The Hospital: Life, Death, and Dollars in a Small American Town

by Brian Alexander

To the memory of Bruce Alexander, writer, who kept waiting to see a doctor until his Medicare kicked in

Massachusetts passed a mandatory smallpox inoculation law in 1809

The big health systems were getting bigger partly to give themselves more leverage with insurance companies and suppliers so they could drive down their costs and drive up their own pricing power—and partly to fend off rivals who were doing the same thing.

He and Stephanie married in 2011. They were happy, but it wasn’t all bliss. He felt the pressure of his new responsibilities. Not only did he pay support for his own child, but Stephanie, who at forty was almost a decade older than Keith, had had other relationships with other men. She’d given birth to five children of her own. They cost money, too. Then, in 2013, Stephanie gave birth to Caleb, who, as it turned out, was autistic and nonverbal. And some of Stephanie’s relatives weren’t working much. Cash just had a way of drifting out of the house. In his darker moods, he figured he was supporting eight people: an exaggeration, he knew, but still.

Despite such friction, Keith always called Stephanie his soul mate. He appreciated the way she held the household together and looked after Caleb while he was at work, the way she kept an eye on him and made sure he took his insulin. She called Keith, whose childhood nickname was Teddy, “Teddy Bear.” They were the best thing that had ever happened to each other, they said. “We had a good marriage,” Keith said. “We did stuff together,” like going to NASCAR races so Stephanie could watch her favorite driver, Kyle Busch, and to RC car events. “I am now married to the most wonderful man in the world,” Stephanie said.

On January 9, 2017, close to dinnertime, Chad called Stephanie. They were talking on the phone when Chad stuck the barrel of a rifle into his mouth and pulled the trigger. He was thirty-six years old when he became one of the 920 people in Ohio who would kill themselves with guns that year. “That messed her up pretty bad,” Keith said of Stephanie.

During the month after her visit to Hassouneh, there would be ER visits to CHWC via Williams County ambulance, a urinary tract infection, a kidney-related emergency (fallout from the cancer), drives to Parkview Hospital in Fort Wayne for oncology treatment, testing, then admittance to Parkview on July 22, where, finally, at 7:44 in the morning of July 23, Stephanie died. She was forty-six. The last twenty-four hours of her life produced bills for drugs, supplies, labs, the ER, respiratory care, pulmonary function tests, vascular diagnostics, echocardiology, a CT scan, blood, doctor’s fees, and observation adding up to over $41,000, but she was still dead.

Cameron was Morris Fishbein’s apex exemplar of the doctor as Caesar, master of his own empire. Like Fishbein, he despised even a hint of government involvement in medical care. He despised taxes, welfare, and regulation, too. He believed “there should be available to taxpayers a list of the recipients of welfare in each county” because “a little more available publicity would keep the names of a fair number off the dependency roll.” Taxpayers, he argued, “could at least dream about … a requirement that the name of every citizen put on the welfare recipient list be automatically removed from the voter list. Candidates for public office would not have to cater to this class of citizens.” In the United States, Cameron believed, there was almost never a good excuse for anybody to be receiving aid from the government. Poverty was evidence of moral failure. While medicine’s newfound abilities to save lives proved a boon to mankind, “among indigents, a medical triumph often adds to the taxpayer’s burden.”

George Magill, the doctor who ran the wound clinic, had become so sensitized to seeing the effects of diabetes on the feet of Williams County residents, he could spot the diabetics in Walmart with their slight shuffle, the foot slide, a gait that seemed a little off because people couldn’t feel their feet. Twelve percent of adults—including 16 percent of all men and 27 percent of all people over age sixty-five—in Williams County had been diagnosed with diabetes. More probably had it but didn’t know.

As an accounting consultant to the industry wrote to buy-here-pay-here dealers, they were “selling money, not cars.” And there was a lot of money to be made selling money to poor people. Buy-here-pay-here dealerships made net profits of about 12 percent, while new car sales netted profits of between 2 and 4 percent. The dealers typically bought high-mileage cars from auto auctions. (“In BHPH one fact of life is vehicle breakdowns,” a consultant advised dealers in 2019.) Operators spruced the cars up a little and then sold them—often at double the wholesale price they paid for them. NIADA dealers like the one Keith turned to charged, on average, 20 percent interest for a car loan. (Regular auto loans at the time of Keith’s accident could be had for about 3.5 percent from credit unions by customers with good credit.) Buy-here-pay-here businesses expected a lot of their customers to default, so they installed GPS tracking devices, and often “kill switches.” That way the dealers knew just where the car was at all times and could disable it if the customer was late with a payment. “Lenders [are] repossessing at a record pace,” the same consultant wrote. Once they repossessed the car, they could sell it again. And again.

Keith found himself negotiating with a newly unleashed buy-here-pay-here dealer who sold him a 2007 Saturn Outlook SUV with 140,000 miles on it for $15,000. Keith handed over the $2,500 insurance money and drove out owing $12,500 he had no hope of repaying (though he insisted he could): $110 every week, at 21 percent interest.

The helicopters that flew into Bryan to pick up emergency transfer patients weren’t so understanding. A ProMedica flight to Toledo, a Parkview flight to Fort Wayne, or to either from any of the other companies that flew around northwest Ohio cost between $47,000 and $55,000 depending upon the level of care needed in flight. Insurance covered some patients, but others found themselves in life-altering debt.

Working-class wages in the United States just about flatlined from 1979 to 2017. Over that thirty-seven years, the bottom 10 percent of earners saw a 4.1 percent rise in wages. Meanwhile, economic productivity rose 70 percent. Most of the reward for that productivity was scooped up by the top 5 percent of earners, who enjoyed a 69.3 percent rise in real wages. The top 0.1 percent increased their haul by over 343 percent.

In 2008, a dose of Narcan cost Hicks about $14.50. It cost $78 now. Albuterol, used to treat asthma, shot up 3,400 percent. Saline bags used to cost $5.95. Now they were $22. A drug for cardiac arrhythmias that was first marketed more than fifty years ago and should cost only a dollar or two inexplicably rose to $180 a vial. Hicks waited two years to get morphine after companies stopped making the generic version. When he finally did get some, it cost $12 for a 1 cc vial. He used to buy twenty-five of them for $43.

While the ability of working people to join together to increase their own power via unions or by class action lawsuits had been under attack for decades by corporations like Menards, by state laws dubbed “right to work,” and by the evisceration of federal bodies like the National Labor Relations Board, the business of health in America had become a race to consolidate: to get as big possible. Each industry within the healthcare octagon bulked up to combat every other industry in it.

That strategy used ProMedica’s market power. First, it blackballed St. Luke’s from its for-profit insurance business, Paramount. Paramount was one of the largest insurers in the region, so being in-network with Paramount could make or break a medical practice or a hospital. Before 2001, St. Luke’s was part of the Paramount network, but then, at the behest of ProMedica, Paramount refused to give St. Luke’s a contract, costing St. Luke’s about three hundred admissions per year, and forcing the leadership at St. Luke’s to conclude that Paramount would “only let us back in when we give them [ProMedica] the keys.”

There was no such thing as a free market for medicine in the United States, and there hadn’t been for some time. Asking patients to become consumers burdened them with the responsibility to shop wisely in an opaque economy, even as hospitals introduced high-cost, hotel-like extras to lure them through the doors. The idea that doctors could or would steer patients to low-cost hospitals or to high-quality ones was laughable. Doctors had no idea what hospitals—even hospitals where they worked—charged for services, and neither did most other people. Hospitals and insurers kept their pricing and their insurance contract negotiations confidential. So a broken leg for one patient could wind up costing much more—or much less—than the exact same break would cost someone else.

The appeal to the free market also papered over another inconvenient reality of the medical economy: doctors were consolidating, too. Just as Parkview bought out the Bryan Medical Group, practices were selling themselves to health systems, hedge funds, private equity (PE) firms. And every one of those investors had the expectation—and sometimes the requirement—that doctors would send patients to a hospital preferred by the investors. That’s one reason hospitals wanted staff doctors—and why Ennen wanted to open the specialty clinics.

One might have thought that a nonprofit hospital system like ProMedica would pass it on to the public. ProMedica, Parkview, OhioHealth, Mercy: most of the consolidated regional systems in the United States, including the state university systems, were all officially nonprofit. They were supposed to serve charitable functions, receiving 501(c)(3) tax-free status from the Internal Revenue Service. That was why their profits were officially called “operating surpluses.” But there was no meaningful difference between the behaviors of for-profit giants like Hospital Corporation of America and those of the big “nonprofit” systems. Michigan’s Spectrum Health, for example, took in $6.9 billion in operating revenue in fiscal year 2019 (for a 14.7 percent total margin), while providing only $6 million in charity care. They were all big corporations. They all acted with the same goal in mind: to increase market share.

Prices rose—not just in Indiana or in California, but everywhere. From 1998 through mid-2019, the United States experienced 57.6 percent inflation for all goods and services above the 1998 baseline. Hospital services rose over 200 percent.

The big “nonprofit” systems, which often advertised increased efficiencies as justifications for their mergers, didn’t lower rates, they raised them. In 2015, the average margin made by “nonprofit” hospitals in the United States was 3.4 percent, a margin CHWC would celebrate. Parkview’s Wabash Hospital made 49 percent, the highest in Indiana. In Colorado, hospital profits increased 280 percent from 2009 through 2018, from $538 per patient to $1,518. They then took those profits and, instead of distributing the cash to shareholders as a for-profit might, paid big salaries and stored dollars—billions of them—away in cash hoards and investments. (ProMedica parked money in “Central America and the Caribbean.”)

Hospitals had ventured far afield from fixing sick or injured bodies. They acquired real estate and became developers. Mercy Health announced that St. Vincent’s, in Toledo, would build a block of apartments and retail stores. Michigan’s Beaumont Health developed a new shopping center and hotel complex. Sanford Health, of South Dakota, went into the golf business. ProMedica announced plans to build a hotel, apartments, and a restaurant on land near its Toledo campus.

Insurance companies, drugmakers, and suppliers were not going to stand by and watch as hospitals formed giant corporations without responding. So drug giant CVS—which, in addition to its omnipresent stores, ran the nation’s largest pharmacy benefit manager (PBM) operation, CVS Caremark—bought out insurance giant Aetna for $69 billion. Aetna had earlier acquired Prudential Healthcare. As a Columbus Dispatch investigation showed, CVS Caremark used its consolidated power against small pharmacies in much the same way ProMedica did against St. Luke’s. CVS, which ran the prescription operations for three of Ohio’s managed care plans, reduced plan reimbursements for drugs sold by smaller stores. CVS then sent those stores letters warning of impending financial distress due to the lower reimbursements CVS itself was handing out. CVS offered to relieve that distress by buying out the small stores. (In response to the Columbus Dispatch investigation, CVS and another PBM, OptumRx—part of the Optum insurance giant—sued Ohio Medicaid to prevent the release of information showing they’d charged the Medicaid program $224 million more for dispensed drugs than they had actually paid out to pharmacies.)

To better compete, many doctors sold their practices to hospitals—as the Parkview doctors in Bryan did, giving them a near-monopoly in Williams County. (Only the few doctors who worked for CHWC provided any competition.) Those who didn’t already work for hospitals started to consolidate among themselves, with one large practice buying up smaller practices in a region. The Bryan branch of the Specialty Eye Institute, where Barb Purvis sent Keith, was part of a ten-office chain in Ohio and Michigan.

Emergency rooms were especially lucrative because people didn’t shop for ER care; they just went. Many hospitals, especially small ones, contracted with ER doctor staffing companies because staffing their own ERs with their own employee-doctors could be so daunting: you had to hire four or five to run a 24/7 operation, and pay their salaries and benefits. And so people often wound up going to a hospital that was in their insurer’s network, but whose ER was staffed by doctors who were out of network. Out-of-network doctors were not held to a contract price—they set their own prices, at an average of 637 percent of what Medicare would charge.

Because the PE firms used borrowed money to finance these transactions, they needed to have a lot of cash spewing from the other end. They tried to maximize that cash by cutting costs and stripping assets. They sold off hospital real estate and kept those proceeds, then had the hospitals they controlled lease back the same real estate. After a few years, the firms would “exit” by selling the chain to some other party—if it hadn’t gone bankrupt first. Apollo Global Management paid $5.6 billion for LifePoint, a chain of hospitals whose outlets were located mainly in smaller southern towns. It then merged that chain with one it already owned, RCCH HealthCare Partners. The new company had hospitals in twenty-two states. The CEO of LifePoint walked away with nearly $70 million. In late 2019, Apollo had LifePoint sell ten hospitals to a real estate investment trust for $700 million and then lease them back.

After Blackstone acquired TeamHealth for $6.1 billion in 2017, its subsidiary, Southeastern Emergency Physicians, a Tennessee-based ER staffing company, began an aggressive program to sue patients over billings. As news organizations ProPublica and MLK50 found, Southeastern had filed 4,800 lawsuits in Shelby County (Memphis) in about two years—more than three big Memphis hospitals combined. The firm’s bills did not tell patients, many of whom were poor, that they may have been eligible for charity care. In response to the reporting, TeamHealth backed off the lawsuits.

When the floor opened for new discussion, Kevin Park, the Parkview physician who was also the county coroner, stood to say something about prescription drugs. Doctors should be aware, he said, that drug prices varied by wider amounts than most of them realized. They had little idea what their prescriptions cost patients unless they were a patient themselves. One of Park’s had told him that Walmart charged $217 for a month’s worth of a cholesterol drug called Crestor—thirty pills. “Two hundred and seventeen dollars!” Park shouted. He let that hang in the air for a moment. The patient, he continued, decided to do a little research and found an equal amount of Crestor for $17 at another pharmacy. “My patients are being ripped off by Walmart!” he said, his face reddening. Doctors ought to know that. They ought to do something about it.

She arrived to find an office, a computer, a cop who was rarely there, and a mandate to take charge of the neighborhood’s health. She had no idea just how to do that. “I was, like, ‘What the fuck?’”

Doctors didn’t want to take Medicaid patients. Hospital ERs were too busy to follow up with patients, and they weren’t the right place to seek care for a chronic condition like high blood pressure, anyway. So Sunderhaus started walking the neighborhood, including Victory Village, knocking on doors. Sunderhaus became the crazy white-lady nurse in sneakers who chatted up pregnant teen girls, old men, women working multiple low-wage jobs. When her friends expressed alarm she was walking around a neighborhood that had a reputation for crime, she’d say, “If I want to be loved, I go out in the neighborhood. If I wanna be beaten up, I go to the hospital.”

Sunderhaus envisioned a comprehensive, one-stop medical clinic where nobody would be turned away. Patients would be assessed for their overall health, receiving primary care, dental care, mental health counseling, and prescription drugs—all at an affordable price.

the CHWC executives held another strategic planning meeting. As part of the “current state analysis” they were all trying to create, Patrick had been assigned to collect Ohio Hospital Association data on geographical hospital market share. All of them were concerned about “leakage.” How many people in their core market (Williams County, mainly) were leaving to buy services from competitors? That could mean Henry County in Napoleon, Hillsdale, Hicksville, the Mercy and ProMedica hospitals in Defiance, and the hospitals in Toledo and Fort Wayne, among others. Conversely, they wanted to know how much opportunity there was to nip some business away from those facilities, and, if so, what “service lines”—ob-gyn, radiology, cancer, wound healing, lab testing, and so on—they’d need to promote or establish in order to do so.

Tinkel suggested that more marketing and advertising might be necessary: an appeal to consumerism. The big for-profits advertised, marketed, and then hired paid greeters and patient escorts. They redecorated rooms and made them all private. The big nonprofits followed suit. The elderly volunteers who said good morning as you walked in the front doors of CHWC were sweet, but maybe it was time to make CHWC a bit more like the Ritz and then market the high-touch “concierge” service.

But maybe they should start talking money up front. Ennen suggested a prescreening of customers—what some in the industry called a “wallet biopsy”: a meeting to “confront the patient about how much they will be responsible for, and how they will take care of it.” Perhaps CHWC should work out a payment plan before any procedure. The hospital had done such a thing on a small scale. But now, Ennen said, maybe the hospital should require a deposit before every single elective or nonemergency surgery, as some other hospitals did.

Other doctors came to Bryan for the money. “Nobody will lie about that,” the Parkview surgeon Mike Liu said. Rural areas were forced to pay a premium to attract talent, so much so that doctors could make a third more in Bryan than they could in many metro areas of the United States. Bryan doctors were rich—a vast change from the 1930s, when a doctor in the region could expect to take home about $45,000 in 2019 dollars—not only because of the high salaries, but because the cost of living in Bryan was so low. That attracted young doctors like Liu, who were carting around a couple of hundred thousand dollars in medical school debt.

With such competition for doctors, CHWC sometimes had no choice but to offer top salaries. Chad Tinkel’s wife, Jodi Tinkel, the hospital’s medical cardiologist, made $616,489 for the fiscal year ending in September 2018—higher than the 75th percentile for nonsurgical cardiologists ($563,130) in the United States. Michael Nosanov, who ran CHWC’s ear, nose, and throat clinic, made $546,519.

Lobbyists for the convenience-store industry convinced legislators that requiring more fresh fruits and vegetables—and more varieties of other foods—was too burdensome. The Trump administration agriculture department agreed. So a can of ravioli in tomato sauce counted as a vegetable. The Dollar General offered the bare minimum of the even more relaxed food menu, and yet a long aisle of sugary drinks, because the drinks produced high profit margins and were also eligible for purchase with food stamps. The SNAP program paid billions of dollars a year—about $4 billion, by one estimate—to the soft drink industry, to the stores, and, by extension, to the sugar and corn syrup industries, via SNAP recipients. In other words, taxpayers were subsidizing the promotion of diabetes and obesity.

Sociologists had tried for years to tell politicians that drug abuse was a symptom, not a cause. The kind of drug was irrelevant. Yes, heroin and fentanyl were deadlier than meth, and meth might be deadlier than alcohol. Alcohol might be more immediately dangerous than obesity, lousy dental care, poverty and low wages, crummy housing, depression, trauma, and anxiety. They were all part of the same pathology, though, and arguing about which was worse obscured the underlying causes of the abuse.

The resistance Ennen met when advocating for all employees to get flu shots wasn’t only the result of false beliefs like “the flu shot will give you the flu,” a common one in the county. The county commissioners didn’t require EMS crews to get flu shots because they didn’t think government should tell people they had to get vaccines. In the ER one day, Marv Stalter asked a young single mother who worked at Menards and who relied on Medicaid if her small child was up to date on his vaccinations, and she made it clear she didn’t trust pronouncements from the government. “Oh, we do not vaccinate,” she said. Stalter made a short sound of concern with the intake of his breath, then launched into the same litany he preached to every such young parent—about polio and iron lungs and lives saved—but he knew not to bother being too insistent. When Jan David spoke to a neighbor about the importance of getting a flu shot, the neighbor replied, “That’s from the government. You don’t know what they’ll put in it.” A hospital employee filled out the required statement explaining why she refused to be vaccinated: “Religion is Pentecostal. Obamacare is putting a ‘chip’ in the flu shot to track people’s whereabouts for the ‘666.’ Not going to take the ‘devil’s shot.’ Took it last year but felt forced into it. Husband was very upset. This is already happening in Wyoming and other countries.” The employee was apparently referring to an anti-Obama conspiracy theory about radio-frequency identif...

For all the county’s antipathy toward big government, it lived off big government—just as in the days of the Great Depression, when the feds made all those payments to farmers and built part of Bryan’s infrastructure. Williams County residents received medical payments of $150,323,000 from government in 2018. Total government transfer payments to individuals came to $339,480,000. In 2019 and 2020, more federal money arrived via payments to county farmers from the Market Facilitation Program, the compensation to farmers hurt by Trump’s trade war. Farmers who qualified could receive $67 an acre, up to $250,000 per person or farm corporation. Even if they didn’t plant a crop, they could receive $15 an acre.

Of course, Bryan’s biggest employer, the hospital, would shut its doors without federal payments, as Ennen had always liked to point out. “Very conservative community we live in,” he told a group of employees at the Montpelier hospital during a meeting. “‘Socialized medicine.’ Well, if you are opposed to sociali...

inequality in America declined in the decades following World War II. Ronald Reagan was elected president in 1980, ushering in an era of union-busting, financial deregulation, leveraged buyouts, and the financialization of the American economy. What ensued was a precipitous increase in inequality, whether measured by income or by accumulated wealth, and except for short pauses, it kept rising. By 2019, the United States was one of the most unequal countries on earth.

too many people in Williams County were being used the way mining companies used coal in West Virginia. Human beings were the object of an extractive industry. They were mined for their labor and for their money. Too often, they were a “workforce” and not people at all. The goal was to pay them as little as possible and to get as much work out of them as possible while taking the least amount of responsibility possible. The modern American version of capitalism encouraged—even demanded—that employers extract the value from their employees while returning scraps to them and their communities. And then others—like some medical professionals, business owners, politicians—questioned why poor and working-class people didn’t take care of themselves. Why didn’t they comply? This was the same argument employers had used in 1916 to oppose a state health plan, blaming the working class for “absences caused by intemperance, by ball games.” If they were sick, they had only themselves to blame.

The health industry, like other industries, had also figured out how to siphon off what wealth people had and add that to its own bottom line. There was no better example than diabetes: between the insulin, the monitors, the test strips, and the pumps, diabetes was a rich vein of cash that would last as long as a diabetic lived.

What America did have was a jumble of ill-fitting building blocks: the doctoring industry, the hospital industry, the insurance industry, the drug industry, the device industry. They’d all been able to tweak and sand the corners of proposed “solutions” to benefit themselves. Lobbyists and political action committees spent millions to do so until the edifice of American medicine looked like a fragile Tower of Babel, rotten with holes and the crooked passageways where money was hidden. There was so much money. Trillions. And there was so much incentive to embrace the insanity because the insanity was so lucrative.

Around Bryan, though, just about everybody also agreed on solutions. The answers seemed so obvious. If Mike Liu, the Parkview surgeon, was correct that medical care was a human right, then what? Well, you could blow up the entire crazy structure and start over. The United States could create a national health plan, proposed over a hundred years ago. The government could go into the drug business to manufacture drugs that had gone off patent. It could regulate drug prices, especially for drugs that had been created with the help of taxpayer research money. It could shorten patent protection and ban copycat patents. Medical school costs could be slashed, especially for general practitioners and family practitioners. Hospitals could be funded with grants, and in return charge patients nothing: many hospitals, including CHWC, already received most of their income from the government.

The crisis seemed to smother the United States and the world with sudden fury, but it wasn’t sudden at all except in its particulars. Over the previous forty years, fissures radiating from the deepening fault lines of inequality, racism, suspicion, paranoia, and the propaganda of financial self-interest carved their way through America’s landscape until the country and its people had become fragile. Covid-19 just exploited the weaknesses until the crust collapsed, revealing to Americans what had become of their nation. If it hadn’t been Covid-19, it would have been some other catastrophe.

When it finally came to America, the virus seeped into the fault lines created by America’s pathologies. The country had changed from being an ongoing project to improve democratic society and live humanistic ideals to being a framework for fostering corporate profit. Politicians declared their intentions all the time: America should be run like a business and led by a businessman. And so a program of starving the nation of public goods while showering private interests with dollars entrenched itself until it seemed as if America had always been that way and the new version of capitalism came to be equated with patriotism. But that new capitalism was killing people.

As Trump sent insurrectionist messages to his Twitter followers, encouraging them to “liberate” states, the mood in the county darkened. The danger really was a hoax, some said. Trump was right. The threat was overblown.

Trump was a lying sociopath. But many in Bryan, and in the state and the nation, believed he was their lying sociopath, and anybody who contradicted his increasingly lunatic pronouncements became an enemy of freedom and right. Dr. Amy Acton, the state health chief, faced abuse from Republican members of the state legislature. Representative Nino Vitale accused her of destroying liberty and called her “an unelected Globalist Health Director,” using a slur known to refer to Jews; Acton was Jewish. State senator Andrew Brenner likened Acton’s health mandates to actions taken by Nazi Germany. Gun-toting protesters appeared on Acton’s lawn. She received death threats.