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The boxes are empty and the votes are final. In Madison County, voters said no to a hospital district by more than 1,000 votes. The failure comes only two months after Grimes County voters turned down a similar proposal.
Madison County residents will not see the formation of a hospital district.
The decision has Saint Joseph hospital administration re-thinking the future.
"We're a mission driven hospital, we believe in our ministry, but we also believe the community has some ownership and responsibility for the healthcare of their citizens," said Vice President of Rural Hospitals Reed Edmundson.
Edmundson said the problem lies with healthcare. With the number of uninsured Americans on the rise, hospitals like St. Joseph in Madisonville are stuck with the bill. The Madisonville hospital is hundreds of thousands of dollars in debt.
Administrators feel that if the state of healthcare doesn't get any better or something isn't done locally, the hospital could be nonexistent.
Duane Standley was on the temporary hospital board to promote the hospital district. The district would have taxed citizens to help fund healthcare in their area.
Standley fears the worst.
"St. Joseph, they sunk a lot of money into this deal and at some point in time they're going to say no more," said Standley.
But, Madison County Judge Cecil Neely said the county is not in a position to help.
"There are many things in small counties that you just simply can't afford. This is one of the things that people voted that they just felt they didn't need a fourth taxing district," said Neely.
"I'll be the first one to tell you I don't want to pay anymore taxes, but I also don't want to do without healthcare," said Standley.
Neely said if the hospital is managed correctly, the worst could be avoided.
Hospital administrators aren't giving up; they plan to continue educating voters on what a hospital district would mean for the community.
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