NEW SALEM, N.D. (AP) – Dr. Tom Kaspari says it’s not true he works at the medical clinic here for free.

“I usually get jars of plum jelly or some salsa,” he says.

It’s enough for him. But it may not be enough to keep the New Salem Community Clinic in business. Even with a staff of volunteers, the clinic is in the red.

“I don’t know how much longer we can stay open,” says 89-year-old Milt Grube, one of Kaspari’s regular patients who also serves on the clinic board of directors. “We need some federal money to keep afloat.”

But getting money for the clinic seems questionable in a region with a dwindling population.

All across the country, declining rural areas are looking for doctors and nurses. But in North Dakota, one of the few states that has lost population, the challenge is especially daunting.

Grube, a retired farm implement dealer, said many of the town’s 800 residents are elderly, “I suspect like most other small North Dakota towns.”

The number of rural clinics in the state fell from 80 in 2002 to 62 this year, said Bill Finerfrock, executive director of the National Association of Rural Health Clinics. The country as a whole lost only 100 rural clinics during that time.

Grube said the New Salem clinic had about 3,100 patient visits in the past year and a half. Finerfrock said a clinic that size probably needs at least 4,200 visits a year to stay afloat.

Sitting west of Bismarck, New Salem is the home of Salem Sue, a huge fiberglass cow statue standing watch along Interstate 94. The clinic is near a vacant 1970s-era shopping mall with a gravel parking lot.

Kaspari (pronounced KAS-per), 44, comes to the clinic every Wednesday afternoon and evening, dressed more like a cowboy than a doctor. He sees up to 21 patients with all kinds of ailments. Thank-yous and occasional jars of homemade goodies are his payment.

“It wasn’t my plan to be here two years, but that’s the way it’s ended up,” he said recently as a half-dozen, mostly elderly people waited in the lobby.

Grube said the town is fortunate and that Kaspari reminds him of “old Dr. Gaebe,” who served the community a century ago. “People used to pay him with a half-dozen chickens or a pig,” Grube said as he waited for a blood pressure check.

If the New Salem clinic closes, the nearest doctors are in Bismarck, the state capital just 30 miles away. But even that distance can be a problem for many old people.

“We have a lot of elderly who don’t have transportation,” Grube said, adding that many seniors who do drive, shouldn’t.

The problem is it’s too expensive for the city hospitals that run the small clinics to keep them open, said Brad Gibbens, with the University of North Dakota’s Rural Health Center. “Whether it’s a hardware store or a hospital, all businesses need thresholds.”

Bismarck-based Medcenter One Health Systems closed the New Salem clinic two years ago, along with six others. The company said it was losing $675,000 a year on the satellite health centers because of low Medicare reimbursements and rising health care costs.

New Salem managed to reopen and has stayed alive because of Kaspari and volunteer nurses and other staff, along with donations. Grube said the clinic is also seeking about $25,000 from a local tax-supported economic development fund, but it would still need about $45,000 a year. And that’s without a salary for Kaspari.

Gibbens said a few towns have joined a network of community health centers that get some federal money. The clinics share administration and costs while getting reimbursement based on a patient’s ability to pay.

The New Salem clinic has been pursuing such an arrangement, and a community network is seeking federal funding to add New Salem to the group. But government support has languished.

“The federal budget has a lot of pressure on it,” said Karen Larson, of the Community HealthCare Association of the Dakotas. “I’m not sure when money will become available.”

Kaspari, a North Dakota native, believes the preventive medicine done at rural clinics not only saves lives, but also saves taxpayers money in the long run.

As Grube sees it, the clinic is crucial for the life of the town, too. “The clinic is an asset to our community. We have to have it to survive.”

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