Phil Ennen walked into the fourth-floor boardroom, just down the hall from his office. The auditors from Plante Moran were already seated.
“How’s it going, Phil?” asked one.
“We’re open!” Ennen replied.
Ennen wielded sarcasm the way some people said good morning—an effect of growing up with mostly brothers in a big Irish Catholic family that used mordant bons mots as love taps. In Ennen’s case, the dark jokes overlay a sometimes exquisite sensitivity.
Thirty days before, on October 1, 2018, Community Hospitals and Wellness Centers had entered a new fiscal year. Every month of the past year had ended in the red, and there wasn’t yet any sign money had stopped leaking—the first month of this year would end in the red, too. The hospital’s operating loss for the past year would turn out to be nearly $1.5 million on patient revenue of $79.6 million, for a −2 percent operating margin.
CHWC was a nonprofit hospital, like nearly 60 percent of all U.S. hospitals. (About 20 percent of hospitals, usually city-based, were owned by states or other government entities, and another 20 percent were for-profit, like those belonging to big outfits such as Hospital Corporation of America.) As a nonprofit, CHWC was organized as a 501(c)(3) private charity, freed from most tax liabilities. But it was very much a business, too, and it could go bankrupt. So Ennen always sought to make a small margin—an “operating surplus” in the official lingo—to invest in new equipment, people, and the physical plant. Big nonprofit chain hospitals in suburbs often made a 6 percent margin, and sometimes much higher than that. Unlike a state-owned hospital supported by taxes, CHWC couldn’t afford to lose money for long. Thus the meeting with the three auditors from Plante Moran, an international accounting firm based in Cleveland, who had come to find out if they should prepare a damning “going concern” statement for the annual report. Such a statement would alarm debt holders, not to mention the community.
Ennen saw more at stake than just a black eye for the hospital. Well into the second decade of the twenty-first century, CHWC had become a keystone of the Bryan economy. It may have been tiny—the flagship fifty-bed hospital in Bryan, the twenty-five-bed hospital in Montpelier, and a clinic in Archbold, just over the Fulton County line to the east—but it was the biggest employer and most sophisticated outfit going in Bryan, and it was Ennen’s responsibility. Local people, Ennen, and the board of directors were all adamant that CHWC remain an independent community hospital—a Bryan and Williams County asset—even as such hospitals elsewhere folded or were taken over by bigger chains, one after another. CHWC was part of a dying species, and everybody knew it.
Sometimes in secret, some of Ennen’s own leadership team—the vice presidents who sat in offices along a carpeted corridor on the fourth floor—whispered that a takeover was inevitable. His chief financial officer, Chad Tinkel, figured it could happen within three years, maybe five at the most. The geology of American healthcare had shifted since the days when Donald Cameron opened his little shop. The CHWC of today stood athwart tectonic plates whose movements were lubricated by a massive flow of dollars. The hospital had little chance of avoiding being swallowed. But Ennen believed he could juke and jive his way through American healthcare to keep CHWC as it was—and even to grow it.
Phil Ennen was not only a Bryanite but the George Bailey of Bryan—the man tantalized by thoughts of what his life would have been like had he lived and worked in the bigger world. His two daughters and son had gone off to college and were now making lives in faraway cities. He remained a big wheel on a small bike. He served on local boards. He acted in community theater. He established a charity drive for a big civic project. He was the man who saw all the flaws in his hometown, sometimes losing patience with it. He once even tried to leave Bryan for a job elsewhere, yet he loved and defended the place. Ennen didn’t think it was healthy for the hospital to have the outsize economic and social roles it did, but that was how it was, and it had become his life’s work to keep the place alive.
The Plante auditors sat on one side of a square formed by four tables. A sink on the back wall seemed intended to have been a wet bar, but it had never been used as one. A silver shovel hung on the wall above it. A framed photo with a group of smiling people looking uncomfortable in suits and ties commemorated the day the shovel had been used to break ground on $62 million in renovations and new wings that turned CHWC into “that Lego blocks place.” The bonds were floated, the money borrowed, the ground broken—and then the worldwide economy imploded in the Great Recession. Ennen took over as CEO in January 2008, just in time to catch the fallout.
The five vice presidents—Tinkel; Wade Patrick, chief information officer; Angelia Foster, vice president for human resources; Mike Culler, chief operations officer; and Jan David, vice president for patient care—entered and took their seats across the table from the auditors. Chitchat subsided, and an uncomfortable pause settled over the room.
“Well,” one of the accountants began, “where do you stand today?”
Ennen waited a beat. “I have no response,” he said.
Ennen could be tetchy inside the hospital. He could sometimes be impatient, defensive, brusque. He hated meetings, often sitting silent and grim-faced in the back of a room and projecting impatience, as if he couldn’t stand to wait while others arrived at an answer he already knew. He also hated process, and he hated meetings about process most of all.
Plante Moran had been the outside auditor for the hospital for more than twenty years. It had a large hospital practice, with clients around Ohio and up in Michigan—some of whom had been forced to shut down, or been taken over, or been bought out. Each one had a tale of its own, but they all shared the same basic outline. The auditors weren’t going to be surprised by anything Ennen might say: this meeting was about soothing them out of a damaging “going concern” judgment, and everybody in the room knew that by the time it was over, Plante Moran would be soothed.
Back in March, and again in September, CHWC had broken loan covenants with Fifth Third Bank that required it to maintain a cash-to-debt ratio of 1.25 (meaning that for every dollar of debt, CHWC had to have 1.25 dollars of money). Even one breach would allow Fifth Third to take the hospital from the board. Nobody believed any such thing would happen—not yet, at least—but a covenant break was a serious matter, and Plante wouldn’t be doing its job if it didn’t at least consider the notion that the break signaled a risk that CHWC might not be viable in the long term.
The bank didn’t want to own a hospital, so, of course, if it ever took over CHWC, it would sell it off. But when Bucyrus Community Hospital, south of Toledo, went bankrupt and was then bought out of bankruptcy and folded into a health system chain, the lenders, Plante calculated, didn’t recoup all the value. That was a perverse bit of good news for CHWC: Fifth Third had to know that the bank was much better off letting CHWC slide on the covenants.
CHWC paid $4.5 million per year in principal and interest on debt of $55 million. As a sign of Fifth Third’s wariness, CHWC was being forced to maintain $19 million in the bank, so Fifth Third already had a protective cushion.
Ennen argued that, covenants aside, CHWC was financially healthy. True, the losses over the 2017–2018 fiscal year whittled away at the hospital’s “days of cash on hand,” a figure representing how many days it could remain open in a hypothetical scenario in which it received zero operating income. Days of cash, a common metric in the hospital industry, indicated how close to bankruptcy a hospital might be. In March, CHWC had 324 days of cash on hand. Now there were 295, but some hospitals had 30 or less.
Plante Moran understood all of this but was concerned about the trend. Fifth Third, one auditor said, “is going to want to know if the breaches are a blip this year, or if this is the way it’s going to be the next two, three, four years. What will you do going forward?”
That was the question on everybody’s mind—on Ennen’s, on the board’s, on the hospital staff’s, on the mayor’s, and on the county commissioners’. Tinkel, CHWC’s chief financial officer, worried more about the covenant breaches than Ennen did, and some of his fretting had rubbed off on the board. Though it had a long history of keeping its hands off the management, the board had grown nervous about the breaches over the summer and fall. Ennen could feel it pulling against the reins. For the first time, it asked him and his leadership team to hire an outside consulting firm to help draft a strategic plan for the future.
Ennen thought the prospect of consultants was a useful bit of information to drop to Plante as a way of saying “we’re on it”—that the hospital was engaged in change to create better fiscal outcomes—but he didn’t appreciate the board’s instruction to hire outsiders. He had a near-overweening confidence in his ability to manage out of trouble. He knew what to do, and he didn’t need to spend tens of thousands of dollars on consultants to tell him. “Initiatives,” he told Plante, were already under way.
Ennen had started the initiatives in the spring, when it was becoming clear that CHWC was in the middle of a tough year. In June he told the board that CHWC wasn’t in “panic mode” but that everyone should prepare for an honest reckoning: necessary changes were coming. He needed twelve, maybe eighteen months to execute those changes. Meanwhile, the hospital would operate on a cliff edge. The board, he thought, gave him the autonomy to “find a glide path that gets the job done.”
The challenges to CHWC weren’t mysterious; they were systemic and long-term. As a Plante auditor said, “The pressures on a rural community hospital are great.” People in Williams County, as in a lot of rural counties, were growing older, poorer, sicker, and more reliant on Medicaid and Medicare. More than two-thirds of CHWC’s income was paid by the government, but the hospital collected a lower reimbursement from Medicaid and Medicare than it did from insurance companies. Private, employer-based health plans helped less than they might have because CHWC was so small it had little leverage with which to negotiate contracts with those insurance companies.
The Montpelier facility of CHWC was classified as a critical access hospital—a designation most often bestowed on hospitals of twenty-five beds or less that were distant from another hospital—so Medicare paid it 101 percent of “reasonable costs.” That guaranteed 1 percent margin from Medicare in Montpelier helped, but not enough.
CHWC benefited from the expansion of Medicaid under the Affordable Care Act—Obamacare. Before then-governor John Kasich bucked his own Republican Party to expand it, about 15 percent of Williams County residents had no health insurance. After the expansion, that figure dropped by half, helping more people afford hospital care and improving Ennen’s customer base. But the Republicans in the legislature remained steadfast in their desire to dismantle expansion, and Donald Trump ran for president on the threat to do so. Ennen knew he had to be prepared for the possible disappearance of Obamacare, and for the loss of coverage for about a thousand Williams County residents.
Hospitals could try to milk a few extra drops of revenue out of the system by playing with the codes that designated medical diagnoses and procedures. An industry had arisen over decades to help do just that. In 1994, for example, the hospital received a pitch from a firm called Quest Health Enterprises. “I’m sure you’ll agree that President Clinton will quickly push for legislation to CONTROL the ‘high cost’ of healthcare,” it began. “If Congress enacts these proposals into law, then healthcare providers will certainly experience the following:
1. Reimbursement deterioration without recourse.
2. Cash flow insufficient to meet current liabilities.
3. Bottom line ‘red ink.’”
And “even if Congress puts the ‘squeeze’ to your hospital in the name of ‘managed competition,’” the company promised a “pricing solution”: a software that could massage billings “TO PUT MONEY IN YOUR CHECKING ACCOUNT”—sort of like upcharging in a restaurant.
By 2007, Quest was charging hospitals $1 million a year to license the software. But such manipulations had reached their limits: there was no more cash to be gained. And just cutting expenses wouldn’t work, either. Choosing layoffs and deleting services would lead to a cascade of other decisions, none of them pleasant. Which services to the community do you eliminate? How many employees? How much do you reduce wages and benefits? Besides, cutting could eventually prove self-defeating: as services declined and equipment aged, people might stop coming.
Ennen wanted to try a combination of cost reductions and new investment. Some job openings would go unfilled to lower the employee count. CHWC’s nurse-to-patient ratio on the medical/surgical floor was one registered nurse for every three patients, while other hospitals in the region used a one-to-five ratio. Ennen had told his nursing leaders that if the hospital were taken over, “corporate” would set the ratio at one to five, so CHWC had better do it on its own, and now. About eighty employees were sixty-two or older, and some were continuing to work only because CHWC’s health insurance plan was cheaper than Medicare. Ennen thought he might be able to nudge such employees onto Medicare so they could step away from the hospital. If any of their positions had to be refilled, he could hire a younger employee at a lower wage.
Such trimming around the edges, though, wasn’t ever going to counter the long-term trends that were killing independent community hospitals. 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. Ennen believed the federal government was encouraging such consolidation, or was at least unsympathetic to protests against it, because it was simpler for CMS, the Centers for Medicare and Medicaid Services, to deal with fewer giant outfits than with many small ones.
CHWC sat in the crosshairs of Parkview Health in Fort Wayne, to the west, and of ProMedica in Toledo, to the east, both of which eyed CHWC as a possible acquisition. In 2010, faced with uncertainty about the future of the hospital, the Bryan Medical Group, the county’s physicians partnership located across from the hospital on High Street, had voted to sell itself to Parkview.
Ennen had tried to counteroffer by suggesting the creation of a foundation—something like what the Cleveland Clinic had done—that would join the for-profit medical group with the nonprofit hospital, but the doctors weren’t convinced. “We were symbiotic with the hospital in the past,” explained Diane Conrad, the group’s lead physician. “But we looked for a safety net. There was no security at the hospital.” Now, thanks to the big Parkview sign at the physicians group, a lot of people in Bryan thought the hospital already belonged to Parkview.
CHWC was forced to talk to both Parkview and ProMedica about entering into joint ventures like an ambulatory surgical center and a cancer center. The board didn’t like the talk about deals with the big systems, but it recognized that CHWC had little choice. There was, after all, nothing stopping Parkview from building a surgery center of its own and starting a war for customers. But as one board member told Ennen, a joint venture was Parkview’s chance to “leverage in on us.”
During the summer, as the talks proceeded, Ennen compared them to “dancing with a fella, and the fella grabs your hip, tighter and tighter. We will try to keep creating space, but keep the Parkview dance card open as we go across the floor. And then ProMedica will sidle up and say, ‘Hey, let’s talk.’” Ennen hoped to play one big boy against the other to get what he wanted without climbing completely into bed with either. “The problem is there’s not a lot of comfort or even trust between the organizations.”
Now, in the Plante Moran meeting, he skipped all the backstory details but cautioned that the situation with the board was delicate. “Parkview will put co-management on the table,” he told the auditors of the possible joint ventures. “That’s a bridge too far for our board.” He expected that, should a joint venture come to pass, Parkview would want its signage on the Bryan hospital’s property. “That,” he said, “would be emotionally very difficult for the Bryan board.” He described ideas for investments CHWC might make on its own.
CHWC had survived so far because it had financed more—not fewer—services, giving the people of Bryan and Williams County reasons to stay local for medical care. Unusually for a small town, CHWC ran its own radiation oncology center to treat cancer patients. Ennen had placed a young woman named Kim Owen, a Williams County native, in charge of it, acting as a management mentor for her. The center was one of the few “service lines” to make a profit.
The hospital also ran its own cath lab for performing cardiac catheterizations, during which stents were inserted to prop open arteries. The cath lab was the most profitable part of CHWC. It was run by a doctor named Damoder Kesireddy, a native of India who had come to Bryan decades before.
Building on the examples of the cath lab and the radiation oncology center, Ennen created more clinics within the hospital. Just a month before the Plante Moran meeting, CHWC had opened a gastrointestinal center headed by a new hire, a young doctor named Matt Cooley.
The year before that, he established a women’s clinic by recruiting a Michigan ob-gyn named Hanan Bazzi. Ennen pursued Bazzi with a special determination. The other ob-gyns in town were Parkview doctors, which meant Parkview reaped their service billings even if those doctors used the hospital’s facilities. Also, one of those doctors was older and would retire soon, which would leave the community shorthanded. And in the modern American world of hospitals, many procedures were now being performed on an outpatient basis because payers believed it was cheaper. Birthing babies remained an inpatient staple, and Ennen wanted to be sure CHWC could harvest as much revenue as possible by having his own ob-gyn on staff.
Bazzi was a hijab-wearing Muslim. Ennen had worried she’d be reluctant to come to an overwhelmingly white, Christian, and conservative county where many residents could—and did—quote the Bible in casual conversation, where 69 percent had voted for Donald Trump, and where a local politician could blame problems associated with a Bryan business on the fact the owner was “not of American extraction” and know he wouldn’t hear any disapproval.
Bazzi grew up being the different one. Born in Texas, she spent most of her childhood in North Carolina. She was a sophomore in high school and wearing the hijab on September 11, 2001. Kids taunted her. They tried to tear off her hijab and slammed her locker door shut when she opened it. “They’d say, like, ‘Go back to Afghanistan,’” she recalled, “and I was, like, ‘I was born in Texas, thank you very much.’ We would go to a mall or restaurant, and we would hear comments.”
The idea of coming to a town like Bryan, in a county like Williams, gave her pause because she had young children and didn’t want them to experience the same prejudices. Ennen, however, impressed her by admitting that while he couldn’t guarantee community reaction, he’d stand with her, come what may. When she visited Bryan, he and his wife, Mary, hosted a dinner party at their home and didn’t serve alcohol. Bazzi noticed. She also noticed that the people she met at the hospital seemed nice and welcoming. And Ennen’s deal was a better offer than she’d get almost anywhere else in the country. Though she was fresh out of her residency, she’d head up her own clinic and could design it however she wanted, modeling it after the one at the University of Michigan—where she’d trained—if she chose to. Since then, Bazzi had been joined by Samar Hassouneh, another Michigan transplant and another Muslim.
Sometimes when she was out in Bryan, Bazzi would notice suspicious looks. When she ran on the YMCA’s indoor track wearing long pants and her hijab, she could sense eyes following her. At school, her children faced questions—some good-natured, and some not—about the clothes they wore, and about why they didn’t eat in the daytime during Ramadan. But she faced little outward disapproval and received no hate mail. Ennen did. “Are you hiring Isis?” it read. “The only good Muslim is a dead Muslim.” He didn’t tell Bazzi.
She and Hassouneh seemed to have little trouble attracting patients. “The vast majority of my patients—I love them, and they love me,” she said. But the clinic was still losing money, as had been expected during its start-up phase. Bazzi and Hassouneh ordered in-house lab work and radiology images, both of which made a profit. But, for the time being, the clinic itself was a drain.
Before establishing the ob-gyn center, Ennen opened a pain clinic—a joint venture with a pain management medical group—and a wound clinic, headed by George Magill, a former ER doctor. Magill’s office lost money, too—but, again, the ancillary services derived from the clinic made up the difference. In time, Ennen believed, all the clinics would show a profit. He just needed the board to give him the twelve to eighteen months he asked for: his glide path.
Turbulence in the glide path was already appearing, however. Neither Bazzi nor Hassouneh was sure if they’d stay in Bryan beyond the three years of their contracts. Bazzi and her family left almost every weekend to visit relatives in Dearborn, Michigan, so she wasn’t as invested in Bryan as her home as Ennen had hoped. When Trump ratcheted up his anti-Muslim rhetoric, her doubts grew. Both she and Hassouneh found themselves formulating plan Bs.
Bazzi also ran into conflict with the Parkview ob-gyns. Traditionally, the local doctor on call at night or over a weekend delivered the babies, no matter which doctor had cared for the mother during her pregnancy. But when Bazzi started in Bryan and took her first on-call assignment while her family went to Dearborn, her phone didn’t ring. So she checked in. “Oh, yes,” a labor-and-delivery nurse replied. “We have a patient in labor now.” When Bazzi asked why she wasn’t called, the nurse explained that a Parkview doctor was delivering the baby. Bazzi believed the Parkview doctors were freezing her out—delivering not only their own patients but hers, too, when she wasn’t at the hospital—as a way to keep the revenue within the Parkview practice. “Okay, they wanna play that game?” Bazzi thought. “They wanna shut me out? I will deliver my babies, whenever it is. It doesn’t matter if I’m on call or not: I will deliver my own patients.”
If Bazzi or Hassouneh decided to leave, it wouldn’t be easy to recruit replacements. But the Women’s Clinic was the least of Ennen’s personnel worries: Kesireddy’s retirement carried more potential danger. Kesireddy was in his seventies. His stamina for work had become legendary; his family had to force him to go on vacation. Hospital staff joked that someday he’d just die in his scrubs and fall into a patient’s bed. But not even Kesireddy could stop time. At some point he was going to retire—the betting was in two years at the most—and since he was the only interventional cardiologist in the county, the cath lab would have to close if Ennen was unable to find a replacement.
The hitch, however, was that Kesireddy was a Parkview doctor, so recruiting such a replacement was Parkview’s responsibility. The big health system could decide to cut off CHWC from the cath lab revenue by refusing to hire a new interventional cardiologist, instead referring patients to the Parkview “mother ship” in Fort Wayne. Then CHWC would have to hire its own doc, assuming it could even attract such a physician to a rural town, or concede the cath lab income.
Another personnel issue had started as an annoyance but was now growing into a problem. Kim Owen, the radiation oncology center director, was beginning to rethink her own career with CHWC—though it wasn’t Plante Moran’s business, and it wasn’t generally known around the hospital because Ennen and those concerned were doing their best to keep it quiet. Over the previous summer, she’d complained of being harassed by a contract physician. He allegedly sent non-work-related texts after hours, invited her to dinner, brought small gifts to the clinic, and left an apple with a corny message: “An apple a day won’t keep this doctor away.”
As his approaches continued, Owen spoke to Ennen, saying she wanted to try to manage the situation herself. Ennen agreed, giving her some advice about how to shut the doctor down without causing a lot of drama. The doctor backed off, but not for good. When Owen reported that to Ennen, he called the doctor. You’ve been in the wrong, he said. The behavior had to stop immediately. If it didn’t, Ennen would take it to the medical staff—and that was the last thing the doctor, or Ennen, wanted. “That uncorks a variety of bad things, like a more public airing, perhaps questioning,” Ennen said. At the time of the Plante Moran meeting, the harassment had eased—at least as far as Ennen knew. Owen, though, had begun to think it might be worth taking some of the phone calls she received from headhunters looking for radiation oncology managers.
Ennen also faced necessary, but expensive, cash outlays, including for new technology. The hospital’s phone system was collapsing. Wade Patrick, the CIO, figured a replacement would take about half a million dollars. The hospital used an electronic medical records (EMR) system that had been cobbled together in the rush to comply with a 2009 law called the Health Information Technology for Economic Clinical Health (HITECH) Act. The law created a land grab by both established corporations and startups to supply the EMRs, and big hospital operators adapted whichever system they chose to their own needs. Community hospitals struggled to pay for the systems, and setting them up proved devilish. Because Parkview owned the medical group across the street, and because those doctors used Parkview’s system, CHWC was under pressure to adopt that system for itself. Doing so would save money and time, but it would also be one more dance with Parkview with its arm wrapped around CHWC’s hip.
Ennen didn’t hide any of this information from the Plante auditors, but he didn’t volunteer any of it, either. As far as he was concerned, the less discussion, the better. The meeting was a chore to be gotten through.
Outside the modern walls of CHWC, the people of Bryan wrestled with their own financial crises. A decade after the Great Recession, Bryan residents still spoke of it the way an older generation remembered December 7, 1941. It was a disaster—not just because of the immediate events that triggered the recession, but also because of the way it landed atop thirty-five years of setbacks, compressing the discrete elements of Bryan’s long decline into a focused lens of desperation.
There was a time when, on spring and summer Friday afternoons, people in Bryan could stand outside, look toward the county airport, and watch the private planes streak overhead. The planes carried ARO Equipment executives and customers, or Bard people, or Ohio Art people going to New York or Chicago. ARO had about two thousand employees, dressed in either blue work shirts or short-sleeved white shirts with ties and a couple of pens in their pocket: the engineer’s uniform. The ARO executives drove Buicks and Chryslers and served on boards and civic organizations.
During World War II, ARO made pneumatic tools for Rosie the Riveter and breathing masks for high-altitude pilots. Then it supplied NASA. Every piece of equipment was stamped with BRYAN, OHIO USA. Ohio Art shifted from making metal picture frames and little tin toys (the company’s main building was on Toy Street) to putting an Etch-A-Sketch in the hands of seemingly every kid in America. BMWs and Mercedes dotted the headquarters parking lot. Up in Montpelier, about three hundred people worked at Mohawk Tools, making specialized industrial drill bits and other cutting devices for use by carmakers and aircraft manufacturers. The salesmen, executives, and customers at all these companies packed the Orchard Hills Country Club, just outside Bryan, and stayed at the Colonial Manor, a nice little motel near Ohio Art.
But then came the Reagan era and the explosion of mergers, acquisitions, and leveraged buyouts. In 1985, Todd Shipyards, in deep financial trouble, raided ARO to add its solvent pension fund to Todd’s assets. Todd failed anyway, and ARO was handed off to industrial giant Ingersoll Rand. Ingersoll shut down the huge Bryan plant by the water tower and sent the jobs to North Carolina, a right-to-work state where there were no machinists unions, and to plants in India and China.
Ohio Art sold off the Etch-A-Sketch to a Canadian toy outfit and became a tiny fraction of its former self as it returned to its roots in metal lithography, making items like decorative boxes for Jack Daniel’s bottles. Mohawk, caught up in a wave of consolidation of auto suppliers, shut down about the same time as ARO. There still was a Mohawk Special Cutting Tools company, but it was now based in Shannon, Ireland. Montpelier’s school sports teams were still called the Locomotives, but the railroad jobs were mostly long gone, too.
The details may have been different, but hundreds of communities throughout Ohio, Michigan, Wisconsin, Indiana, Illinois, Pennsylvania, and upstate New York could tell similar stories. The planes stopped flying, the country clubs’ fairways grew over with weeds, and empty windows faced the town squares.
When the recession hit, unemployment in the United States rose to 10 percent, but in Williams County it was 17.2 percent. About 60 percent of the county’s land was devoted to growing corn, soybeans, and a little wheat—but farms had consolidated into big operations, so only a few hundred people still farmed full-time. Many worked for small manufacturers, and many of those were tied to the car industry. The recession made clear what had been denied for decades: nothing would ever be the same again.
By late 2018, unemployment had receded, and just about anybody who wanted a job had one. The jobs seemed fragile, though. As the CHWC leadership confronted the hospital’s budget woes with the auditors, Valerie Moreno, a forty-six-year-old wife, mother, and Williams County native, confronted hers. She’d recently left Multimatic, a company in Butler, Indiana, across the state line. Multimatic made dashboards for Ford F-150s and Silverados, as well as a bumper for the Tesla Model S. Valerie inspected welds, mainly, and applied clips and screws. The job wasn’t bad, but she wanted to move on: she was classified as a temporary employee, despite working seven days a week, which was why she made only $12 an hour. Her husband worked at a metal fastener manufacturer, but still, money was always tight. So Valerie kept looking. She found a spot at Sauder, a maker of institutional furniture. She worked in Stryker, a village in eastern Williams County, but because she’d just started, she had no health insurance and no paycheck yet.
Marc Tingle, the village contractor who would find himself dying of a heart attack in the CHWC emergency room, felt the recession coming before many others did. He worked in assembly plants—first near Bryan, and then in Indiana—putting together manufactured homes: the single-wides and double-wides that housed a lot of people in the rural parts of both states. For a while in the early 2000s, the companies, owned by big, out-of-state corporations like Warren Buffett’s Berkshire Hathaway, couldn’t keep up with demand. They offered sketchy loans to buyers with poor credit scores, who then snapped up the homes. But many buyers couldn’t make the payments, so their homes were repossessed, and manufacturing slowed until finally, as the recession hit, it stopped altogether. By then, Tingle, realizing the $35 hourly wages were stopping, too, had started his one-man contracting business and left his health insurance behind. While the vice presidents and Ennen talked to Plante Moran, Tingle was on a job, swinging a hammer.
Meanwhile, on Cherry Street, Keith Swihart was also trying to figure out how he could survive. Back in March—when CHWC was first breaking the loan covenant—his wife, Stephanie, sat crumpled over in the little dilapidated house she shared with Keith and their son, Caleb. Her abdomen ached. She was having a menstrual period, but there was so much cramping and bleeding she worried something was wrong.
Though she worked off and on as a home health aide, Stephanie feared doctors. Not just doctors, really. Stephanie feared the medical system, whatever that meant: all the machines and clinics and hospitals and bills and people who always said they knew more than you. And while they did know more than you—that was true—they had a way of making you feel small about it. And everything cost so much money. Stephanie was afraid of a lot of things, not just medical stuff, but at that moment in March something medical was happening, so Keith begged her to see a doctor. “I have insurance,” he argued. He did have insurance, along with a job, a 401(k), a wife, a child. A lot had changed since he left Michigan. He figured the bad times were long behind him.
After being laid off at Hi-Lex, after working for the soda bottler, after his divorce, Keith realized he was going nowhere in Michigan. He knew a few people down around Angola, Indiana, and in Bryan—and though in 2010 the economy was disastrous in those places, too, he decided to drive south to see what life there might bring. Keith first bunked with a friend named Chad Underwood. Chad was a good dude. He helped Keith get a used automobile and other things Keith needed to start a new life, and he introduced him to his friends.
Then Keith found a job in Ashley, Indiana. Ashley Industrial Molding manufactured thermoformed reinforced plastic parts—for example, a piece for the Oshkosh mine-resistant military vehicle. It made parts for tractors. Between the military orders and the reviving farm economy, Ashley’s business was improving.
Keith always was a good worker. In his early twenties, he’d worked for a computer numerical control (CNC) machining company, and they liked him so much they sent him out to Las Vegas for a few days of training. Vegas was crazy. The New York–New York Hotel had manhole covers with steam coming out of them, like the real New York streets he saw on TV. Keith had never forgotten that, but he didn’t have much desire to go back: Keith wasn’t a Las Vegas guy.
Keith met Stephanie through Chad. “She saw me, and looked at me, and we started talking, and it was really comfortable,” he recalled. “And one time she asked me, ‘Why don’t you come see me?’” Christmas Eve was coming up. Keith tried to plan a good first date. He thought of a movie, but the theaters closed early on Christmas Eve, so they went to the Applebee’s down in Defiance. Keith fell in love right away. “She had a smile. It was one of them things—you see the smile. Her green eyes, red hair—I mean, she had a smile like no other. And she had the personality.”
Stephanie, Keith, and Chad became a trio of best friends. Sometimes they all hung out with Chad’s fiancée, the mother of his three children. Keith always said he wouldn’t have the life he found if it weren’t for Chad.
Keith made good money at Ashley. He figured that with overtime and with the money Stephanie made, some years they brought in $60,000 before taxes, maybe more. The drive to Ashley from Bryan could take him an hour, even ninety minutes in the snow or ice, which made for a long day, but the hassle was worth it. Keith reckoned the health insurance was decent, too. It included some pretty big deductibles for him and his family—and a big number for any medical costs he’d have to pay if the shit really hit the fan—so he tried to economize, including on his insulin. But he knew a lot of people who didn’t get health insurance at all, so he figured he had a pretty fair deal.
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.
After a long time of feeling controlled by events and powers he didn’t understand, “I was in control,” Keith said. “Things was goin’ good.” When he looked back, he wondered if the spiral down started with what happened to his friend Chad. Chad suffered from what Keith called “mental issues.” He wasn’t sure just what those were: maybe Chad was bipolar, or just had basic depression or something. Anyway, in late 2016, Chad seemed to get worse. There was some family trouble, too. So Keith invited Chad to come live with Caleb and Stephanie and him in the green-shingled house they rented for $600 a month on Cherry Street. He wanted to return the favor Chad had done him. Chad wouldn’t even have to pay anything—he could get himself straightened out, maybe get some counseling somewhere. Chad was open to the idea, but he wanted to think about it for a while.
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.
Ever since Caleb’s birth, Stephanie had been fighting some anxiety and depression of her own. They both adored their son. “My child—when he smiles and looks at me and laughs…,” Keith said, not finishing the sentence. “It’s one of them things. If I had a bad day, he’s the one who gets me through my day.” And for the world, for their relatives, for themselves, they focused on that smile: not on the squirmy havoc and their son’s sometimes impenetrable remoteness and their worry about his future. Inside, though, Stephanie couldn’t escape the anxiety. Over time, it enveloped her. Then Chad’s suicide left her as brittle as a dried autumn leaf.
Later that year, in October 2017, Stephanie noticed she cramped and bled more severely than usual during her menstrual period. At Keith’s urging, she made an appointment to see a doctor over at the Parkview group on High Street, across from the hospital. Stephanie was, as Keith liked to say, “a big lady.” At about five foot seven, she weighed 295 pounds. Maybe her weight influenced her bleeding condition, or maybe not, but after examining her vagina and cervix, the doctor found nothing worth noting. Stephanie would not let the doctor perform a Pap smear to test for cervical cancer—she was too afraid. Besides, the last time she’d had the test, the results were okay.
That she was bleeding abnormally was obvious, so the doctor cited the medical name for it—menometrorrhagia—and prescribed Mirena, an intrauterine device (IUD) containing the hormone levonorgestrel. Usually women have an IUD placed to prevent pregnancy, but sometimes it’s used to prevent heavy periods, and that’s what the doctor had in mind.
Though Stephanie told the doctor she’d have the IUD inserted, gave her consent for its insertion, and was then tested to be sure she wasn’t pregnant, she didn’t follow through. Her fears were stronger than her desire to stop the cramping and bleeding. She needed a psychiatrist as much as she needed a gynecologist, but Williams County didn’t have a psychiatrist.
Stephanie tried to control her ache and bleeding with birth control pills, but they didn’t help. She became anemic. She started taking iron supplements; they made her constipated. Then she was injected with Depo-Provera, a hormonal birth control that lasts about three months and can stop periods.
The bleeding subsided until the gush of blood and the abdominal pain in early March 2018. Again Keith urged Stephanie to see a doctor. But the bleeding soon stopped so Stephanie decided not to go. Six days later, though, she was worse, plagued with a fever and nausea. Keith drove her over to the ER at the CHWC Bryan hospital. A computed tomography (CT) scan of her abdomen appeared to show inflammation around her colon: perhaps Stephanie had appendicitis.
That day, CHWC transferred Stephanie to Mercy Health St. Vincent Medical Center in Toledo—part of a chain of twenty-three Mercy hospitals across Ohio and Kentucky. Keith drove Stephanie there. The doctor in the St. Vincent’s ER decided Stephanie was suffering from sepsis and admitted her. Over the next five days, she was treated with IV fluids and antibiotics, and though the sepsis subsided, another CT scan revealed a mass on her cervix. The way Keith remembered it, “When she was in St. Vincent’s, they said they thought they seen something on one of her CT scans, but it didn’t go any further.”
The bills added up: the office visit in October 2017, the pregnancy test, the CHWC ER charge, the CT scan, red blood cells to treat her anemia, five days at St. Vincent’s in Toledo, and separate bills from providers to the hospitals—the radiology company that worked inside the Bryan hospital, the ER staffing company that covered CHWC’s ER, a pathology corporation in Toledo. Keith had never heard of any of them before the bills came.
Keith’s insurance covered a lot of it, but he was still on the hook for thousands—he never did know the exact amount. The mailman dropped the white envelopes through the door slot on Cherry Street, but between trying to care for Stephanie, looking after Caleb with help from Stephanie’s niece, and working, Keith was already swamped.
By June, Stephanie’s abdominal pain wrapped itself around her back, worse than ever. Though still reluctant, she made an appointment with the CHWC women’s clinic. Samar Hassouneh knew within minutes of beginning her examination that cancer had invaded Stephanie’s cervix and that it was well advanced. Bits of Stephanie’s cervical tissue crumbled away the moment the doctor touched it. Hassouneh sent this tissue to the hospital’s pathology lab, where pathologist Shannon Keil confirmed invasive squamous cell carcinoma. Hassouneh knew the diagnosis had come far too late—Stephanie was about to die.
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.
Keith didn’t like to admit it because he thought it sounded bad, being a diabetic and all, but he drank some after Stephanie died. He’d get Caleb down to sleep, sit in the recliner, and drink. He knew he shouldn’t. He knew he should take care of himself, but he didn’t do that, either. He missed insulin shots. When Stephanie was alive, the house had been bedlam even on good days, thanks to Caleb. Now anarchy ruled. A relative of Stephanie’s came by a lot to look after Caleb and to do some cooking; for a little while she practically moved in. But she couldn’t replace Stephanie.
Keith was low. Designing, ordering, and paying for a headstone for Stephanie’s grave consumed his energy. And when he looked at Caleb and thought about driving to work in Ashley—where he’d be an hour away if Caleb needed him—he decided he had to quit his job, figuring he could go to work at the big distribution center for Menards, the home improvement retailer, where lumber and other supplies were shipped in and then shipped back out to stores around the region. The center was up by Holiday City, a tiny collection of motels and gas stations near the Ohio Turnpike about twenty minutes from Keith’s home. Menards always seemed to be hiring. Keith couldn’t see any other way.
For decades after it opened in 1936, Donald Cameron’s Bryan hospital cruised along as an unremarkable part of the local fabric. A year after opening, Cameron united his Angola and Bryan operations into a single tax-exempt charitable corporation: Cameron Hospitals, Inc. He imagined himself in the mold of beneficent medical pioneers like the Mayo brothers, the Menningers of the Menninger Clinic in Kansas, and Cleveland Clinic founder George Crile. He would bring medical excellence to rural America.
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.”
Cameron was particularly galled after 1946, when the federal government entered the hospital-building business. The passage of the Hospital Survey and Construction Act, called the Hill-Burton Act after its sponsoring senators, Republican Harold Burton of Ohio and Democrat Lister Hill of Alabama, provided in-kind grants and loans to communities wanting to establish nonprofit hospitals. Cameron saw the law as “an example of waste and extravagance with taxpayers’ money.” “Almost any geographic taxing unit,” he argued, “which will take the usual pauper’s oath that it is too poor to build its own hospital may apply to the federal government for a grant in aid, and if approved by the State Board of Health may receive a gift from our rich uncle.”
Hill-Burton hospitals built in nearby counties competed with Cameron’s own in markets he hoped to dominate. (They “surround us,” he complained.) Cameron tried to enlist the help of state and federal legislators to shut down Hill-Burton, but building hospitals proved too popular with both Republicans and Democrats.
Cameron did take charity cases: few were turned away for lack of funds, and he boasted that his hospitals admitted “many colored people.” (Hill-Burton, reflecting its origins as a compromise between two senators from opposite sides of the Mason-Dixon Line, permitted states to discriminate against African Americans in admittance policies.) But whether or not to provide such charity care should, Cameron believed, be his decision to make. He’d used his own money to build two small hospitals where there’d been none, and now he felt entitled to be left alone to manage his business on his own terms.
His hospitals were lucrative. The nonprofit corporation leased the hospitals from him, and he headed and controlled the board. The hospitals provided him with an arena in which to practice surgery and, of course, to collect his fees. He recruited and set up doctors in small, one-man practices in villages by purchasing houses they could use as both residences and offices. The new doctors understood that, in return, they were to refer patients only to the Cameron hospitals, where Cameron was the head surgeon. Fee-splitting—similar to a kickback and now largely outlawed, in which one doctor pays another for a referral—was standard procedure. The hospitals also offered on-site offices to doctors who, in turn, paid 25 to 30 percent of their fees to the hospital via a pooled fund. They also paid a monthly fee to Cameron personally. By 1962, Cameron was receiving $500 a month (about $4,200 in 2019 dollars) from the funds in Angola and Bryan.
In 1959, in the middle of an IRS investigation of the Cameron hospitals’ business arrangements with doctors, Cameron sold the buildings, real estate, and equipment to Cameron Hospitals, Inc., which then deeded them to the people of Angola and Bryan, respectively. The municipal court set up a new board of directors, and the hospital became a private, nonprofit community asset. In an effort to resolve the appearance of participating in a for-profit outfit operating under the guise of a nonprofit, the doctors formally signed an agreement to create the Bryan Medical Group and to move out of the hospital and into a building across the street. Cameron retired from the board and severed his business relationship with the corporation in 1964.
Thanks to Bryan’s prosperity, the hospital continued to prosper, too—at first. It expanded and renovated. But Cameron was right about the Hill-Burton hospitals. They did siphon off some of Bryan’s business. Thanks to improved highways and the growth of specialty medicine, more Williams County residents chose to drive to Fort Wayne or Toledo to see specialists. In 1952, the county’s townships built Williams County General in Montpelier, offering patients a public option within the county itself.
By 1973, the hospital found itself in deep trouble. Parts of its physical plant were old, and so was the equipment. When Phil Ennen’s mother, Mary Helen, began working there as a nurse, she was so appalled by the unsafe conditions that she quit. Small-town people weren’t stupid, she said; they knew lousy care and facilities when they saw them, so they’d stop coming. And they did. A short time later, though, she was offered a job as chief of nursing. Come back, hospital officials told her, and do something about it. So she returned—only to be fired after confronting doctors about their poor treatment of “her” nurses.
Grant Brown, a board member who owned Brownie’s Drive-In—a Bryan institution—had a son who lived in Columbus. His son had become friendly with a man named Oreste “Rusty” Brunicardi, who happened to be director of patient care at Ohio State University’s hospital. Brown called Brunicardi, telling him that the Bryan hospital was about to go broke. As a favor, could Brunicardi come up to Bryan to troubleshoot? It’d be temporary, maybe three years—just long enough to plug the money drain. Brunicardi told his wife they were taking an unexpected detour to a small town in northwest Ohio but that they’d soon be back in Columbus. The detour lasted thirty-five years.
Once in Bryan, Brunicardi responded to the crisis by mounting an immediate fund drive for $150,000 and by launching a campaign to reinforce the idea that the hospital was a community asset. Then he spent. If Bryan didn’t have a service patients needed, he tried to supply it. After the nurses kept mentioning Mary Helen Ennen, he hired her, and both she and her husband, Jack, befriended Brunicardi. He recruited staff doctors. He spent on new technology and specialized care, even establishing the radiation oncology center. “Just because we choose to live here in a small town doesn’t make us second-class citizens,” Brunicardi would say. He built the clinic in Archbold in hopes of fending off westward expansion by Toledo giant ProMedica. He figured Fulton County doctors could refer patients to the Archbold clinic, then on to Bryan if necessary, and not to ProMedica’s facilities.
Brunicardi ran his strategy partly by ducking and dodging through an increasingly complex and chaotic healthcare maze—bending a rule here, avoiding a rule there. He managed with little oversight by the board. He also recognized that healthcare was a political enterprise as much as a scientific or financial one, so he made sure state and federal politicians heard his voice. “I’d go to the doctors and say, ‘Look, this person is going to get elected. Would you please make a $100 donation [to the campaign]? We’re going to need his support.’ And then I’d send it in on the letterhead of the hospital.”
He slowly convinced reluctant county and Montpelier officials that two hospitals in the same county duplicated services, and that the competition for patients damaged both. He assumed administration of Williams County General in 1978. In 1986, they formally merged. Williams County General’s status changed from public (meaning it was supported by taxes) to private nonprofit (meaning that it was controlled by a private board but qualified as a nonprofit organization under the federal tax code and supported itself on the fees it charged).
Mary Helen and Jack retired to Florida immediately after Phil graduated from Bryan High. So he attended Florida State, then entered the school’s master’s program in public administration while working for the Florida legislature. On a visit back to Bryan to see his longtime girlfriend, Mary Ebersole, he took her to dinner at Sam’s, a diner in a one-stoplight village called Blakeslee. There, Ennen—a man given to quoting Looney Tunes cartoons, old movies, and the sorts of books English majors read in class—looked across the wooden table at Mary and proposed by asking, “So, we gonna do this?” Knowing what she did about the Ennen clan’s preferred forms of communication and Phil’s sense of humor, Mary considered the proposal romantic.
After a spring wedding in Bryan, Mary moved to Tallahassee, and the couple settled in. As Ennen was finishing his master’s degree, he received a permanent job offer from the legislature. Then, on another visit back to Bryan, he walked into Brunicardi’s office just to say hello. “I’ve been trying to find you,” Brunicardi said. “You have a few minutes to talk?” Brunicardi offered the twenty-three-year-old Ennen a job as chief operating officer of the hospital at a starting salary of $26,000 and with the understanding that one day he’d fill Brunicardi’s shoes as CEO. Ennen didn’t know a thing about running a hospital, but to Brunicardi, that was the point. He wanted an apprentice he could shape in his own mold.
“His mom and dad were special people,” Brunicardi told me. “I just felt he would be a good person because he knew what it would take, and because he was very intelligent. I always had it in my mind he would take over, from the very beginning.”
The Ennens liked Tallahassee. But they were both Bryanites. And here was a job that promised to one day put Phil at the top of one of the town’s most important institutions, and at a good starting salary. By saying yes, he could be set for life while many of his peers were still trying to find their way.
Brunicardi retired in December 2007 as the undisputed leader of what was now Community Hospitals and Wellness Centers. When he drove out of town, he passed through the intersection of Main Street and Brunicardi Way. Though Ennen took over as CEO in January 2008, for over a decade after, staff members would still ask, “What would Rusty do?”
Just as Brunicardi hoped, Ennen had absorbed many of his lessons. For example, Ennen’s personal politics were what used to be considered pragmatic middle-of-the-roadism before the age of Trump but since then could be called moderately left. Trump disgusted him. Even so, he held a fundraiser at his home for Bob Latta, the Republican congressman who represented the district and whose main accomplishment was carrying water for Trump. But Latta held the office, and Ennen wanted his ear.
Ennen managed CHWC with nearly the same amount of independence from the board as Brunicardi did—and Brunicardi had taught him that the CEO could, and should, run the place in any way that got the job done. American healthcare was an absurdist game of Jenga. You had to juke and shuffle your way around it and through it, and you couldn’t wait for permission to hustle. But almost from the moment he took over, Ennen faced turmoil unlike anything Brunicardi had. There was no playbook for guiding a community hospital through the deepest economic downturn since the Great Depression.
People stopped coming to the hospital because they couldn’t afford it. “It has become clear the national and international economic problems will not be resolved quickly,” Ennen wrote to the employees in October 2008, nine months after becoming CEO. “Effective immediately, I am placing the hospital on a fiscal watch.” He limited overtime, incentive pay, travel, and hiring.
Those measures weren’t enough. A month later, he cut $1 million in employee benefits. The first layoffs came two weeks after that; more followed. Ennen felt each one. He recognized, in a way few others in Bryan did, that the hospital wasn’t just a place where sick people went for care, or an amenity that could attract business, like in the old days. In this new economic realm, it was the business: an economic lifeline to the town. “In many cases, I know we have employees who are the only family member with a job due to cuts all over the area,” he wrote in December 2009. “The economic recovery that Washington keeps talking about has not arrived in Northwest Ohio.”
The hospital eventually did begin to recover, and Ennen, who’d proven he was more than Rusty Brunicardi’s protégé, would be chosen by peers to a term as president of the Ohio Hospital Association. But by then the Bryan Medical Group, seeking safety, had sold itself to Parkview. That meant more and more patients were being referred to Fort Wayne. And CHWC’s customers emerged from the recession changed. Forces from outside their community had triggered fear, not only about work, but about the foundations of life in America.
A few days after the meeting with the auditors from Plante Moran, a group of about twenty new hospital hires sat in chairs behind institutional-style tables facing a white screen. The new-employee packets at their fingertips lent a first-day-of-school air. Some had long experience working in hospitals; others had none. It didn’t matter. They were gathered for an indoctrination into the CHWC tribe.
Kim Jerger was already an honorary member—he’d been born into it. He sat smiling in his scrubs, thinking about his mother, who had worked at the hospital when he was young. If he were to walk out of the room and go to a window facing Garver Park, he could look down on the old family home, a small white clapboard-sided house where, on icy or snowy nights that turned driving into a life-or-death adventure, half the hospital staff, so it seemed, would camp out on the living room floor. He graduated from high school with Phil Ennen’s brother. Brunicardi’s son was a best friend. The two teenagers earned a little extra spending money by helping Brunicardi compile a database of rural hospitals.
Now he was back, after making a career of nursing. He’d climbed the rungs of the healthcare ladder, moving from one hospital to the next in Ohio and Indiana: Cincinnati Children’s; the Mercy hospitals in Urbana and Springfield, Ohio; a hospital in Fort Wayne, where he worked in infection control. But he’d had enough of the larger systems. The other hospitals were too commercial, too bottom-line, too paternalistic, too alienating, and not at all what he remembered from his old Bryan days. The Fort Wayne hospital trapped itself in a financial morass and in poisonous staff politics. So when CHWC looked for a director of perioperative services on the surgery floor, he leapt.
Nurses from other hospitals formed part of the incoming class, too. There were also a couple of clerical workers, a former law enforcement officer, and a maintenance man.
One by one, the vice presidents entered the room to introduce themselves, make a short speech, and cover a few points pertaining to their areas of responsibility. The introductions, though, weren’t the most important message: Over and over, they talked “family,” “friends,” “community.” CHWC was different, they said. CHWC put the patient first because the patient was the old woman you saw in Walmart, or the kid on your twelve-year-old’s soccer team, or your junior high English teacher.
Jan David, the vice president for patient care, started. A nurse at the Bryan hospital for decades, David was a slight, soft-spoken woman with dark, bobbed hair who never seemed to remove her white hospital coat. The patients, she said, are our people: they are us, and we are them.
Chad Tinkel, the chief financial officer, followed. The picture of the buttoned-up accountant with his brown shoes, sweater vests, closely clipped hair, and nondescript glasses, Tinkel embodied the notion of CHWC as local family. He’d grown up in Bryan, attended Ohio State, and graduated with an accounting degree. Like Ennen, he’d married a Bryan girl, Jodi, whose mother was in labor at the hospital at the same time as Tinkel’s. Jodi had gone to medical school and now worked as CHWC’s staff medical cardiologist.
Wade Patrick, the chief information officer, was a newcomer to Bryan. A brick wall of a man, with a shaved head, Patrick had worked as a bar bouncer back in college at Purdue and still regularly heaved weights at the gym. Though he’d been hired on only about a year before, Patrick embraced the family ethos, too: his romantic partner, Janice Bearer, worked as a nurse in the ER, and his daughter was about to start work as a medical scribe in the ER. His time at other hospitals was still fresh in his memory, he said, teaching him that “we’ve got something special going on here.”
Mike Culler, another native Bryanite, was a part-time farmer. Tall, balding, bespectacled, with an excitable manner and a still-strong Ohio country accent, Culler held Ennen’s old job: chief operating officer. He was married to Dina Culler, Ennen’s executive assistant.
Ennen entered. “Welcome,” he said, “to this crazy family we have.” He told the incoming employees how he’d been there thirty-two years—the only hospital he’d ever worked at. He meant it to be a statement of continuity, but then he warned that the continuity—the “family”—was under threat. “None of our customers want to be here,” he explained, but the customers paid the bills, and the hospital and their jobs depended on that money. So customer service and safety remained, now and always, the priorities. “There’s a lotta stress in our world right now,” he said. “There’s a lotta stress in the town. But we’re still this independent organization. We are bucking the trend right here. It’s just us. Nobody owns us, and we’d like to stay that way. In order to stay that way, the patients have to like us.”
Angelia Foster, vice president for human resources, whose show this was, spoke last. Like Patrick, she was a newcomer, and more than any other member of the C-suite team on the fourth floor, she projected a corporate veneer. She’d trained as a consultant at Arthur Andersen, once one of the biggest accounting firms in the world. She was steeped in the business and process of modern American management to a greater degree than anyone else in the organization.
Foster arrived at CHWC after having worked for another community hospital, Passavant Area, in Jacksonville, Illinois. Passavant was also once independent before a chain, Memorial Health System, took it over. Foster worked there at the time. Just before starting at CHWC, she had been diagnosed with breast cancer. She told Ennen she’d give up the job she’d just been hired for, explaining that she didn’t want to burden CHWC’s own health plan and that there’d be a delay before she could occupy her position. Ennen promised to wait and insisted she accept.
A nurse new to the staff had a question regarding guns. She wanted to carry hers. “What is our policy on concealed carry?” she called out. Foster explained that guns were not allowed in the hospital. “Can we at least have a gun in our cars?” the nurse asked.
Foster broke the room into small huddles and assigned each group’s members to introduce themselves to one another and explain what had brought them to CHWC. “I’ve worked for ProMedica,” a newly hired nurse explained of her time with the Toledo-based chain, “and it’s nothing like it is here.” CHWC, she said, was much more laid-back. And then she invoked the words “family” and “community.”
“I’ve been through the different systems,” another nurse added. “Three name changes, bought twice, and the fourth time, I was back in the ER”—a position she had tried to escape. That’s what awaited CHWC should it fall to outsiders. Her testimony was all that the retired law enforcement officer, a longtime Bryan fixture just starting his new job as a hospital security officer, needed to hear.
“Everbuddy is comin’ after this hospital,” he said, his voice growing louder with each sentence. “Those people can’t stand to have a facility like this. I’ve lived in this town fifty years, and most of ’em involved in the community, for fifty years, and it makes a difference” that the town has its own local community hospital, he explained. But, he warned, “investors, ’n this ’n ’at, they know what’s happenin’ here. They’re chompin’ at the bit to take this over.”
All these fears—all the machinations and plans and glide paths and financial intrigues—overlooked a paradox hinted at by Ennen: CWHC didn’t make any money by keeping people out of the hospital. It depended upon the sick and the accident-prone. It needed people to have heart attacks and blocked arteries so they would fill Kesireddy’s cath lab. It needed the diabetics, the smokers, the obese, the cancer-stricken. Its life depended on them because CHWC was a business in search of customers. Luckily for the hospital, there was no shortage. On a micro scale, CHWC was a family home where the ill and injured could come for solace. The family was dysfunctional sometimes—and not everybody loved everybody else—but it was Ennen’s family. On the macro scale, CHWC was a piece on a political and economic chessboard, and if Ennen wanted to help realize the ambitions of that family, he had to play like a master.