Janis Sunderhaus was a walking contradiction. She was a “terrible” Catholic who attended mass most every Sunday. She swore like a thirteen-year-old street tough and claimed to “never cry” but went weepy at stories about the kindness of nurses. She built and ran one of the biggest healthcare operations in the state, but collected a long list of medical enemies and relished any chance to verbally punch them in the nose by throwing rhetorical jabs like “I was like a raging, friggin’ lunatic! I get in this doctor’s face, and I’m, like, ‘You take my patient or I’m fucking calling Medicaid. And I’m calling fraud lines’” and “They always say that shit! Doctors say whatever they want to say. Listen, listen: I’ve seen doctors fuck people up unbelievably, and then say, ‘We found it.’ And people are, like, ‘Thank you, Doctor.’ Oh my God!”
But belief embodied her most profound contradiction. She was as cynical as a film noir private eye, and yet Sunderhaus believed. She believed in inspiration and faith and justice, and when any of these beliefs were violated, she couldn’t help but be outraged and then try to do something about it.
Nursing had made her that way (“I’m a crazy nurse. I have two daughters who are nurses. Nursing is my identity”), and her experiences nursing in the poorest neighborhoods of Lima, Ohio, as well as her life since, had taught her a hard truth about the American medical economy and how it had evolved.
Sunderhaus was part of a Lima tradition of nurses creating new ways to care for the city’s people. Nursing nuns from the Sisters of Mercy founded St. Rita’s, one of the two big hospitals in Lima. The nuns came to town in 1918 to minister to the sick among Lima’s industrializing workers during the ravages of the same influenza epidemic that had once prompted Bryan to seek its own hospital. St. Rita’s became Mercy Health St. Rita’s Medical Center. Its crosstown rival, Memorial, began life as a tax-supported community hospital. Now it was Lima Memorial Health System, a ProMedica affiliate with the big green signage beckoning from atop its buildings.
Sunderhaus, a Lima native who had watched the transformations from the inside, developed a dark view of big nonprofit hospitals. “Nonprofits all began for a mission. There’s a reason it’s a nonprofit. You know, you believe in puppies, or whatever. People are committed to that. And you work hard, and you’re committed, and you build this organization that then takes care of all the puppies. And then you’ve got all these people that are now committed to taking care of puppies that now are this big organization. And at some point, you say, ‘Oh my God, if we don’t get more money in here, we can’t pay for everyone to take care of the puppies.’ And then pretty soon the conversation becomes more about the organization and less about the puppies. And then, pretty soon, you don’t even know there are puppies around. The puppies are drowning in the river right next to you, and you’re worried about keeping everyone employed. That’s what happens to nonprofits.”
Sunderhaus ran a nonprofit, Health Partners of Western Ohio, that operated the Bryan Community Health Center, the clinic that helped Keith Swihart. She didn’t see any contradictions in being a mass-attending terrible Catholic who cussed her way through life and viewed nonprofits with cynicism while running one.
Lima, the seat of Allen County, boomed with the rest of northwest Ohio during the first half of the twentieth century. European immigrants, whites from Appalachia, and African Americans from the South traveled north to work in foundries, to build battle tanks, to manufacture auto parts. By 1950, nearly 50,000 people lived there. Allen County’s population peaked in 1980 at 112,000—and then slid, year by year, as the American middle deindustrialized. By 1990, Lima’s population had dropped to about 45,000. (In 2019, it stood at just over 37,000.) Lima found itself with two large hospitals, Memorial and St. Rita’s, trying to survive on a diminishing population. The city didn’t need both. There was talk of a merger.
As one experiment among several in how such a merger might operate, the two hospitals supported a free clinic to serve the city’s growing population of poor people. At the time, Sunderhaus worked as a nurse at St. Rita’s. She also had four young children and was studying for her master’s degree in nursing administration. Her husband taught at a Catholic school. She thought the proposed clinic, slated for operation from six to ten each night, could be an opportunity to escape her impossible schedule. Her husband could be home with the children on those nights, and she’d have weekends off.
She worked as a behavioral health nurse, not as a public health nurse or as a primary care nurse. But once she started working in the free clinic, she realized how blind she’d been to her own patients’ needs. “All of a sudden, I’m dealing with high blood pressure, diabetes, and all this shit. And I just immediately fell in love with it, because it was my mental health patients now seeking medical care. And I was, like, ‘Now I’ve got the full picture.’”
The people she saw for mental health problems also required help with their hearts, their teeth, their weight, their budgets, their diets, their homes. The medical system, whatever that meant, had failed them. Hospitals like St. Rita’s and Memorial, doctors, nurses like her, public officials, and whoever it was who dealt in money had all failed them. Everybody said they cared about the young pregnant woman living in Victory Village, the barracks-like housing built by the federal government during World War II to accommodate segregated African American workers. But there was no place for that young woman to go for prenatal care aside from an emergency room, where she’d sit and wait with other scared pregnant young women to see a doctor she didn’t know and who didn’t know her. If you valued that young woman and her baby, that’s not what you’d do.
The clinic experiment didn’t last long because relations between the hospitals floundered. Then, during the Clinton administration, the city of Lima applied for and received a grant for neighborhood policing. Storefront police stations opened around the city. St. Rita’s suggested placing nurses in some of those storefronts with the neighborhood cop. After an African American minister in Lima’s south end badgered the hospital to assign a nurse to his neighborhood, Sunderhaus, who’d grown up there, requested the job.
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?’”
She received some schooling when a fifty-eight-year-old woman walked into the office complaining that she didn’t feel well. Sunderhaus took her blood pressure. It was around 240/120. “I was, like, ‘Yee! She’s gonna stroke out on me. I’m a little psych nurse. Threaten to kill yourself, jump out a window: that doesn’t bother me. Threaten to stroke out in my office, and I’m, like, ‘Ehh, I really don’t want you to die here.’”
She closed up her office, put the woman in her car, and drove to the St. Rita’s ER. Treatment there forced down the blood pressure, and, that night, Sunderhaus bragged to her children over dinner that Mommy had saved a woman’s life.
Her self-congratulation proved premature. Three weeks later, the woman returned. What’s wrong? Sunderhaus asked. The woman’s blood pressure had spiked again, back to where it was. The hospital, the woman explained, “‘gave me this list of people. I called every one of them, and nobody would take me. They gave me two weeks of meds, and I ran out.’” Well, Sunderhaus told herself, you didn’t save a life. You did pretty much nothing.
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.”
“I saw a glimpse of the healthcare system from a poor black perspective that very few white people get to see,” she recalled. People were getting pushed around. Doctors would use any excuse, like a missed appointment, to kick a Medicaid patient off the practice’s rolls. They’d charge money to get back on the rolls, or charge money up front to see the patient in the first place—money many didn’t have. There was no preventive care. Then, when people became sicker, they wound up being admitted to the hospital, costing Medicaid and Medicare many more thousands.
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.
Such places already existed, and had for a long time. “Dispensaries” were as old as the United States. They were often founded for a specific group, like workers in one factory or residents of one neighborhood, and they could be affiliated with a nearby hospital or with a charity or social service organization. The concept expanded during the Great Depression—some served tens of thousands of people annually—then faded, then surged again during Lyndon Johnson’s Great Society push with the Community Health Centers program. These clinics (somewhat reminiscent of Frank Dresser’s proposal for “consulting stations” made during the early twentieth-century battles over government healthcare) aspired to be what Sunderhaus wanted for Lima: one-stop primary care providers servicing poorer neighborhoods for free or on a sliding scale. Support came from the federal government. They became “federally qualified” for aid.
George W. Bush reinvigorated federally qualified health centers by pouring money into an effort to open twelve hundred of them during his first five years in office. Sunderhaus believed a single-payer national health plan was probably a better answer to America’s medical care needs, and that Bush’s advocacy for the centers was a way to deflect comprehensive healthcare reform. But as long as the money was out there, she saw a way to open the kind of service she’d hoped for since she first worked in the free clinic.
Sunderhaus established the South Side Planning Committee in 2002, with representatives from the Red Cross, United Way, both hospitals, city hall, and local neighborhoods. They held meetings. Soon the hospitals stopped coming. The Red Cross and United Way dropped out. The health department abandoned the committee, too. Then she went to mass.
The priest told a dramatic parable about a young boy who ventured deep into a canyon his elders had been afraid to explore but where they’d hoped a treasure awaited them. The boy reached the end of his rope. On faith, he let go, dropping onto a soft landing, where he found himself surrounded by jewels. “And that priest looked directly at me, and he says, ‘Sometimes you have to trust that the Lord will have a soft landing.’ And my husband looked over at me, and he’s, like, ‘Hee-hee-hee.’ I quit my job the next day. It was Martin Luther King Day.”
In July 2003, Sunderhaus opened a space—borrowed from the local Head Start program—with a used exam table, some boxes, a staff member she’d pried loose from the CEO of St. Rita’s, and a young doctor who’d been moonlighting at Memorial’s ER. They saw eight patients their first day even though they had no phone, no advertising, no news coverage. By the end of the week between twenty and twenty-five patients were coming to the clinic every day. Each uninsured patient paid $4, with Medicare or Medicaid covering the rest. A few neighborhood people donated money. “We had a little old lady, her name was Alice. She started sending us $2 a month. She was ninety-three. I’ve kept all the letters she sent me. We would be ready to drop, and we would get a letter from Alice with $2.”
By the time Keith walked into the clinic in Bryan that previous fall, Health Partners of Western Ohio had fifteen clinical outlets and a budget of $34 million, and was serving 37,000 patients—including Pastor Greg Coleman and his family. Fifteen percent of the patients had no insurance. About 60 percent were covered by Medicaid, 12 percent by Medicare, and the rest by private insurers imposing high deductibles. Health Partners worked on a sliding scale, with a $10 minimum fee. Sunderhaus, who went unpaid for the first six months she was in business, now earned $228,000. Her doctors and nurse practitioners made median national wages for their jobs. (Barb Purvis, the nurse practitioner who cared for Keith, made $120,000 a year, plus a bonus that was dependent upon her patient volume.)
Sunderhaus managed all that by applying for grant money and subsidies, and by going into the drug business. Health Partners ran a 340B drug program. Under 340B—a federal rule—drug manufacturers who wanted their products approved for reimbursement by the Centers for Medicare and Medicaid Services had to agree to sell “outpatient” drugs at a steep discount to federally qualified services like Health Partners. On average, such entities received about a 22 percent discount off the wholesale price of the drugs. CMS would then reimburse the centers for dispensed drugs at the same price as non-340B providers. Health centers could keep that profit to fund themselves, and still save their patients money. During the first week in operation in Lima, Sunderhaus recalled, “we had a lady who came to get her blood pressure medicine. It was like $58. And she probably lived on $800 a month. And Jenny said, ‘I’m gonna try to put it through [the new system] and see what happens,’ and it came through, and it rang up $22. That was the savings from the 340B price. And the patient cried. The patient cried. That’s thirty bucks. If you’re living on $700 or $800, that’s big.”
The pharmacy business brought Health Partners to Bryan. The Four County Alcohol Drug Abuse and Mental Health Services board, where Tonie Long worked and Les McCaslin was chief, had made a commitment to provide psychiatric drugs to patients who could not otherwise afford them. But the drugs were costing the board a fortune. Sunderhaus offered McCaslin the benefits of her 340B discount.
But, she told McCaslin, “‘your psychiatrists don’t know what the fuck they want.’ And a report came out, and mentally ill people were dying twenty-five years earlier, based on high blood pressure, diabetes—all that. Crazy people need primary care stuff, too.” The more they talked, the more convinced McCaslin became that Health Partners should just open a facility in the area. At first the fledgling clinic worked out of McCaslin’s offices, but McCaslin provided $200,000 out of his budget for a place of their own.
Sunderhaus and McCaslin scouted Defiance, but they faced the Mercy-ProMedica battle for patients there. The hospitals “didn’t want us,” Sunderhaus said. Then they found an empty building just off Bryan’s town square. McCaslin provided $1.2 million for building out the interior to accommodate a medical operation and to pay for bright, sunny decor and professional-looking furnishings (Sunderhaus was adamant that her facilities look spiffy: “It says, ‘I value you as a person, and you deserve this. You deserve it, no matter what. Because you’re human. You just deserve it’”).
The Health Partners clinic wasn’t the only or the first alternative provider in Bryan. A local minister opened the Compassion Clinic on the east side for limited hours in 2005, with different volunteer doctors taking turns at providing care. Spangler Candy contracted with Activate Healthcare, a private equity–backed corporation, to give basic primary care to its Bryan employees at a cost of about $31 per enrolled employee. The city of Bryan followed suit not long after Spangler. (Such on-site company clinics were once common in the United States.) Activate was bought out in 2019 by Paladina Health, another private equity–backed outfit that promised to deliver “value-based” primary medicine and to “transform healthcare in America.”
From the earliest days of the dispensaries, doctors moaned about free and discounted care. During the rise of the Great Society clinics, AMA president Milton Rouse called them “unnecessary” and “wasteful.” Some local medical societies pressured hospitals to refuse admitting privileges to doctors who worked for the clinics. When the Bryan Community Health Center opened in January 2016, there was opposition in Bryan, too—from both doctors and dentists. “They don’t like the competition,” Sunderhaus said. “You have to be willing to piss off a few.” When the center bought a dental van with help from the ADAMhs board, and when the van began visiting the county’s schools, there was more blowback from the local dentists, who accused the health center of stealing patients from them. Yet not a single private-practice dentist in Williams County accepted Medicaid patients—in a county where a lot of children were on Medicaid, even if their parents were not, and where far too many suffered from “Mountain Dew mouth,” if not meth mouth. The need was so great that the dental clinic in the Health Partners building had a six-month waiting list.
And Parkview doctors weren’t much happier with the center, Sunderhaus believed, “because they’re charging hospital outpatients for everything. And their job in Bryan is to refer those patients to big services in Fort Wayne. Their job is merely as a feeder site for testing. And for their specialists. That is their only purpose for having family practice there, to feed their beast. Feed the beast of the MRI, the CAT scan machine. They keep track of those docs: how much they prescribe, how many tests they ordered. That’s how they decide who gets bonuses and who gets big bucks. Yeah! We piss everybody off!”
Ennen figured the new Health Partners clinic was like the Spangler Activate clinic: one more primary care site that could feed his beast, send patients his way for more advanced procedures, specialty services, imaging, tests. And he was happy some people who wouldn’t walk through the doors of his shop were at least receiving some care—what Sunderhaus called “a hug of services.”
The Bryan clinic’s medical staff consisted of one physician, two nurse practitioners, a medical technician, a chiropractor, a full-time dentist, three dental hygienists, three pharmacists, and two mental health counselors. They were all very busy. “We are so far behind!” center director Ronda Muehlfeld said one morning shortly after the doors opened.
They saw a lot of people like Keith. Rationing of insulin was common, and so the effects of rationing insulin were common, too. Insulin could cost a diabetic $500 to $600 a month. “That’s rent,” Muehlfeld said. A vial of Levemir could cost over $300 in a regular pharmacy. Their patients could get it for $10.
A young woman in her late teens and wearing a Team Jesus camo T-shirt approached the reception desk with other members of her family. She was new to the clinic and hoped to establish care there, because she wanted to see a dentist. She’d never seen one. It would be a long wait, the intake clerk told her—months, maybe. The young woman said she’d waited this long, she could wait until then.
Customer after customer checked in: another young woman, who’d missed a Pap smear and dental appointments because she didn’t have a way to get to them; an old lady who’d arrived from Mexico to live with her son; a woman, about sixty, who’d had a stroke and could no longer speak; a bronchitis case; a flu case; a mother pushing her wheelchair-bound epileptic daughter, who received Medicaid, and so could not find any other doctor in town who would take her. A clerk phoned a thirty-two-year-old woman who wanted to start Vivitrol, a drug used to treat opiate addiction. She’d missed two earlier appointments and was now late for another. No transportation, she said. Many other doctors would write her off as noncompliant and unreliable. It’s very important you start, the clerk said. How about one-fifteen?
The Smiths* were married, in their late thirties. Belle was obese, diabetic, and had not had her insulin lately. John was dressed in a ball cap and camo pants and was missing a front tooth. Both worked as cleaners at the service plaza on the Ohio Turnpike, out by West Unity, for a turnpike contractor called Any Domestic Work, or ADW.
John was originally from Tennessee. Belle lived in Williams County. They had met through Plenty of Fish, an online dating service. She came down to Tennessee for a visit, and then they moved together up to Williams County. John found a job at Rassini Chassis in Montpelier for a while, making $11 an hour, then did a stint at Kamco, and after that worked security at Menards for over $11, but his sciatica got worse. After some time off, they both started with ADW so John could save up money to fix his vehicle—or to get it good enough, at least, to make it to New Jersey, where, he said, a buddy might have a job for him that paid $20 an hour. ADW offered health insurance, but it didn’t kick in for ninety days, and, anyway, they each made only $9 an hour. He handed over a paycheck to prove it. The Ohio Turnpike Commission paid ADW $342,000 a year to keep that plaza clean.
As the Smiths were starting care at the Health Partners clinic, in the fourth-floor boardroom, 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.
Angelia Foster favored creating a psychiatry service line. Nobody in any position to know—Jim Watkins at the health department, the mayor of Bryan, leaders at the ADAMhs board, Jim Hicks at EMS—had any doubt that Williams County’s mental health was a shambles. The county’s crisis wasn’t any more or less severe than a hundred other counties in the United States, urban or rural, but, being rural, Williams lacked for diagnosis, treatment, and care.
Foster also mentioned geriatrics. Like many other rural areas, the county was aging but had no geriatrician—no geriatrics program at all. CHWC could capture Medicare payments by starting such a service line. Ennen added that perhaps they could put that service line in Montpelier, the critical access hospital (CAH), so CHWC could reap the 101 percent of “reasonable costs” Medicare paid to CAH facilities.
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.
The message Ennen took away from the data wasn’t so much about what new services CHWC could offer as it was about how well CHWC already performed. Despite the “Band-Aid station” rep, CHWC took close to 70 percent of the market share. “The same market share we had in the nineties,” he said—before Parkview bought out the doctors, before the big systems had grown so big, before the Affordable Care Act, before two recessions.
At the much larger hospitals where Foster and Wade Patrick had worked, CEOs and boards considered 70 percent market share the best they could achieve. “And I’m just saying, a more fair comparison of CHWC and Williams County, versus where you guys came from, would be CHWC owning the docs in Williams County. That is the more fair comparison.”
Parkview owned the docs in Williams County, but CHWC still wasn’t suffering much leakage. Ennen didn’t say so outright, but the undercurrent was clear: he hadn’t done such a bad job on the last strategic plan, back in 2016, and he didn’t need fancy consultants and a monthslong process, or any acronymed business-school techniques.
Foster pushed anyway. “Can we talk about Plante?” she asked. Plante Moran, CHWC’s auditors, had offered the services of one of their rural hospital specialists to help “facilitate” the strategic planning meetings. What that meant wasn’t clear, but Plante would charge nothing for the help, and Foster thought a third-party referee in the room could prevent tortured sessions in the future. “It is very difficult to be a participant and also facilitate, especially given our group dynamics,” she said. “If I challenge your assumptions, I still have to deal with you all the next day.”
Ennen was skeptical. He foresaw a conflict of interest when an independent auditor would also be serving as a consultant. Besides, he noted, the “free” offer was probably a wedge to tempt CHWC into signing a consulting deal. To Foster and Patrick, Ennen’s skepticism sounded like opposition, but that wasn’t necessarily so. Ennen understood the value of outside eyes that had seen hospitals face many kinds of dilemmas. But the idea of bringing in another professional smacked of expanding the strategic planning mandate beyond what he thought they’d all agreed to do. For this iteration, the point was to get something done by August that would satisfy the board, and then set the stage for paying the big dollars a year or two down the line for Root—their preferred consultancy—to take over the job next time.
“I can tell you this much: if you guys turn this over to me, we will have a strategic plan by August,” Ennen said, “because I will make sure we have one by August. But I’m not sure it will accomplish what we want to accomplish.”
“For me, it’s the ability to have the difficult conversations we need to have that, in previous sessions, were very difficult to have—which is why I would like to have someone facilitate,” Foster added. “Because I am not gonna do it again.”
After some back-and-forth, Foster lost this round. Tinkel agreed with Ennen that once they’d decided against hiring an outside consultancy, it was foreordained that deep analysis and a new, profound vision for the hospital’s future would have to wait. Meanwhile, Tinkel said, they could still make headway: “Whatever we accomplish is better than not trying at all.”
Ennen tried to soothe Foster, but she still wanted a facilitator: “Last time, I left really defeated.”
“I’m sorry you felt that way,” Ennen replied. “I am really sorry you felt that way. Because we made it through. It wasn’t pretty, but we made it through.”
This was CHWC as a business—but as a business being run by people who also claimed to abide by a mission, people struggling not to lose sight of the puppies. But how to apply the new American religion of corporate efficiency and return on investment metrics to a “community asset”? This inherent contradiction made for tortured conversations.
How, for example, to address the bad debt? Ennen mentioned billings to self-pay patients as a way to curb the problem. In the past, CHWC hadn’t often sued people for overdue payments; records from courts in Williams and nearby counties did not contain many entries. CHWC preferred to work out payment plans, offer grace periods, or, if all else failed, write off an unpaid bill as bad debt, take the government credit, and move on.
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.
“My ex-wife had to pay her $2,500 up front before they even scheduled her elective surgery,” Patrick said, “and that was at the hospital she works at.”
Like any other business, CHWC employed people, and there, too, they struggled to juggle their mandates. Ennen felt both a collective responsibility—to Bryan, to keep people on the rolls—and a responsibility to individuals, the employees. He hated that some of his own workers made so little money in full-time labor that they qualified for Medicaid, just like some at Menards. And now he’d fired Culler—the first time in thirty-five years the hospital had cut loose a vice president.
Culler’s firing had spooked the staff, Foster told Ennen. Some thought it meant more layoffs were coming. Ennen had taken great care to craft his memo about Culler to avoid that very situation, but now he worried he’d misfired by asking leadership not to talk about it to other employees. Of course everybody found out anyway—this was Bryan, Ohio—and then wondered why their bosses hadn’t explained. In the absence of information, they made up stories, most of them conjecture that CHWC’s finances had collapsed and that Tinkel’s cheerleading the tiny margin last quarter was just pablum.
“I dunno,” Ennen said. “How do you [fire people] well?” He thought about 2009, when he’d had to lay off so many as the recession pounded the county. The experience left a scar. “I guess I hope we don’t get good at it,” he told the others.
They suggested Ennen address Culler’s departure in more detail in an upcoming leadership meeting. But Dina Culler would be at the meeting, too, and Ennen worried about her feelings.
Ennen’s concern illustrated the yin and the yang of his role at CHWC, and why the board had supported him all those years—but also why that same board now worried about his leadership. Both the board and the community wanted—demanded—a community and a family focus. The hospital was special. It wasn’t only a community asset in the legal sense; it was a community glue, a community economic powerhouse, a community source of employment, a community lifeline.
People in Bryan often talked about the hospital. Nurses and patients told stories about running into each other in Walmart, just as Shayla had run into Marc Tingle in church. “We were in bed together once,” a man told one of the veteran nurses upon being introduced to her at the Bryan bowling lanes. “You didn’t recognize me ’cause you never seen me with my clothes on!” Any mention of CHWC in any café or bar in Bryan would produce a comment from somebody who had a relative who worked there.
In November 2011, as the county’s recession dragged on while other parts of the country recovered, Ennen sent one of his “fiscal watch” memos. Continued government payments were at risk, he wrote. The composition of the Congress had changed after the 2010 midterms, and the new Republican-led body—still angry over the passage of the Affordable Care Act—was going to fight President Obama all the way. “CHWC is today staring at $2.7 million in Medicare cuts over the next two years,” he wrote. “That is almost $1 million more than our budgeted margin for this year.
“There is no reason to panic. There is every reason to plan. So that’s what we will continue to do.… We don’t get nasty and rude. We just find a way to make it work. We cope. We provide excellent service. We treat each other with respect. We bond with the communities we serve. We support them. They support us.… If we all make a commitment to one another, if we build a culture of resilience against the negative—if we do that, then we can find ways to cope with the bad times and rejoice in the good times. But we have to make a total family decision.”
These weren’t phony platitudes. Ennen recalled times when Bryan had fought to keep its local character—not out of insularity, but because the local relationships and the local ownership mattered. His father once tried to keep a bank from being absorbed by a bigger, regional outfit. “My dad was part of lots of conversations about ‘we need to keep this bank solvent and independent, because it’s gonna be better for all of us if it is,’” Ennen recalled. “‘Because if we don’t, all the decision-making is going to go someplace else.’” The bank was swallowed up anyway, and his father’s prediction came true.
Some other CEO—say, one brought in by a Parkview or a ProMedica—wouldn’t hesitate to fire people. They’d cut and meet the numbers. Some board members, after the loan covenant breaches, were asking for that kind of cold corporate calculation.
To soothe the nerves jangled over Culler’s firing, on the day of the planning session Ennen sent an unexpected message (full of ellipses, as was his manner) to all the staff: “I know that we had planned to share financial information quarterly … but all of us in senior leadership believe you need to see our most recent data … that now includes January. What you will see is that we continue to perform ahead of budget. This is our 3rd month in a row with a positive operating margin. We are busier while maintaining our costs. Net revenues are up 8% … while operating expenses are up 3%. You … we … us … we’ve done really excellent work … and it is showing in our financial performance.
“I know this is not easy work … especially for certain department[s] where we have been focusing … but the effort is worthwhile. I’m sorry that things feel so confusing … I wish I could always give everyone more clarity.”
The talk of the personnel change at the top sparked a conversation about others who might be leaving. The potential losses could prove disastrous, yet Ennen—and to a lesser degree the others as well—visibly relaxed when they talked about them, as if the near-term problems were easier to confront than the long-term vision.
Nobody knew when Kesireddy—it was always Kesireddy—would retire. “One thing we have to be honest about is, when he is done, the cath lab is done,” Ennen said. “That is the way we would have to forecast it, and then we could try to keep it going. I wanna try to be pragmatic about it,” he added. “Getting three interventional cardiologists to try to see the value of an emergent interventional cath lab in Bryan is gonna be really hard. And I think it is gonna take three to replace his three-hundred-some days, and we’d still have to bring in locums coverage for probably as much or more than we do now.”
To some prospective Bryan doctors, the number of Marc Tingles spread over Williams County was less important than how much money there was to be made by setting up shop in the city. This was true not only for interventional cardiologists, but for all kinds of physicians. Recruiting doctors to rural communities was never easy and grew more difficult every year.
Back in the 1980s, Brunicardi had targeted foreign doctors eager to find a place in the U.S. When he thought he’d hooked one, he reeled the doctor in by treating them like royalty. For Zoher Vasi, originally from Gujarat, India, and then practicing in Halifax, Nova Scotia, it began with a phone call.
“He said, ‘I like your voice. I want you to come,’” Vasi marveled. Vasi had arranged to visit a brother in Cincinnati. “He said, ‘No problem. We will come and get you in Cincinnati.’” Brunicardi, the chairman of the hospital board, and the mayor of the village of Sherwood (south of Bryan, across the Defiance County line) all piled into the chairman’s private plane, picked up Vasi, and flew him back to Bryan. In the hospital’s boardroom, they introduced Vasi to local officials, a school principal, and other board members. Brunicardi promised to transform an old Sherwood motel into a fully equipped office for Vasi. He loaned a personal car to Vasi’s wife.
Immigrants like Kesireddy and Vasi made up a significant portion of Bryan’s medical community. “We have been blessed with talented people from Iraq, Jordan, Israel, India, Pakistan, Mexico, the Philippines, Jamaica, Egypt and Canada,” Ennen wrote to the area’s federal legislators in the wake of Donald Trump’s 2017 anti-Muslim travel ban. Doctors from foreign countries often had a difficult time finding positions in desirable metro areas, so they turned to rural places and small towns as a way to gain a foothold in the American medical economy.
Some, like Vasi and Kesireddy, grew to love the places and stayed. Ennen valued them. “The actions of the Trump Administration to further restrict immigration is having a direct and negative impact on our hospital,” he wrote in a challenge to local sentiment. “Please know that rural America is quite often the place where medical professionals of foreign descent (both U.S. citizens and non-U.S. citizens) choose to practice their craft.… They each made a commitment to our community and we returned that commitment to them.”
He invoked the experience of Hanan Bazzi. Though born and raised in the United States, Bazzi had family in Lebanon. “In celebration of completing her long medical training, the family was planning a summer trip to Lebanon, to visit with all of their Lebanese family. They wanted to celebrate the start of their new life in Bryan. But now there is great concern about whether they would be able to safely get back into the United States. The entire trip has been canceled. What should be a happy family celebration has been crushed.… The clear fact is that rural America needs immigrants to serve our communities.”
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.
When Liu first thought of coming to Bryan, he saw job postings for both the hospital and the Parkview Physicians Group. Because he’d worked at Cleveland Clinic, where surgeons were hospital employees, he spoke to Ennen in addition to the group across the street. Ennen offered $350,000. Parkview offered about $500,000. “So I said to Phil, ‘Why aren’t you able to meet what Parkview was going to offer, to make it more enticing for me to sign with you?’ He said, ‘That’s the limit of what I can do.’” What’s more, CHWC had no family doctors in its employ. All the family docs worked for Parkview. Liu could count on those family doctors feeding their patients to him. “They will keep everyone in-house, in the system,” Liu said. “They are well aware of where that revenue is going. I am actually very surprised at how business-oriented they were.”
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.
Both the medical group and the hospital paid signing bonuses, too. When Keil hired on as CHWC’s pathologist, Brunicardi paid her a bonus of $50,000. Years later, in 2018, the average signing bonus for all physicians across the United States was still only $33,707. This competition for doctors occurred at a time when doctors—with the exceptions of family and general practitioners—were making more money all the time. Taken as a whole, with all fields of practice combined, physician compensation rose over 16 percent in the four years between 2013 and 2017—a period when wages for hourly workers remained flat.
As it turned out, Kesireddy’s probable departure wasn’t the only one Ennen and his team would face sooner rather than later. A Parkview oncologist was about to retire, too. If the cancer joint venture with Parkview was to become reality, CHWC might have to hire an oncologist of their own. The medical group was also losing an ob-gyn to retirement, leaving a shortage in the community. Parkview had known of the retirement for months, but corporate didn’t seem to be in a hurry to find a replacement. That would mean busier days and nights for Bazzi and Hassouneh—which might be good for the hospital’s bottom line, but not for their lives. “Bazzi’s contract comes up first, and she could say, ‘This quality of life thing he gave me is going away,’” Ennen said. He wanted to keep both of them happy so they’d stay. “I want them to solve this problem,” Ennen told the others, referring to Parkview. But if Parkview didn’t, Ennen might have to hire another ob-gyn of his own. Nosanov was probably leaving soon, too. If they couldn’t find another ENT specialist, that clinic might have to shutter.
Kim Owen, the radiation oncology center chief, had also announced that she was quitting. Ennen’s instinct had failed him. He’d wanted to protect both Owen and the hospital by keeping his handling of Owen’s alleged harassment off the books. Thinking the problem had disappeared, he’d planned an announcement of Owen’s new position as cancer care coordinator to the staff. He had not, however, clued in Foster or Chad Tinkel.
In January, Owen spoke to Foster. She told Foster how the doctor had made working conditions inside the center intolerable. New job or no new job, Owen had had enough.
Upon hearing the details of the doctor’s actions from Owen, Foster decided that, as the hospital’s human resources boss, she was compelled to conduct an investigation, and that she should have been informed the first time Owen mentioned the harassment. She also worried that any lawyer looking in would match Owen’s complaint and the new job offer from Ennen, and think quid pro quo. “If I’m a lawyer, I would run wild,” she said. Elevating Owen made sense, but it looked bad. “I said, ‘As chief HR officer, I need to protect the organization,’” Foster told Ennen, “‘and remove you from [the situation].’ You can’t talk to the doc, [the contracted group], Kim. No more emails. This is to protect you and the organization.”
Ennen resisted. He felt he had acted in the best interests of all concerned. But Foster, well aware of the new Me Too movement blazing hot amid allegations of assault swirling around high-profile men like Harvey Weinstein, believed Ennen’s way of trying to protect Owen by warning off the doc and easing out the group hadn’t been sufficiently aggressive. “The law doesn’t care about your intent. The law holds you culpable as CEO to take action when a woman says she’s been harassed.”
Foster also worried Owen would sue; Owen had, in fact, consulted a lawyer. Reasoning that Owen would be less likely to pursue legal action if she still worked for CHWC, Foster tried to get her to rescind her resignation. As of the strategic planning meeting, Owen had not, though Foster believed she was making progress. “I think I can salvage it,” she said, “and can say to attorneys that we’ve done all we’re supposed to.”
After her investigation, Foster concluded that Ennen’s initial instinct to avoid a medical staff meeting was the correct one. She planned to recommend to the board that the doctor not be allowed on the CHWC campus, but that the hospital not formally rescind his privileges. “He could mount a defense. That could get very public. I told [the doctor], if he really wants what’s best for [the group], CHWC, patients, he can’t be in our building anymore. The financial incentive to figure this out is in his best interest.” But one thing Ennen wanted to avoid—telling the board, which was scheduled to meet one week after the strategic planning session—became unavoidable the moment Foster began the investigation.
His handling of the Owen situation rippled outward. Word of Owen’s new position infuriated another staff leader, who felt wronged that Ennen did not post the job and give other employees a shot at it. CHWC may have been the biggest employer in Bryan, with about five hundred at the main campus and another two hundred between Montpelier and Archbold, but it was, as Ennen liked to call it, a “family.” Now the family was upset.
Ennen could be both reactive and thoughtful. He sometimes appeared to reject a suggestion or comment out of hand, only to come back to it fifteen minutes or half an hour later, having considered it anew. He thought over the planning session the rest of the day and through the night. The following day, he sent a memo to the vice presidents that was at once contrite for leaving the impression he wanted to assume control and write the plan himself—and for how difficult the group’s relationship had become—but also defensive about the value of his previous strategic plan. “I agree it is not specific, not targeted … there is no SWOT … there is no SOAR … there is no ‘Current State’ … there is no ‘Future State.’ … It was a good plan.” He apologized to Patrick and Foster, who’d tried to coach them all through the process, for anything he’d said or done that made their work more difficult, but insisted he was not opposed to strategic planning. “I do work at the behest of the Board … I’m fully aware of that … and I have no desire to lose my job.”
Rather, he knew that in this business you couldn’t count on anything. Perhaps everyone would stay in their jobs, and perhaps Ennen could find replacements for Kesireddy, and maybe the government’s payouts would remain the same, but you never knew. You could spend much precious time and money laying out the most sophisticated multiyear projections and strategic plans, but they wouldn’t necessarily be worth much in the real world of a small, independent community hospital.
Henry County hospital, down in Napoleon, had a consultant-driven strategic plan, and they lost money all through 2018, too. Every little indie hospital in the region lost money in 2018. Foster’s and Patrick’s old employers had SOAR and SWOT, and they were taken over. Since at least 1973, when Brunicardi arrived at the failing institution, the leadership of CHWC had avoided that fate through seat-of-the-pants opportunism to build what the community needed. That culture now clashed with the culture of the twenty-first-century corporation. But CHWC wasn’t making injection-molded parts for cars. They were trying to take care of human beings, to be an economic lifeline for the town, to survive.
That afternoon in West Unity, Shilo* and Jimmy* settled into their new home. They’d started in Toledo, back when they fell in love—when she was just seventeen, when she dropped out of high school. That was 2003. He bought an engagement ring for her. It was nice; she looked at it often. Then he bought a big pickup truck. By 2007, they had a baby boy.
The engagement was a long one and still ongoing because the relationship was pretty turbulent. He had a child with another woman, a heroin addict; the boy now lived with him and Shilo. And there was the time she had sex with the man who was dating his mother—the mother who’d abandoned Jimmy before he was two years old. She wished he’d just get over that and forgive her, but he carried a grudge about it. She was pretty sure he needed a counselor.
Jimmy had had possibilities once. He went to community college, but after two years he had too much student loan debt. So he took a job driving. Then he screwed up and got slapped with a grand theft auto charge. He lost his job in Toledo, so they moved to Wauseon, where it was cheaper. He got a job there, in a machine shop, but that ended, and so they and the two boys moved into an apartment in West Unity, where the rent was cheaper still, and where a sign out front said NO SMOKING. Their apartment reeked of tobacco smoke.
The truck held up just long enough to get them there. Often it didn’t work at all. The lack of transportation made it difficult for Shilo to get into Bryan, so for now her world was limited to West Unity. Her anxiety meds needed refilling, though. She was already climbing the walls. She skittered around the apartment in her yoga pants and an old T-shirt, burning calories she couldn’t spare off her wispy frame. A doctor wanted her to go on Lexapro, the antidepressant, but she said there was no way she would. The son they had together had anxiety, too, and the son Jimmy had with the addict was already taking Zoloft and Adderall. Shilo hadn’t seen a dentist since she was a kid. She received her drugs through mental health service agencies, paid for through her Medicaid.
She planned to start interviewing for jobs. But since the truck rarely worked, her options were limited to what she could find within walking distance. That wasn’t a rare thing in West Unity; Greg Coleman often watched people without transportation walk by the church to go to work at Kamco and other employers.
Feeding Jimmy, herself, and the two boys was another matter. She received food stamps (Supplemental Nutrition Assistance Program, or SNAP) in addition to her Medicaid, but in West Unity, buying groceries wasn’t as simple as driving to the neighborhood supermarket. Williams County had one supermarket, Chief, as well as the giant Walmart across the street from Chief. Both were in Bryan, twelve miles away.
Without the truck and the gas money to make the 24-mile round trip, Dollar General was Shilo’s only grocery option. There’d once been an IGA. When she was a girl, Valerie Moreno and her family could buy groceries there, including fruits and vegetables they didn’t grow on their own. About 200 yards down the road from the Dollar General, the empty shell of the IGA slumped into what had been its parking lot.
When the private equity giant Kohlberg Kravis Roberts bought Dollar General for about $7 billion just as the Great Recession snuck up on America, some experts wondered why: it was a chain of roughly sixty-five hundred stores that sold cheap stuff to poor people. But soon the recession created lots of poor people. Under KKR’s ownership, Dollar General exploded, spawning more than a thousand additional little concrete-block shotgun-shack stores in one small town after another and in the poor neighborhoods of cities. By 2009, when KKR relisted the stock on the public markets, more than eight thousand Dollar Generals had metastasized across the United States. When KKR sold all of its stake in 2013, the company was worth three times what KKR had paid for it, and the financial press hailed the play’s success.
Two other chains, Family Dollar and Dollar Tree (Dollar Tree acquired Family Dollar in 2013), sprinted to catch up. By 2019, all three chains combined had opened around twenty thousand stores, often wiping out small-town grocers and preventing any new independent stores from ever opening. By the time Shilo and Jimmy arrived in West Unity, the IGA was out of business.
They, and everybody else who couldn’t easily reach the Chief in Bryan, were left with meager pickings. She could use her food stamps at the West Unity Dollar General (“SNAP and EBT accepted here,” the sign on the store read), but if she were to walk in on the day I did, she’d find a tiny section of shelving—about four feet of it—dotted with a few bananas, some garlic, a couple of heads of lettuce, half a dozen tomatoes, four cucumbers, and a couple of green peppers. Some canned vegetables—green peas and green beans, mainly—sat on another shelf.
On the other hand, she could choose from almost any popular soft drink made in America. Their red, blue, orange, and green hues lit up an entire aisle, from the front of the store all the way to the back: Red Bull, Monster, Mountain Dew, sugared teas, flavored waters, Pepsis, Cokes. She could also buy any number of salty snacks and chips. Another entire row offered cheap toys from China.
Stores in the SNAP program were supposed to abide by certain minimum stocking requirements established by the Department of Agriculture. Those requirements were enhanced in 2014 as a way to provide more nutritional options and variety to shoppers, and in late 2016, the Obama administration issued a rule implementing the change. But in 2017, the new Republican-controlled Congress passed legislation: “None of the funds made available by this Act may be used to implement, administer, or enforce the ‘variety’ requirements of the final rule entitled ‘Enhancing Retailer Standards in the Supplemental Nutrition Assistance Program (SNAP)’ published by the Department of Agriculture in the Federal Register on December 15, 2016.”
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.
A cornfield just across the road—Route 20A—lay fallow, ready for the next season’s planting. There was a chance that a product of the corn that grew there would wind up right back in West Unity, on the Dollar General shelf, in the form of the high-fructose corn syrup used to sweeten drinks.
Many in Williams County were poorly nourished. In a county with square mile upon square mile of some of the best farmland in the world, that seemed unbelievable—but it was true. Most of the farmland was covered with corn destined to become feed for animals, fodder for ethanol plants (encouraged by a Byzantine system of government incentives), or high-fructose corn syrup. If they didn’t grow corn, farmers planted soybeans—but most of them weren’t for people, either. The beans would be processed for feed and for industrial products. Corn and soy had long dominated Williams County agriculture, but farmers once also grew sweet corn for people, as well as tomatoes, oats, tree fruits, and vegetables. But fresh vegetables had become a luxury item accessible only to those with reliable cars and the money to pay for the produce.
“We have a lotta people who go there instead of driving back and forth [to Bryan],” Greg Coleman said. Often, he said, he’d look out his office window and see people walk by, toting bags in their hands, even in the deepest cold. “People walk from their homes to Dollar General to pick up what they can, and walk back.”
“Stryker, Edon,” Jim Hicks said, referring to villages in the county, “tried tax incentives to get a grocery store, but it didn’t work. But you got Family Dollar and Dollar General come in. And the first thing you see in those first rows? Chips and snacks and pop.” The dollar-store CEOs knew their market. As Dollar Tree’s chief said, his customers were “one doctor bill or one car repair bill away from not being in such good shape.”
The people at Coleman’s United Methodist did what they could to help. Led by office manager Jane Short, they put on a free dinner every Wednesday. Short and the other volunteers started the dinners in 2010, as the recession dragged on in Williams County, because everybody knew people who were out of work and suffering. They served about ninety people back then. Times were better now, so the number had dropped to about forty-five. About a third of those people were older and living on whatever money they received from Social Security. Another third were church members. A final third were what Short called “your true down-and-outers.”
The volunteers managed to keep the cost down to about $1.25 per meal by providing main courses that hinted of meat, and by using lots of potatoes and noodles. On an evening when they served “stuffed baked potato in casserole form,” the diners ate pieces of potato in a creamy sauce speckled with diced ham, white bread, canned corn, a mini salad of head lettuce with some shredded carrot and cucumber and a cherry tomato, and a square of angel food cake with canned jellied cherries on top—all presented on small styrofoam plates and bowls. They ate with plastic forks and drank water out of paper cups.
A woman over sixty, wearing a Tweety and Sylvester sweatshirt, sat down next to a woman with a walker parked next to her chair and a man with few remaining teeth. “I can’t eat with my left hand,” she said.
“Oh?” said the other woman. “I can’t eat with my right.” They laughed.
“I can’t hold a spoon,” the first woman explained.
They complained about the cold, snow, and ice. “I ain’t been outside in six weeks.”
Younger men and women sat with adolescent children at other tables. Every one of them rushed through their meal, saying nothing, as if in a hurry to escape the future.
Just days later, Ennen prepped for the monthly 8:30 AM board meeting. It looked to be pretty routine. CMS had visited the labs to verify the work of the Joint Commission, and, sure enough, the labs checked out fine. They’d have a conversation about the ongoing negotiations with Parkview for a cancer care joint venture. Kim Owen had agreed not to resign, so that seemed to have blown over. Foster, who’d concluded her investigation into Owen’s allegations and found them credible, told Ennen to go ahead and formally announce Owen’s new job. Ennen figured he’d be out by lunchtime.
Ninety minutes into the meeting, the board went into executive session in order to hear from Foster. As was customary, they excused Ennen, who retreated to his office, figuring he could do a little work for ten minutes or so. Ten minutes became thirty, then forty-five. Foster left the boardroom.
Eventually Ennen’s old friend Chris Cullis, the chairman of the board and the owner and editor of the Bryan Times, walked into Ennen’s office. He looked miserable. The board, he said, was starting a formal investigation into Ennen’s handling of the harassment of Kim Owen with the help of CHWC’s law firm, Bricker & Eckler, in Columbus.
“I think that’s enough for today,” Ennen cracked. “I think it’s in everybody’s best interest if I reduce my role. I don’t want to be here, anyway.” He walked out of the building, across the park, and into his house.
Mary Ennen was out of town, having a girls’ weekend with a friend, so Ennen was alone. A thousand thoughts bounced around in his head. He opened his laptop and began sending emails that amounted to “I don’t understand what is going on.” Meanwhile, the board, turning to the short-term succession plan, appointed Tinkel, who was about to leave for a ski vacation, as interim CEO. “I’m worried I’m about to be suspended,” Ennen wrote to Tinkel. He received no reply. He tried to do a little work, but now found himself frozen out of the hospital’s computer system. He emailed Tinkel, asking if his inability to sign in was deliberate. Tinkel replied that it was. Ennen “freaked out.” He sent a couple of intemperate emails.
The following day, the board held a special session during the lunch hour. At 2:00 PM Cullis called Ennen. The board, Cullis said, had formally suspended Ennen as CEO of CHWC, pending the outcome of the investigation. The only two people affiliated with CHWC with whom he could communicate would be Cullis and Chad Tinkel. A formal letter of suspension arrived the following day, banning Ennen from the CHWC campus. He called Cullis. “Are you shittin’ me?” he yelled.
Cullis now found himself in the most uncomfortable spot of his life. His friendship with Ennen was a strong one. Mary’s mother had worked for the paper. He held the entire family in high regard and considered Ennen “probably the smartest guy I know. When you listen to him talk about healthcare, and the various visions for the hospital, it is just really remarkable. When you talk to him about things not a part of the hospital, he is still that way.” Ennen, the local guy, not only participated in the civic life of the community at large, “he took care of people as well. He will go over to the optometrist and pay somebody’s bill out of his own pocket if that is a need he sees. And I don’t mean one time. He did that a lot, and people don’t know about that.”
And yet Cullis served as the chairman of the board of CHWC and had a duty to the institution. The board itself had Foster talking about legal risks to the hospital, and the big Columbus law firm weighed in via the speakerphone in the middle of the board table. It all seemed pretty serious. In the old days, if such a thing had happened, they would have met over lunch in a closed room and hammered out a solution and moved on. But it wasn’t the old days.
Ennen called his friend Dean Spangler. He sent a text to Dave Swanson, who, in reply, asked about the community play Ennen had been rehearsing as if nothing at all happened, saying he’d like to go. To Ennen—alone, pacing in his house, his thoughts running away with his reason—that sounded incredible. “My career is shredded! It’s a fragile house of cards!” And he believed the board had just done more to risk the independence of the hospital than any loan covenant breach could have. CHWC would spend a fortune in legal fees to Bricker.
Then he thought of his children and wept. “My daughters will have a Me Too dad! I’m one more male trying to cover it up.” He felt humiliated, embarrassed, abandoned after thirty-two years—stunned that not a single member of the board would say, “Fuck the attorney.”
Yet he was still only suspended. He tried to take solace in that. The investigation would show what he had done to make the doctor back off. And he hadn’t even thought of any quid pro quo when he offered the job to Owen: he’d been thinking of the next move for the hospital. Even some of his detractors on the board nodded to Ennen’s tactical mind. “He has things on back burners behind back burners,” marveled Chris Kannel. So maybe it would all blow over. Probably it would. Speaking to his brother on the phone helped. Calling upon the old Ennen sarcasm, his brother pointed out that their mother had been fired back in 1972, so he wouldn’t be the first Ennen to get the sack from the hospital. It could be a family tradition.
The board made no announcement of Ennen’s suspension to the staff, though it did issue a confidential memo to the top department leaders. The story became that Ennen had put himself on administrative leave, which wasn’t false, exactly—Ennen did walk out—but wasn’t the whole truth, either.
“All I could discover is that it’s not health-related,” George Magill, the wound care clinic director, said. “They are keeping this very quiet. Clearly, something major has happened.” Telling people not to speculate, he added, would just make them speculate all the more. And they did.
Ennen had an emotional breakdown under all the stress. Ennen embezzled. “Somebody just told me, ‘He must have used drugs.’ Or he was ‘diddling a staff member,’” one department head said. “And I thought about that and said, ‘Nah, Phil’s way too straight and boring for that.’” Some suggested to the vice presidents that they’d better come up with some more information, because myths were tearing through the ranks, but anyone in a position to know the truth had been warned to say nothing.
Mike Culler’s firing had set off anxiety, but Ennen’s suspension blasted it into the stratosphere. Things must be much worse financially. A Parkview takeover was imminent, and Ennen opposed it. No, a ProMedica takeover was more likely—ProMedica being an Ohio company—and Ennen must have engineered it. No, no: Foster had staged a coup. Whatever happened, surely people would lose jobs. “What a shitshow,” Shannon Keil said. The Ennens weren’t around to hear the gossip. They’d packed up their car and left town.
In response to the rampant speculation, Cullis finally sent a confidential memo on CHWC letterhead to the entire staff. Ennen had been placed on administrative leave, it said. Tinkel was now interim CEO. The board had confidence in senior leadership. It requested “your support and assistance to Chad, Jan, Wade and Angelia during this time. We will update as we can.” This told them nothing they didn’t already know.
Fear was more consequential than the rumors, though the rumors contributed to the fear. Not everybody loved Ennen. When annoyed, he could be abrupt, cranky, and impolitic. But he also inspired loyalty and appreciation for his big-picture vision. Magill, for example, had agreed to open the wound care clinic because Ennen asked him to. Before that, he’d been an ER doc who’d also spent time flying on the choppers out of Toledo. Whatever Ennen did to be suspended, he thought, must have been in the best interest of the hospital. He couldn’t imagine Ennen doing anything wrong—at least not deliberately.
And what now? The family atmosphere, the caring—that would all go. There’d be no collections for survivors from ER staff because, surely, without Ennen, CHWC would be absorbed into some bigger system all the quicker, and Magill had no desire to work in the kind of atmosphere that would result. He’d done it before, in the big Toledo outfits where he’d practiced in ERs: “It’s meet ’em and street ’em. Get ’em in, get ’em out.”
With ProMedica, he said, you might have one interventional cardiologist covering four hospitals, and so heart attack patients might wind up waiting an hour—and that “golden hour” window was so important. As for flying everybody to Toledo, well, that took at least fifty minutes from the time the call came in to the chopper’s arrival in Bryan and then the flight back. Marc Tingle would have died.
“I would like to know what’s going on,” Hanan Bazzi said. Both Bazzi and Hassouneh weren’t sure if they’d stay. “Phil’s been an employee for, what, twenty years? Ten as CEO?” Hassouneh said, underestimating Ennen’s employ by a dozen years. “And they just said goodbye? What makes you think any of us are safe in this hospital?”
Bazzi had come to CHWC because of Ennen. Back at the University of Michigan, when a boss left and was replaced, everything crumbled—and she had no intention of waiting around to experience the same thing in Bryan, Ohio. As the months had passed, she’d grown exhausted by the looks and the awkward conversations resulting from her religion. She still loved her patients, and they still loved her, but relatives of patients sometimes needled her about the hijab: “Why are you wearing that hat? Are you cold?” When she, her husband, and their children went to a community event, she could feel the stares. The scrutiny had grown worse since the election of Minnesota congresswoman Ilhan Omar and Trump’s subsequent rhetoric targeting her, telling her to go back to her native land, Somalia, and the crowds at Trump rallies chanting, “Send her back!”
“It’s more every time, even at the Y,” and if the news showed violence from “Saudi Arabia or anything, I always feel uncomfortable. What will people around me think? That I am related? That I agree with what’s going on?”
Being a teenager in North Carolina after 9/11 had been rough. She wasn’t going to force her own daughter to live through the kind of taunting and hazing she’d experienced. Piling on uncertainty about the hospital’s future added to her doubts. “Listen,” she told her husband, “we have to have a plan B. What if they go bankrupt? What if they close, or Parkview comes and takes them?” She trusted Ennen. Without him at her back, she wasn’t sure what to expect. “If it gets too difficult, we will just leave.”