals willing to accept help. He is right about all of that. What he did not say, because mayors of towns with fewer than a thousand people do not get to say it in the news cycle, is that the infrastructure that would support families, deliver education, and provide treatment has been systematically removed from communities like his.
I wrote two weeks ago about rural hospital closures — one hundred and ninety-five since 2005 per the UNC Sheps Center, with seven hundred and sixty-eight rural hospitals now at immediate or near-term risk. I wrote that the labor-and-delivery ward goes first because Medicaid pays close to half of cost on births and because cutting Medicaid reimbursement collapses the L&D math before any other service line. The Medicaid cuts in the 2025 reconciliation bill are projected to drop ten million people from coverage by 2034, seven and a half million from Medicaid alone. The bill’s defenders pointed to a fifty-billion-dollar rural health fund that Kaiser’s analysis showed could not offset a trillion in cuts. What I did not write in that column, because the column was about maternity wards specifically, is what happens to the rest of the service lines when the hospital closes. Behavioral health goes. Inpatient psychiatric care goes. Substance-abuse treatment goes. The emergency department that used to stabilize an overdose patient and transfer them to inpatient treatment now stabilizes the patient and sends them home, or to a facility ninety minutes away, or to nothing.
The Sheps Center’s closure list does not break out by service line, but the March of Dimes and the Center for Healthcare Quality and Payment Reform both document the sequence: L&D first, then pediatrics, then the ICU, then the front door. The behavioral-health and substance-abuse services are often gone before the L&D ward closes, because those services run at even lower margins in rural settings than obstetrics does. Rural hospitals that are still open are often operating those service lines at a loss and cross-subsidizing them with higher-margin procedures. When the hospital closes, the cross-subsidy ends, and the region’s only detox facility or inpatient psychiatric unit goes with it.
Wendell Berry wrote in The Unsettling of America that the small operator does not lose because the small operator is less wanted. The small operator loses because the rules are written to make the small operator unable to clear the bar. The 2025 Medicaid provisions are this operation transposed from agriculture to medicine. Rural hospitals are not closing because rural counties have decided they would rather not have hospitals. They are closing because the reimbursement formula that keeps a Critical Access Hospital solvent has been narrowed by the people who write the formula. Rural communities are not losing behavioral-health services because rural communities have decided they would rather not treat addiction. They are losing those services because the services cannot operate at the margins the payment structure allows.
CDC data show that rural overdose death rates have been climbing for two decades and now exceed urban rates in many states. The reasons are structural: longer distances to treatment, fewer providers, less access to medication-assisted treatment, higher rates of uninsurance or underinsurance, and the closure of the hospitals that used to anchor the regional treatment networks. New Mexico fits the pattern. The state’s rural counties carry overdose rates well above the state average, and the state average is already fourth-highest nationally.
What Antonette Alguire said — “we just have to live in fear, even saving lives” — is the operational reality of asking volunteer firefighters in a town of fewer than a thousand people to respond to overdoses involving substances they cannot identify, wearing gear that may or may not protect them, without backup from a regional hospital because the regional hospital is gone. Alguire and the other Mountainair first responders did everything right. They performed CPR. They called for backup. They got the patients to Albuquerque. Some of them got sick doing it. They are still alive, which means they did not get the worst of the exposure, but they do not yet know what they were exposed to or what the long-term effects might be. The University of New Mexico Hospital decontaminated them. The hospital is ninety minutes away.
Rural hospital closures have been running for two decades under both parties. The Obama administration’s Affordable Care Act expanded Medicaid in states that chose to expand it, and that expansion kept some rural hospitals open. The Trump administration’s first term proposed Medicaid cuts that did not pass. The Biden administration preserved the ACA’s expansion. The Trump administration’s second term passed the 2025 reconciliation bill, which is now cutting Medicaid at scale. The pharmaceutical industry flooded rural America with opioids under both parties. Purdue Pharma’s 2021 bankruptcy settlement left the Sackler family with billions and civil-liability immunity while the treatment infrastructure the addiction required was never built. The fentanyl wave is the second opioid wave in twenty years, and rural communities are facing it without the hospital-based detox and medication-assisted treatment programs the first wave should have funded.
Mountainair lost three people Wednesday, and its first responders came home sick and frightened. The town will close its municipal offices Thursday. Mayor Nieto said the tragedy is “horrific” and that the community is tight-knit. That is true of every town of fewer than a thousand people. The membership Wendell Berry names is real. What is also real is that the membership has been losing the material infrastructure that makes the membership sustainable. Mountainair does not have a hospital. If Mountainair had an emergency department with a behavioral-health staff, the four people found unresponsive Wednesday might have been treated locally. If Mountainair had a detox facility or an outpatient medication-assisted treatment program, the three who died might have been in treatment before Wednesday happened. None of that infrastructure exists, and it does not exist because the economic model that sustains rural healthcare has been systematically dismantled.
We Too Chapter 16 calls this the Community Collapse Contradiction — the coalition whose rhetoric celebrates small-town values is the coalition whose policies hollow out the small towns. The 2025 reconciliation bill is the clearest recent example, but the consolidation has been running for decades. The rural hospital that closes in 2026 is often a hospital that has been losing service lines since 2010, that has been operating at a loss since 2015, that has been on the Sheps Center’s at-risk list since 2020, and that finally closed in 2026 because the most recent Medicaid cut was the cut the spreadsheet could not absorb.
Antonette Alguire is a volunteer. She is not paid to perform CPR on overdose victims. She did it anyway. She watched her colleagues get sick. She told a reporter she is afraid. The question the rest of us are responsible for answering is whether we are going to build the infrastructure that would let her do that work without the fear, or whether we are going to keep asking rural volunteers to face national crises with the gear they own and the training they can afford and the hospital that used to be ninety minutes away but is now not there at all.