Tim Thuering and Mike Thomas settled into their recliners inside the Williams County EMS headquarters for the night shift ahead. Thuering had worked as a printer most of his adult life before taking up medic work, figuring it would be a more fulfilling retirement than messing around in the yard. Thomas was younger, nearing middle age. He’d begun riding ambulances as a Boy Scout and took to it. Tonight they’d be Life Squad 2, assigned to cover the southern half of the county. Life Squad 1 would take the northern half.
The previous night, a sixty-eight-year-old male DOA had taken up a lot of their shift. The other squad picked up a thirty-seven-year-old male DOA: a drug overdose case. They hoped this night would be a quiet one—Thuering wanted to catch Jeopardy. He was a fan of the show and the current champion was on a streak. Sometimes the big flat-screen hanging from the wall could be finicky, so he turned it on to make sure it would tune to the right station.
Life Squad 1 took a call from Rassini Chassis, up in Montpelier. A fire had broken out in one part of a building, as it sometimes did at Rassini, where they bent hot metal. Nobody knew if there’d been any injuries, but the squad would drive up just in case, prepared to help the firefighters. It wouldn’t be an up-and-back trip. Life Squad 1 would have to wait, which meant it might be unavailable to accept any other calls for a while.
A short time later, Thuering and Thomas decided to visit “Station 4,” the Circle K store in central Bryan. Most stops at Station 4 unfolded in the same way: the crews would come in and fill a soda cup, maybe pick out a candy bar or chips, and then make a show of attempting to pay. The cashier would do a little head nod or say “Nah,” and the crew would say, “Thanks a lot,” and walk out with Mountain Dew, or with coffee and a Kit-Kat. A man about thirty, in a hoodie and camo ball cap, got to the cashier first, though, to buy a couple of Bud Light tallboys and some beef jerky, so it took a minute for Thuering to catch the cashier’s eye. He checked his watch. They could just make it back to headquarters in time for Jeopardy.
Thuering’s butt hit the recliner at just about the same moment that the beeps and buzzes sounded from the radio loudspeaker, followed by a dispatcher’s voice: code 4—auto with entrapment on the Ohio Turnpike. That would have been Life Squad 1’s call, but they were at Rassini, so Thuering and Thomas scrambled out of their chairs and into the ambulance. It was 7:15 PM on a dark, cold, wet night. Once they left the garage, Williams County’s residents would have no full-time, professional EMS available to take another call.
Thuering drove. Eighteen minutes later, after the ambulance passed through the toll gates by Holiday City, it sat motionless on the turnpike, siren screaming. Interstate 80 had turned into a long, narrow parking lot. Thuering maneuvered to the inside shoulder, then accelerated as fast as he dared to squeeze the truck between the median guardrail and the stopped traffic. When he pulled up to the scene of the accident, both men thought they had another DOA.
An overturned red 2008 Ford F150 pickup lay on its side, the undercarriage facing a farmer’s field. Engine fluids and blood pooled outside the driver’s-side window, which was now hard against the pavement. The pickup truck had hit the guardrail—at full speed, from the look of things—peeling about ten yards of steel rail and wood posts out of the interstate. It had then slid for some distance.
Jim Hicks had already arrived. He wasn’t on duty, but he lived out in the country nearby. Hicks kept the dispatch signal on in his house, and when he heard the call, he had run to his truck, driven it off-road, and then parked it on a rise above the berm off the turnpike so its headlights would shine onto the road. As Thuering and Thomas approached, they found Hicks smashing the windshield with a hatchet.
“Cover your eyes!” Hicks shouted to the driver, John Ryder,* a man who was, by some fluke of physics, alive.
“What are you doing to my windshield!” Ryder shouted after the first strike.
“Windshield’s the least of your worries!” Hicks shouted back. “Cover your eyes!”
A Montpelier fire truck pulled up, and Hicks asked the firefighters to affix an adjustable brace to the undercarriage. The truck was wobbling with each of his strikes, and Hicks didn’t want it tipping over. Other firefighters used cutting tools to open the roof like a can of peas. “My truck!” Ryder shouted. “My whole life is in this truck!”
And it was. The cab was packed with a walker, a three-legged cane, a box of Winston cigarettes, Tagalong Girl Scout cookies, clothing, soft-drink cups, open snack packages, broken pretzels, white trash bags, a BiPAP breathing machine, and money: lots of money, bundled in plastic wrap. A toilet inside a big cardboard box had been in the bed, but it now lay shattered and scattered on the turnpike like a broken pot at an archeological dig.
Ryder was a big dude. Hicks had intended to pull him out of the windshield opening once the glass was removed. But, when it became clear the man wasn’t going to die any second, Hicks stopped smashing the glass to assess the situation further. He realized there was no way Ryder was going to be pulled out through the windshield frame: extraction would have to wait until the saws did their work to peel the roof back so they could roll the man out. Then they had to hope he could stand long enough to lay himself down on the ambulance gurney, because, as Thuering and Thomas were about to discover, Ryder weighed 477 pounds. He was fifty years old.
“Thank God I had my seat belt on!” Ryder said to nobody in particular. The combination of the seat belt and his bulk—his body was its own airbag—may have saved his life.
A state trooper walked around the accident site, taking it all in and jotting down notes. With the benefit of a few minutes to wait, Ryder began to think. And, when he thought, it occurred to him that a state trooper might have questions about bills wrapped in plastic film and boxes of Girl Scout cookies in a bag with more cash on an interstate that every drug cop coast-to-coast knew was a narcotics delivery route to Detroit and Chicago.
“I work for a troop of Girl Scouts,” he said, again to nobody in particular. And then, to Hicks: “I brought my life savings with me. Fifteen thousand dollars.”
Hicks, wanting to keep Ryder calm, said, “I carry cash a lot, ’cuz I don’t trust the banking system.” Hicks may or may not have trusted the banking system, but he for sure never carried thousands of dollars around in his truck.
Once the roof and windshield frame were opened wide enough, firefighters cut the seat-belt strap, and then a group of them helped maneuver the man out from the truck. With help, he was able to lie down on the ambulance gurney. Thuering and Thomas exchanged glances. They were grateful Hicks insisted on buying mechanized lifts for their trucks to raise the gurney into the ambulance. These days, the people they carried were just too heavy.
“Save my Girl Scout cookies!” Ryder shouted. “My bag. They’re in my bag. Can you bring my bag?” Pumped with adrenaline and cortisol, he launched into a monologue while Thomas worked on his bloody arm and took vital signs and Thuering drove. Thomas asked his name, date of birth, and if he had any health conditions. “I got sarcoidosis, neuropathy, high blood pressure,” he said. He lived in West Virginia and was driving to Michigan for a long weekend at his brother’s place.
“I just took this real deep cough—took a drink of my Mountain Dew, then put it down, and took a real deep cough, and then it went in slow motion.” The truck had swerved, hit the guardrail, and flipped. His arm scraped along the road, and his body was banged up and hurting, but his injuries didn’t appear serious.
“I cannot frickin’ believe I did this to myself. They’re gonna think I’m a drug addict going across the country. I was bringin’ my brother a toilet. I got tired of sittin’ on his girlie toilet. I finally got my damn disability. I’ve watched enough TV to know what they’re thinkin’,” he said of the state police. “Finally got a chance to buy some family land.” That was why he was carrying his $15,000 life savings. And the cash in the bag with the cookies was Girl Scout money. “I’ve made half the payments on that truck. Now I pissed it off real good. I just got my ACA insurance three months ago. It’s real good.”
Ryder asked Thomas for his phone, then dialed his brother. “Hey, bro! Guess where I’m at! In an ambulance, so I’m gonna be late.” He laughed. Then he turned to Thomas: “Where you takin’ me?” He put the phone back to his ear and told his brother, “They’re takin’ me to some town called Bryan, Ohio.”
The town talked. It talked over the warm olives and wine at Kora’s. It talked over the craft beers at Father John’s, the pancakes at the Four Seasons diner, the soup at the Seasons café, the deep-fried cheesecake at Shaffer’s. What was up with Phil Ennen? They talked about him at the Knights of Columbus fish fry—where, for just $9.50, you could eat all the fried fish, baked beans, coleslaw, mac ’n’ cheese, and green beans your stomach could hold. “I heard Phil Ennen is on leave,” a middle-aged woman at the fry said to an older companion. They speculated, as everyone did, about what was going on. Surely Ennen hadn’t done anything wrong.
“He’s such a nice man,” the older woman said. “Well, you know, Rusty—Rusty was wonderful.” They knew Brunicardi had trained Ennen, and felt that was a good thing for the hospital and for the town.
The Knights of Columbus hall sat hard by the railroad tracks. It was a blustery evening: chilly, spitting rain, a hard wind blowing. A train clacked by, hauling freight to cities far away from Bryan and drowning out conversation.
After a pause, the middle-aged woman said, “That hospital is so important to this community.”
“We’re so lucky to have it,” her friend added.
Keith—and people like Keith—didn’t talk about Ennen. He’d never heard of Ennen. He’d never set foot inside Kora’s. Nobody he knew had been to Kora’s.
Jim Watkins didn’t know what to make of Ennen’s suspension, but he figured “it was a great way to shoot yourself in the sack. It wouldn’t be the first time.” He pointed out all the good Ennen had done around Bryan and the county. When Watkins contacted Ennen, all he could get out of him was “It’s for the lawyers to work out.”
Only a handful of people knew the truth—that Phil Ennen had already been fired. Chris Cullis had called the Ennens while they were still out of town to deliver the verdict. The board decided Ennen had violated hospital policy, Cullis said.
Of course he had. Ennen had violated the hospital’s human resources policy in the way he’d handled the alleged harassment of Kim Owen. He should have turned it over to Angelia Foster right away. Nobody needed the two-week investigation by CHWC’s Columbus law firm to prove that, because nobody, including Ennen, ever disputed the basic events. But saying Ennen violated a policy and then firing him for it was like arresting a driver in the Indy 500 for breaking the speed limit. Ennen believed that CHWC existed because its leadership, starting with Brunicardi and continuing with Ennen, sometimes fudged policies and processes and procedures—not in the way CHWC took care of patients or of safety concerns, but in the politics of the medicine business. That’s what you had to do if you wanted to survive.
It wasn’t just the way CHWC had started the cath lab. The other moneymaker, the radiation oncology center itself, wouldn’t have been in Bryan if Brunicardi and Ennen hadn’t played the political game. At the time Brunicardi first tried to start the center, Ohio was governed by what was known as “certificate of need”: too many hospitals and other facilities had been built with Hill-Burton money, legislators thought, and so to avoid wasting resources though duplication—like having two CT scanners across the street from each other—operators of proposed facilities had to apply for a certificate of need to gain approval. Big hospitals often tried to use certificate of need to block competition, and they often succeeded. Toledo hospitals argued that Bryan didn’t need a radiation oncology center and lobbied hard against it. But Ennen and Brunicardi had figured a way around the denial.
Everybody—the nurses in Montpelier who massaged patient reports so people could receive the help they needed, administrators who “upcoded” diagnostic notes so Medicare or private insurance would fully reimburse for services, drug company CEOs who tacked a pointless molecule onto an old drug so they could patent it all over again—knew that American medicine was one big grift. The only question was whether you were grifting to benefit people or to cash in. Whatever your motivation, you had to game the system. The CHWC board had often congratulated Ennen on such maneuvers because they’d helped to keep the hospital alive and independent.
“He spent his entire life threading needles,” Chris Kannel, the young board member and Montpelier council member, said of Ennen and the board’s vote. “He thought if he could thread this one right, he could fix it.” Now the board thought that he’d tried to thread the wrong needle and had placed the hospital in legal jeopardy. The lawyers at Bricker, the law firm, Cullis said, “were certainly very influential.” It wasn’t only the harassment situation, though: the board considered Ennen’s payout to the GI specialist, his reluctance over strategic planning, the way he walked out after being notified of the Bricker investigation, his impolitic emails in his moment of panic over the possible loss of his job, his apparent lack of contrition when interviewed by the investigator.
(My presence in the hospital also caused concern. Bricker, as was typical of a law firm, opposed allowing access to a journalist. At Ennen’s insistence, Bricker acceded, but drafted a nondisclosure agreement so restrictive it would have been impossible to report this book. Ennen drafted a new version with an expiration that would predate publication. On the day Ennen was suspended, Tinkel, with support from some board members, revoked my access. Other board members prevailed, however, and my access resumed a month later.)
Ennen did not deny his mistakes. He admitted he’d let his satisfaction over landing a GI specialist—any GI specialist—for Bryan lull him into rationalizing the hiring of the doctor, in the hope he would adapt to CHWC culture. He wound up having to pay $1 million. He’d wanted to protect Kim Owen, and also ease out the radiation oncology group, without creating drama. He got drama. He screwed up. He deserved some sort of reprimand, he thought, for not using the HR executive he’d hired. But he felt the totality of his successes at CHWC far outweighed his errors.
Nobody on the board questioned Ennen’s motivations or his integrity. “It was a culmination of that consistent, pervasive threading of needles that progressively eroded the board’s confidence in Phil,” Kannel said. The final vote wasn’t close. Swanson regretted having to vote to remove Ennen, but he did so. So did Kannel and most of the rest of the board. Cullis voted against. The episode, Cullis said, “was the most difficult thing I have ever gone through in my life.” (He would later apologize to his friend for failing to protect him.)
After getting Cullis’s call, Ennen and Mary drove back to Bryan and sequestered themselves in their house. Dean Spangler, whose brother sat on the board and had voted with the majority, dropped by. He was furious—a member of “Team Pitchforks and Torches”—and told Ennen there’d be a local revolt. Nick Walz, the now-retired family doctor and local institution, was angry, too, Spangler said. There was talk of mounting some sort of countermove to rescind the termination—but, though nobody said so, it was clear they all recognized that the well had been poisoned, the decision made. The only question left centered on terminology: would Ennen be fired, or would he be “allowed” to resign?
After a few days, some consultations with an attorney, and a little negotiation, the Bricker lawyers drafted a separation agreement. Ennen hesitated to sign it. Several days later, though, he woke up to the realization that, as shattered and bitter as he was, at least he didn’t have to worry about what to do when Kesireddy retired, or how to find another ob-gyn, or whether the cash would flow, or any of a dozen other things. He could move on. He was still only fifty-five. There was time for a second chapter. And if he resigned, he’d keep his severance package and health insurance.
He called a group of friends to come for lunch. Walz, Spangler, and others gathered around in the Ennen kitchen, ate sandwiches and potato chips, and listened as Ennen announced his decision and his reasoning.
His thirty-two years at the hospital—and his life in Bryan—were over. Before the year was out, he and Mary, the Bryan natives, would sell the house across the park from the hospital, store the family treasures, pack up the car, and drive out of town. Bryan would lose another bit of the glue that held it together. Chad Tinkel announced Ennen’s resignation to the hospital staff with tears in his eyes.
Days after Ennen took Cullis’s call, concerned local officials held another meeting. This time they gathered in the basement of the county health department in Montpelier. Tracy Plouck, an Ohio University addiction services expert, had gotten hold of some grant money. Now she was there to ask how she could help the county better confront the problem of drug abuse. Fred Lord, chief of the county’s Jobs and Family Services (JFS) agency; Anna Meyers, a JFS supervisor; Brian Davis and Terry Rummel, county commissioners; the health department’s Jim Watkins and its director of nursing, Rachel Aeschliman; Rob Giesige, the new chief of the Four County ADAMhs board; and several others sat around a long table.
Meth was still the drug of choice for abusers, but lately police and the ER had been seeing an increase in fentanyl, and sometimes meth with fentanyl. This, they told Plouck, was their first aggravation. After wishing away the opioid epidemic, Ohio state government had finally begun facing it and appropriating money for enforcement, interdiction, and treatment. But because most OD deaths—and news about OD deaths—involved opioids, the money had been designated for only that. It couldn’t be used for meth-related projects. This was folly, they said.
Sociologists had tried for years to tell politicians that drug abuse was a symptom, not a cause. The kind of drug was irrelevant. Yes, heroin and fentanyl were deadlier than meth, and meth might be deadlier than alcohol. Alcohol might be more immediately dangerous than obesity, lousy dental care, poverty and low wages, crummy housing, depression, trauma, and anxiety. They were all part of the same pathology, though, and arguing about which was worse obscured the underlying causes of the abuse.
That message was a much tougher sell than going after a single drug. Few people wanted to question some of the most basic presumptions about how the country operated—and why. Most politicians preferred not to think too hard about why people might be depressed, anxious, and traumatized. Even when they did, they latched onto easy answers that resonated with their electorate.
There was no better example than the comments of politicians at the April 2019 “opioid summit,” a weekend-long community event held at Northwest State Community College and hosted by the college and CHWC under the sponsorship of the Montpelier auto parts maker Rassini Chassis (more evidence that opioids attracted the money). During the wrap-up summation and Q-and-A session in the college’s auditorium, Craig Riedel, a state representative, stood and took the microphone. The state spent $30 billion on Medicaid and education, he said. The opioid issue took up another $2 billion. Yet the drug problem grew. In case the implication wasn’t clear enough, Riedel made it explicit: “Government isn’t going to solve this,” he declared. Watkins, who was sitting at a table in the back of the room with Bryan’s mayor, Carrie Schlade, sighed.
“Our religious community has to be very involved in this,” Riedel continued. “I believe that, as a society, we have to be more Christ-focused. I believe we will be relying heavily on our religious community and Christ to get this thing solved.”
Watkins’s forehead hit the table in front of him. He rolled it back and forth. Schlade, a woman who’d opened a Bryan Chamber of Commerce event “in Jesus’s name,” shook her head. The audience applauded, though; it was the first time it had applauded all afternoon.
“We’ve been working with faith-based for thirty years!” Watkins said over the applause. “So, how’s that going?” It would be tough to find a more conservative Christian part of Ohio than the northwest corner, where separation of church and state was considered more advisory than mandatory. A giant marble slab carved with the Ten Commandments sat embedded in the front lawn of the Paulding County Courthouse. IN GOD WE TRUST. WITH GOD ALL THINGS ARE POSSIBLE, read a framed sign depicting the U.S. and Ohio flags mounted in the main hall of the Fayette public high school. The obituaries of the overdose dead often cited their religious affiliation and their love of Jesus.
Watkins dug his phone out of his pocket. He looked up the percentage of Americans who declared no religion—about a quarter. And what of the six million or so Jews? And the more than three million Muslims? Throw in Hindus, Buddhists, Zoroastrians, Sikhs, and Confucians, and Riedel was writing off an awful lot of Americans.
Riedel’s Christian chauvinism wasn’t what bugged Watkins most, though. “Why did he run for office?” he asked. “If government can’t do anything, why run for a government office?”
Most of the people around the table in the basement in Montpelier were government employees of one kind or another. Most of them wanted to channel the energies of government to improve the health of the people they served. Doing so in Williams County, however, came with the extra burden of knowing that so many people there distrusted—and sometimes even hated—government. From the time Ronald Reagan declared that “government is not the solution to our problem; government is the problem” in his 1981 inaugural address, that slogan, too, had become part of the Williams County gospel, reinforced over and over through the decades by the politicians voters elected to government offices.
The resistance Ennen met when advocating for all employees to get flu shots wasn’t only the result of false beliefs like “the flu shot will give you the flu,” a common one in the county. The county commissioners didn’t require EMS crews to get flu shots because they didn’t think government should tell people they had to get vaccines. In the ER one day, Marv Stalter asked a young single mother who worked at Menards and who relied on Medicaid if her small child was up to date on his vaccinations, and she made it clear she didn’t trust pronouncements from the government. “Oh, we do not vaccinate,” she said. Stalter made a short sound of concern with the intake of his breath, then launched into the same litany he preached to every such young parent—about polio and iron lungs and lives saved—but he knew not to bother being too insistent. When Jan David spoke to a neighbor about the importance of getting a flu shot, the neighbor replied, “That’s from the government. You don’t know what they’ll put in it.” A hospital employee filled out the required statement explaining why she refused to be vaccinated: “Religion is Pentecostal. Obamacare is putting a ‘chip’ in the flu shot to track people’s whereabouts for the ‘666.’ Not going to take the ‘devil’s shot.’ Took it last year but felt forced into it. Husband was very upset. This is already happening in Wyoming and other countries.” The employee was apparently referring to an anti-Obama conspiracy theory about radio-frequency identification tags being injected into human beings via vaccines.
For all the county’s antipathy toward big government, it lived off big government—just as in the days of the Great Depression, when the feds made all those payments to farmers and built part of Bryan’s infrastructure. Williams County residents received medical payments of $150,323,000 from government in 2018. Total government transfer payments to individuals came to $339,480,000. In 2019 and 2020, more federal money arrived via payments to county farmers from the Market Facilitation Program, the compensation to farmers hurt by Trump’s trade war. Farmers who qualified could receive $67 an acre, up to $250,000 per person or farm corporation. Even if they didn’t plant a crop, they could receive $15 an acre.
Of course, Bryan’s biggest employer, the hospital, would shut its doors without federal payments, as Ennen had always liked to point out. “Very conservative community we live in,” he told a group of employees at the Montpelier hospital during a meeting. “‘Socialized medicine.’ Well, if you are opposed to socialized medicine, wow, you are way too late. That horse left the barn a long time ago.”
Some of those around the table, like the county commissioners, approved of government welfare for corporations—most recently granted to Love’s Travel Stops, an Oklahoma-based chain of over five hundred truck stops owned by the billionaire Love family. The new truck stop would employ fifty people, Love’s promised, half of whom would make $9 an hour. They didn’t approve of welfare payments to people, though, and the state legislature agreed.
The Republican Party enjoyed a supermajority in the legislature, thanks to gerrymandering, and it used that power to cut taxes over and over again. Meanwhile, state funding for Jobs and Family Services ranked fiftieth out of fifty states. “It would bankrupt the state just to get us to forty-ninth,” JFS chief Lord said. Counties were expected to contribute money to the local JFS outlets, too.
The problems Lord faced—like the drug abuse being discussed around the table—only grew. In 1979, Williams County’s poverty rate had been 7 percent. Now, in 2019, it was 13.5 percent, despite full employment. With poverty and near-poverty came drug abuse and a host of other ills, Jim Watkins said. The data showed it, and everybody knew where the hot spots were: on Bryan’s east side and in depressed Montpelier.
When Tracey Plouck asked about mental health facilities for treatment and overdose care, Rob Giesige, the new ADAMhs board chief, pointed out that there were no crisis stabilization beds in the entire four-county region where they could put a person suffering from an overdose or mental health breakdown. Instead, they used the ERs at CHWC and other counties’ hospitals, where they could at least put someone for twenty-four hours. Otherwise, everybody had to be sent to Toledo—and beds there were always in short supply.
To Lord and JFS administrator Anna Meyers, their biggest drug-related problem was children. Ten children had been taken into protective custody to shield them from drug-abusing caretakers in just the past couple of weeks, Meyers told the group. Williams County was swamped with such children. As it was, Brian Davis said, the county had spent $900,000 on child placement. “This is unsustainable,” Davis told Plouck. He appealed to big government for help. “Hopefully, Medicaid will pick that up.”
“Our ability to reunify with these people is almost zero,” Lord said. He turned to Meyers. That was right, she confirmed; in the past three years, not one family had been reunited. “It’s easy to say all those people need to be arrested and thrown in jail,” Lord said, “but most of these people have kids. What happens to those kids once they go into foster care?”
Lord’s small team of investigators was poorly paid, and abuse and threats were routine parts of their jobs. (In the spring of 2019, police would break up a murder-for-hire plot targeting one of them.) As a group, they managed about a hundred cases at a time. At a morning case intake meeting, eleven women—investigators, intake specialists, and a school social worker—received a briefing on the day’s new business. A baby born at CHWC had tested positive for THC and amphetamine; the mother suffered from paranoia. Another mother living in a trailer had been monitored by JFS for a while. There’d been some steadying of the family after the child’s father got a job, but now the little one had been found climbing out a window while the couple was having sex.
Another mother who showed up at Janis Sunderhaus’s Bryan Community Health Center had revealed there was no refrigerator in her house and that she’d been storing food outdoors to keep it cold. She had no stove. She used a George Foreman grill to cook. The family had recently been homeless. Her husband was bipolar. Another woman with five children, all under age five, suffered from severe postpartum depression after the birth of her youngest.
Most people in Bryan had no idea of this reality. “They don’t want to see,” an investigator said. “Or they don’t have to see.”
With so many children in need of so much—and without places to put those children or the money to support them—JFS had no choice but to accept a low bar for parenting. “For us, if they have a roof over their heads, food in their stomachs, clothes on their backs, and [parents] are not doing drugs in front of the kids or beating them, we count that as a win,” Meyers said.
The JFS investigators worked at the edge of what Montpelier’s police chief, Dan Magee, saw as intergenerational dysfunction. Allison Rosenbrock, a JFS investigator, represented the front-line troops. She’d been out of college for a year and made about $16 an hour.
One day Rosenbrock drove out to West Unity to check on Shilo and Jimmy. Shilo had an interview later that afternoon for a job at a gas station in West Unity. That was good news, but there’d been a report of an altercation between them. A little rocking horse had tipped over. One of the children was injured. Shilo may have kicked Jimmy out of the house. Or maybe not. She might have just been waiting for him to cool off and learn his lesson. Rosenbrock wasn’t sure.
She knocked on the door. Shilo welcomed her into the tiny living room. She was wearing a pair of floral cotton tights, which hid most of an elaborate tattoo, and an old hoodie. Both children slept soundly on a little couch, head to feet. A big candy-pink Barbie bag belonging to the mother sat on the living room floor. Barbie’s blond hair fell in sharp bangs just above the frames of her heart-shaped sunglasses, and she flashed perfect, white, straight teeth. One of the boys “got a best new student award,” Shilo told Rosenbrock. (Clients liked to headline any positive news to investigators.) The boy had been very proud. Shilo and Jimmy, amused by their little boy’s bragging, had made fun of the award. She hadn’t done it to be mean, she told Rosenbrock. She just wanted to let the boy know, “Look, kid, they give those things out all the time.” She didn’t want him to have any illusions. The boy still treasured it, though, so she framed it and put it on the kitchen counter for everyone to see.
Rosenbrock asked a few questions, took a few notes, and then informed Shilo about the Bryan Community Health Center. She drove out of the village and past a FOSTER PARENTS NEEDED sign on an empty storefront. Fifteen minutes later, she was cruising slowly through Montpelier, searching for a house. She pulled up to a shack with a long-dead lawn mower out front. “Last time I was here,” she said, “there was a door there.” There wasn’t one now; instead, a thick, old blanket hung over the front doorway to the shack. The temperature was about 40 degrees.
The mother, Jessica,* bedraggled and holding a newborn baby on her hip, met Rosenbrock in the doorway. So did four other small children, in various states of nakedness. Two enormous dogs, a St. Bernard and a Rottweiler, sniffed the newcomers. A row of thirteen cereal boxes, all generic knockoffs of famous brands, sat on a one-by-six plank that had been nailed to a wall. The place smelled of dog piss and poop and mess. The power was on, though—for now. “Our shut-off date is usually the twenty-ninth,” the mother explained.
Rosenbrock interviewed Jessica as the children clung to the visitors. She said that the father of some of the children—the man with whom she was living in the shack—had started a new job that very day, at an injection-molding company. They were behind on rent ($425 a month), but she hoped they could catch up in a month or so. She also hoped she could get in to see one of the Parkview doctors for her crippling depression. But she was worried: “They won’t take my children because of depression, will they?”
That afternoon back in Bryan, Mindy Lemon, a veteran social worker at twenty-seven, knocked on the door of a single-wide trailer in a run-down trailer park. The mother inside had lost her children to Jobs and Family Services due to drug use. But the agency, desperate for a reunification, had since returned them. Lemon could show up at any time to check on them, and so she did.
A tall, skinny man with a military unit’s ball cap on his head answered the door. He was the mother’s fiancé. He, the mother, two boys, and the father of the boys all lived in the trailer together. The five-year-old boy was autistic. The eight-year-old often punched himself in the face.
The mother and the fiancé and the ex had bought the single-wide as a used, empty shell “because we been evicted so many times, nobody will rent to us,” the mother explained. Ever since, they’d been trying to add walls to the interior. So far the walls consisted of two-by-four framing draped with towels and sheets.
The mother, the ex, and the autistic boy all sat on an uncovered mattress in the trailer’s main room with a pizza box between them. A dog in a cage—some sort of Rottweiler mix—barked and lunged against its prison like a lunatic.
Things had been going pretty good, the mother told Lemon over the noise. She’d held on to her job at an auto-parts supplier across the border in Indiana and had received a raise to $16.50 an hour after she put in for and was granted an assignment to the swing shift, from two in the afternoon to ten at night. She brought home about $300 a week. So did the fiancé, who worked at the same plant.
She was worried, though, about medical care for her boys. Now that they were back in her custody and she was working, the boys would lose Medicaid coverage as of the first of the month. Obtaining coverage for the children would be an expensive proposition, especially when she was just finding her footing. Lots of people JFS served faced the same kind of problem. Often they made just enough money to disqualify themselves or their families from Medicaid, but not enough to afford coverage offered by an employer or via the Affordable Care Act.
Lemon invited the eight-year-old to show off his bedroom. She wanted to see how and where he was sleeping. The two of them walked to the back of the trailer and into a small bedroom furnished with stacked bunk beds. The eight-year-old slept in the top bunk.
“What happened to your sheets?” Lemon asked after seeing the bare mattresses.
“I took ’em off,” the boy answered. “I don’t like sheets.”
“How are you doing?” she asked. “You know I worry about you.”
“I know you do,” he answered. “I’m okay. I just get mad sometimes.”
In the early 1990s, medical researchers noticed that people who had survived childhood sexual abuse were more likely to suffer from a variety of physical maladies in adulthood. So in 1995, a group of physicians and public health experts from Kaiser Permanente in San Diego, Emory University, the University of Arizona, and the Centers for Disease Control and Prevention began a study of adverse childhood experiences, or ACEs. They screened thousands of people using Kaiser’s medical services in San Diego, conducting physical exams and having people fill out long questionnaires designed to elicit information about household dysfunction when they were children, including such things as substance abuse in the home, physical and emotional abuse, and violence. The more categories of adverse experiences these people were exposed to as children, the greater their later risk of smoking, obesity, physical inactivity, depressed mood, and suicide attempts as adults. They were more likely to be alcoholics and drug abusers, and to engage in risky sex. And they were more likely to be sick with conditions like heart disease, cancer, emphysema, bone fractures, hepatitis, and general poor health.
Over the next twenty years, physicians, public health researchers, sociologists, and demographers explored the links between socioeconomics and health. Between 1959 and 1979, life expectancy in the United States increased from about seventy years to about seventy-five. There were multiple reasons for this: vaccines against childhood diseases, improved community infrastructure, better antibiotics, and improved treatments for diseases like cancer. It was no coincidence, though, that during this period economic inequality in America decreased. There are a number of ways to measure inequality, and a number of organizations, economists, and government agencies that do the measuring. But all of them show that inequality in America declined in the decades following World War II. Ronald Reagan was elected president in 1980, ushering in an era of union-busting, financial deregulation, leveraged buyouts, and the financialization of the American economy. What ensued was a precipitous increase in inequality, whether measured by income or by accumulated wealth, and except for short pauses, it kept rising. By 2019, the United States was one of the most unequal countries on earth.
Inequality itself was unequal. The gap between whites and blacks grew, and so did the gap between places and education. The well educated flocked to metropolitan areas and worked “knowledge economy” jobs. Rural counties, with few college graduates and a reliance on manufacturing, began to look more and more like poor neighborhoods in urban centers. In fact, many white people in Williams County had a lot more in common with poor black people in places like the Franklinton neighborhood of Columbus than they may have wished to admit.
The gap in mortality rates between whites and blacks began to converge. In 1999, the death rate for non-Hispanic white people ages fifty to fifty-four with a high school degree or less was roughly 30 percent lower than that of blacks. By 2015, it was 30 percent higher. The lines crossed for other age groups, too. Frederick Hoffman, the racist insurance data guru of the early twentieth century, had gotten it wrong: it wasn’t race that made African Americans less healthy, but poverty, lack of education, lack of everything.
The effect held across generations. The life expectancy at age fifty for people born in 1930 was about five years higher in the top 20 percent of income than for those in the bottom 20 percent. But that chasm had grown much wider over the generations. By the time they were fifty years old, those who were born in 1960 and at the top 20 percent of income earners could expect to live until they were nearly eighty-nine. Those who were born in 1960 and at the bottom 20 percent of earnings could, at age fifty, expect to live to seventy-six, a difference of about thirteen years.
The same effect held by location, too. People in rich, better-educated counties lived longer, healthier lives than people living in poorer, less-educated counties.
The increase in socioeconomic inequality brought stress and frustration with it. The constant stress of barely making a living, of hustling for the next meal, of having to keep track of what date the power company would shut off the electricity, of worrying about every bill and every penny, of feeling hopeless about the future, and of knowing that you could work two or three jobs for the rest of your life and never really break out of the cycle in which Valerie Moreno, Keith Swihart, and so many others found themselves living could erode both mental and physical health—not least by creating actual physical changes in both the brain and the body. Family distress was one symptom of the disease, and it generated more adverse childhood experiences. And the wheel turned over to the next generation.
Lack of money wasn’t the only ingredient in the American pathology, so escaping the cycle became tougher all the time. Family, community, and meaning had all broken down as disadvantage in one realm, like financial security, spread the malaise and surrender to other realms, like education. Social mobility in the United States had regressed. Fewer people were able to stand on the shoulders of their parents to make the all-American climb.
If a young person wanted to take a step up—say, by going to a university to earn a four-year degree—politicians made it harder to do so. Tuition plus room and board at Ohio University in Athens cost a state resident almost $26,000 a year. In 1980, it had been about $3,000 a year (roughly $10,000 in 2019 dollars). Ohio State cost about $28,000. Such hikes were typical across the country as states cut back on funding for higher education. Alaska cut state support for the University of Alaska by $100 million in 2019.
Schools around Williams County were starved for money. Bryan’s would rack up a $2 million deficit in 2019, and more deficits were projected in succeeding years. Education suffered. Bryan city schools, Montpelier village schools, and the school in West Unity all received F grades for meeting achievement indicators when rated by the state of Ohio. Montpelier received an F for preparing students for later success. Overall, West Unity and Montpelier received D grades, while Bryan city schools earned a C.
Meanwhile, the Trump administration proposed big cuts to the programs that helped keep people like Keith alive. After Trump’s tax cuts for corporations and the wealthy blew up the federal deficit, he proposed eliminating student loan subsidies, cutting Medicaid (which could be disastrous for hospitals like CHWC), and reducing housing assistance and funding for food stamps. The Trump Administration slogged through the courts in an effort to eliminate the Affordable Care Act.
Local policies didn’t always make it easy for those who stumbled to get back up. Back in Montpelier in the basement of the health department’s headquarters, Plouck, the Ohio University expert, asked the officials assembled around the table about a needle exchange program. A few of them chuckled. Several years before, a small town in neighboring Indiana had wound up with a localized HIV epidemic that resulted from sharing used needles. Williams County itself had a growing number of hepatitis C diagnoses, and the trend was beginning to shift to younger people.
“There’s no way here,” Watkins told Plouck. “We’d worry about the sheriff taking license plate numbers” of cars pulling into a needle exchange location. Many in the county regarded any accommodation to drug users, even in the name of public health, to be encouraging drug abuse. Though medically assisted treatment, or MAT, had been proven effective in treating addicts by providing them with a transitional prescription medication to ease the craving for opioids, many opposed that, too. Handing out Narcan, the drug that could rescue people who overdosed, was “not so politically viable,” either, Watkins said. The belief in a prelapsarian utopia based on universal personal responsibility was too strong in Williams County to tolerate easy access to Narcan, MAT, or needle exchanges. You just had to teach kids to resist the lure of drugs. You had to teach them to comply with the accepted norms of society.
So Sheriff Steven Towns insisted on money for the DARE program (Drug Abuse Resistance Education) in schools, though DARE had been shown to be worse than ineffective back in the early 1990s. (Towns would resign his position in February 2020 in lieu of being charged with felony crimes involving misuse of public money.)
This philosophy contributed to the pervasive belief in drug testing by employers. Few business owners and managers questioned the wisdom of testing applicants and employees—and of insisting, when some failed, that nobody could pass a drug test.
Dave Swanson was a notable exception to this dogma. Why were employers testing in the first place? His company, Daavlin, didn’t. As was the case for most other employers, Swanson’s workers weren’t flying airplanes, handling nuclear fuel, or slicing open a patient for heart surgery. He reckoned that a small minority of his employees might use drugs at least sometimes (he knew some had, in fact), but if anybody were to show up too high to work, coworkers would notice. Keeping people from working because they had THC or even a trace of meth in their system would only guarantee that that person would keep on using—maybe more and more—as they slipped further down the economic and social ladders.
Swanson did bring drug-sniffing dogs through his plant sometimes on weekends, when it was shut down, because he didn’t want anybody stashing drugs on his property. But this idea that having used drugs should keep you out of a job seemed counterproductive to him at a time when the country was facing an epidemic of drug use, and when Williams County businesses were crying out for workers. You’d just wind up making a lot more poor people. Nothing was a guarantee, of course—and people with great jobs could become addicts, too—but Swanson believed that a decent job was more effective at fighting addiction than Jesus Christ was.
At the meeting, when Plouck and the others discussed a number of factors that contributed to the drug problem, they highlighted the same kinds of troubles many other places faced in post-recession America. They talked about housing and transiency, transportation and access to good food, wages and aging and education. They talked of enlisting the help of religious communities.
Jim Watkins was one of the few people in the county to recognize that Americans were faced with a new, deep, and abiding national sickness. He’d begun working with Bowling Green State University’s Center for Regional Development in an effort to bring its expertise to bear on the housing problem and on the low-wage economy. “What’s the reason people are going down this road in the first place?” he asked.
He already knew the answer: too many people in Williams County were being used the way mining companies used coal in West Virginia. Human beings were the object of an extractive industry. They were mined for their labor and for their money. Too often, they were a “workforce” and not people at all. The goal was to pay them as little as possible and to get as much work out of them as possible while taking the least amount of responsibility possible. The modern American version of capitalism encouraged—even demanded—that employers extract the value from their employees while returning scraps to them and their communities. And then others—like some medical professionals, business owners, politicians—questioned why poor and working-class people didn’t take care of themselves. Why didn’t they comply? This was the same argument employers had used in 1916 to oppose a state health plan, blaming the working class for “absences caused by intemperance, by ball games.” If they were sick, they had only themselves to blame.
People were already sick. The medical industry and public health experts had a name for this mix of factors: “social determinants of health.” But even the biggest systems couldn’t do much about them. Those systems were packed with the fanciest gadgets and well-trained doctors and nurses. At CHWC, at least, there was a caring, sometimes even loving staff. Yet, simultaneous with the rise of the giant hospital corporation and the wealth-extracting medical industry, American life expectancy and well-being declined. Decades of research showed that social determinants had an enormous impact on health and longevity—more than medical care itself, which accounted for only about 15 percent of the inequity in mortality.
The medical economy itself, though, was also an exercise in inequality. In 1932, the Committee on the Costs of Medical Care concluded that “as one ascends the economic scale, medical care becomes more adequate. This results in a postponement of death in a certain number of instances.” Since then, nothing had changed. Hospitals, drug companies, doctors, device makers, and insurers were consolidating furiously to protect their power to raise prices. Medical care cost too much because it could cost too much.
The health industry, like other industries, had also figured out how to siphon off what wealth people had and add that to its own bottom line. There was no better example than diabetes: between the insulin, the monitors, the test strips, and the pumps, diabetes was a rich vein of cash that would last as long as a diabetic lived.
Valerie and her family, Greg Coleman’s flock in West Unity, the patients at the Bryan Community Health Center, and CHWC itself were all being crushed by the parallel economy of American medicine. Poor and working-class people, like Roger Metzger dying of cancer in the ER and Sheila Carpentar transported from the nursing home, even died differently than the rich did. Bryan, Ohio, wasn’t much different from many other places. It was a microcosm of America’s sickness.
Life Squad 2 wasn’t back at headquarters long before another call came in at about 10:00 PM: law-enforcement assist on a county road not far from headquarters, just outside Bryan’s city limits. A deputy was on the scene.
The ambulance pulled up to a trailer park of mostly single-wides, most of them giving way to corrosion. An old Chevy Malibu was parked in a little driveway amid the huddle of aluminum-and-tin homes. A deputy leaned into the passenger-side window. He spoke with soft words.
“I think you could use a little help,” the deputy said to a pretty young woman. She was about twenty-five years old, with dark hair and a sad, worn look in her overdosed eyes. Want-ad sections of a newspaper lay crumpled on the car’s passenger-side floor, along with wrinkled, official-looking pieces of white paper: Medicaid forms. “Let these fellas take you to the hospital and get ya checked out,” he said.
She laid her face on the steering wheel and sighed. “I want help. I just don’t wanna get checked out.” Because she wasn’t passed out, EMS couldn’t take her to the hospital involuntarily. She’d overdosed, but not quite enough. The deputy tried again. He reassured her. In her confused state, she insisted she wanted help but didn’t want to be helped. She wanted it—addiction, hopelessness, depression, whatever it was—to go away, as if wishing it away would make it so.
The deputy and the EMS crew stepped over to a group of three people who’d been watching from the front of a crumbling single-wide, shivering in the nighttime cold. The young woman’s mother took a cigarette out of her mouth and said, “She’s been speedballin’.” Her father, warmer in an Ohio State jacket and an Ohio State baseball cap, stood mute.
After a little discussion that amounted to nothing, the deputy declared that there was no point in sticking around because there would be no patient transported. The crew of Life Squad 2 drove away.
For all the talk in Bryan, Ennen’s shove out the door of CHWC didn’t matter much to most people. For them, nothing had changed.
The day after Ennen was fired, Valerie Moreno sat at a card table in the common room/kitchen of the church, counting out Girl Scout cookie money with her daughter and another Girl Scout mother. Betty Franks, the wife of the former pastor and a retired public schoolteacher, was there, too.
Valerie still worked three jobs. Her back still ached. And she was still coughing from something—maybe the flu, maybe a bad cold—that a coworker at Sauder had brought into the factory. Valerie wound up with bronchitis, an inner ear infection, and a sinus infection, but she didn’t miss any work because she had no paid sick leave. “No! I went to work every day,” she said, laughing, which called forth a brief coughing fit. She did visit the Sauder corporate clinic. The nurse practitioner there said, “You’re sick,” and Valerie said, “Yes, I am.”
Her work at Sauder involved mostly standing for eight to ten hours as she wrapped foam and upholstery around sofa arms. “It was tough to go to work,” she said. “I coughed and coughed and coughed.” She was proud she was getting faster on the Sauder line. The day before, her line had completed twenty-one sofas. She’d received a raise—to $13.75 an hour—plus a $1 premium for working the third shift, from 11:00 PM to 7:00 AM. “Fridays, I don’t sleep. I was up thirty-nine hours yesterday.”
Valerie grossed $1,312 for two weeks of work, bringing home $793 after the $186 for healthcare was taken out, along with a little for her 401(k), a little into a health savings account (encouraged by the company with an HSA incentive payment), and some withholding. After the deductions, her take-home total amounted to about $19,200 a year. Her bus job added another $280 a month if she didn’t miss any days, and Franks paid her $150 a month for looking after Franks’s husband. Valerie and her husband were also trying to save for college tuition for their thirteen-year-old daughter—the Girl Scout—who wanted to become a nurse practitioner. And Valerie was determined to make that trip to Disney World.
Valerie did have a little more money in her checking account now, but she didn’t feel any more secure. “I get paid every two weeks. So you eat well the first week, but the second week is a straggler.” She counted out hundreds of dollars in cookie money, arranging them in neat stacks on the table.
With her teacher’s pension and healthcare and her husband’s retirement and Social Security, Franks didn’t feel the same gravity of worry as Valerie, but facing the medical industry was still stressful. She and her husband had a $500 drug deductible. At the start of the year, she went to the drugstore to buy his Symbicort inhaler “and found out it was $300.”
“Isn’t that ridiculous?” Valerie chimed in. “For a medicine they have to have, it is $300 because they haven’t met their deductible.” “And the insurance wouldn’t pay for the other drug he was prescribed,” Franks added, “because that was $400.” After the deductibles were met, they paid about $40 a month for the inhaler. “And I have a good policy!” Franks said, speaking of her state teacher’s insurance. She wondered how other people coped.
“If you are on Medicaid, you are fine,” Valerie said. “But if you’re in between, you have got a real problem.” Valerie knew a lot of people in between.
Valerie’s daughter double-checked the cookie money count. She was excited by the sales. The troop had talked about a big project: some way to bring good food to the small villages around the county—or at least to the West Unity area. Maybe they could get a food truck, or build a greenhouse, growing fruits and vegetables year-round and selling them for just enough money to keep the project going.
Beth Pool understood the dilemmas faced by Valerie and Betty Franks better than anybody else in Williams County. Pool ran a small insurance agency, based in Bryan, that wrote a lot of healthcare policies for small and midsize employers, including CHWC. Over the previous decade, both her business—and the entire universe of American medicine—had begun to feel like they were built on sand during a rising tide.
When she looked over the insurance plan for her own twenty-nine employees, she had to laugh. The plan cost her agency $170,000 annually. “I looked at that big number and thought, ‘How many insurance policies do I have to sell to pay that amount?’ And it’s more than I sold last year.” She wasn’t alone—employers all over the county faced the same problem.
Deductibles weren’t always part of health insurance. They were introduced with arguments appealing to “personal responsibility” and “skin in the game.” Without deductibles, some insisted, people would abuse insurance, and not take care of themselves. By 2008, deductibles had become a way for employers to lower rocketing premiums. After the recession, though, the deductibles kept rising, and so did the premiums. Employers passed the costs on to their employees, but the employers’ costs still rose. One of her small business clients, for example, paid $335,173.56 in premiums. Employees insuring only themselves paid $509.33 a month as their share. An employee also insuring a spouse paid $1,013.53—close to half what Valerie made each month at Sauder, and Valerie’s wages were typical.
To renew this plan for the following year, the insurance company would charge the employer 5 percent more, bringing the total to $352,001.52 annually. The employees’ share would rise, too. Pool figured out a new plan that allowed the employer to reduce the annual outlay to $282,577.80. The employees would pay about $100 less each month. But they’d carry a $5,000 deductible for themselves and a $10,000 deductible for their family, and those amounts would double if they had to go out of network for any services.
“You have insurance, but it doesn’t do you any good,” Pool said. “I get that. That is a sad reality.” For small employers like her, she said, this was not sustainable. Like the businesses she helped, you could scramble for a little while—push more costs on to somebody else—but eventually it would all fail. The farmers she insured could move to one-person and two-person group plans, which were a little less expensive than individual ones, but “they won’t be able to do that forever and ever.”
Dave Swanson knew that all too well. He liked to provide good coverage for his Daavlin employees. To do it, he had to drop a regular insurance company’s plan and switch to a self-insured one by creating a pool of the company’s own money. The plan included a stop-loss to prevent catastrophe. In 2019, when an employee submitted a claim for a drug that cost hundreds of thousands of dollars a year, Swanson’s plan administrator had to figure a one-time way around the first-year cost of the drug. That maneuver worked, but it left Swanson uncertain about the future. “Fourteen months from now, we may be totally screwed,” he said. “I don’t know what we are going to do, because I like to have good coverage. But I am unlikely to be able to afford it. Everyone is going to get hurt. If the insurance pool was 340,000,000 strong,” Swanson said, referring to Medicare for all, “it wouldn’t be a problem.”
Pool believed the entire system of employer-based health insurance was going to collapse sooner or later—maybe even sooner than many thought. She was skeptical of Medicare for all. On the other hand, the system had grown by accident, by ad hoc “solutions” over many years, decade upon decade. If it ever had made sense, it sure didn’t now. “There is so much broken,” she said, “I don’t know what the answer is.”
Jim Watkins was right: there was no system at all. “It isn’t a system!” agreed Kim Bordenkircher, the CEO of Henry County Hospital. “We do not have a system here!”
What America did have was a jumble of ill-fitting building blocks: the doctoring industry, the hospital industry, the insurance industry, the drug industry, the device industry. They’d all been able to tweak and sand the corners of proposed “solutions” to benefit themselves. Lobbyists and political action committees spent millions to do so until the edifice of American medicine looked like a fragile Tower of Babel, rotten with holes and the crooked passageways where money was hidden. There was so much money. Trillions. And there was so much incentive to embrace the insanity because the insanity was so lucrative.
“It’s crazy!” Nick Walz, the now-retired doctor, said in March 2018 as we sat over dinner in Father John’s. “Really. The whole thing is insane.” A year later, he hadn’t changed his mind—and pretty much everybody agreed with him: other doctors, Ennen and other hospital administrators, patients, hospital social workers. Everybody.
There was no end of reform plans. America had been working on reform for a century. Shelves of books, stacks of government reports, entire staffs of think tanks were devoted to reforming American healthcare. Reform had become its own healthcare industry, complete with its own cadre of experts.
Around Bryan, though, just about everybody also agreed on solutions. The answers seemed so obvious. If Mike Liu, the Parkview surgeon, was correct that medical care was a human right, then what? Well, you could blow up the entire crazy structure and start over. The United States could create a national health plan, proposed over a hundred years ago. The government could go into the drug business to manufacture drugs that had gone off patent. It could regulate drug prices, especially for drugs that had been created with the help of taxpayer research money. It could shorten patent protection and ban copycat patents. Medical school costs could be slashed, especially for general practitioners and family practitioners. Hospitals could be funded with grants, and in return charge patients nothing: many hospitals, including CHWC, already received most of their income from the government.
Even in conservative Bryan a lot of people thought such ideas might be good ones. Yet, just as they all agreed that the current medical economy had become a perverse funhouse, they all also agreed that there was nothing to be done about it.
America had gone too far down a bad road and had no choice but to keep going. There was too much money at stake to blow it up. Doctors would make less. So would the drug companies and their shareholders. So would the big hospital systems and the private equity outfits that were beginning to dominate American medicine. The device makers would make less, too, and so would the consultants, the accountants, the medical records software companies, and the ambulance companies. Lots of people in the insurance industry would lose their jobs. Not in a million years, everybody agreed, because nobody wanted to give up their current piece of the pie.
So much depended now on the medical industry. In 1938, at a National Health Conference convened to explore the need for a government health plan, American Federation of Labor lawyer Joseph Padway argued that health was “not an article of commerce.” Ninety years later it had replaced manufacturing as the nation’s big driver of commerce. It had also become a substitute taxing agency for cities looking to replace local revenues with industry largesse, though the upstream source was the pockets of patients. Many medical jobs were in fact low-wage—assistants could expect to make about $33,000 a year, janitors and housekeepers about $26,000, home health aides $24,000, food service workers $22,000—but cities counted on the high prices people paid to the medical economy to help finance billions for new buildings and attract high-paying jobs. Officials at Toledo’s Regional Growth Partnership, a multicounty economic development agency, were ecstatic when ProMedica took over an old steam plant in downtown Toledo and transformed it—with the help of massive subsidies from federal, state, and local government—into its new headquarters campus. ProMedica, they said, would turn Toledo’s inner city around. They imagined chic loft apartments, new cafés, rising property values. The Toledo Blade, which called ProMedica’s CEO, Randy Oostra, “a local hero,” declared that “without Mr. Oostra, we are in trouble.” Nobody wanted to wreck the chances of all that coming true by curing the insanity.
That’s why private equity was taking over so much of healthcare. PE firms may not have known how to run companies, but they weren’t stupid. Like Willie Sutton, the thief who when asked why he robbed banks supposedly replied, “Because that’s where the money is” (words he later denied ever saying), PE investors knew healthcare was the biggest casino in the American economy.
Many patients didn’t want to cure the insanity, either—their distrust of government was too deep. Jennifer Stantz, a young woman who incurred so much medical debt that she and her husband had to sell their house, didn’t approve of the Affordable Care Act. Because her husband was the sole proprietor of his construction company, he didn’t have insurance, and neither did Jennifer. An Obamacare plan would cost $1,400 a month, she said. “That’s my whole income! How could I feed everybody?” Her own medical debt was about to pile up again because she’d been recommended to have surgery for a heart valve condition. “I’m screwed if I get that surgery,” she said.
Yet she rejected the idea of a single-payer government plan. “No, no, no!” she said. “Because then your quality of care is going to be dictated by the government.” Instead, she argued, she should be able to get Medicaid. The state had ruled that she made $200 too much. She was appealing that decision. All three children were already insured by Medicaid. Somehow, Medicaid didn’t seem like a government plan.
Marc Tingle felt the same way. “I don’t believe it should be put in the hands of the federal government that is so inept at handling anything,” he said. “That is the last thing we need to do—I have no faith in them at all.” Yet the Tingles relied on Ohio’s Children with Medical Handicaps program to pay for the many bills resulting from their son’s spina bifida. Funding for that program came from the federal government, along with state funds, county funds, and donations.
Even if the dream of a new system were to come true, what ailed the nation was so much deeper than whether or not people could afford health insurance. Donald Amos was fifty-five when he shot and killed himself at home in Stryker. He had a wife, children, grandchildren, and brothers. He liked camping, hot rods, car shows, motorcycles, and his dog. He was a truck driver for Menards.
Jonathan Fifer was a round-faced kid who liked to fish and play video games. He hung out at the Circle K in Montpelier, took classes at the Four County Career Center, and planned on joining the Marines. Then he and his friend Nicholas Rowland, of Swanton—over in Fulton County—drove a 2009 Ford Fusion about as fast as it would go into a tree up in Michigan’s Lenawee County. The coroner there ruled it a suicide.
The next day, police searchers found thirty-five-year-old Anthony Wyse’s body in the St. Joseph River, out by County Road J. He’d drowned. Kevin Park ruled his death unintentional, but nobody could explain why or how Wyse wound up drowning in a frigid river.
In May, Mick Frisbie, a fifty-year-old deputy sheriff, parked in an empty lot, put the barrel of his service handgun in his mouth, and pulled the trigger. He was taken to CHWC’s ER, where the staff worked on him, but everybody knew it was pointless.
Keith thought about it: Why wouldn’t he? He was sinking like a wounded ship. He was a very sick man. He was more than broke. And he still mourned Stephanie. “I get tired of staring at the same four walls all the time,” he told Carolyn Sharrock-Dorsten as she checked on his amputation wound. She’d asked how he was doing, and he’d replied in his usual way—“I’m doin’ good”—but it lacked even the little bit of enthusiasm he’d been able to muster in the past.
“You know, Keith,” she said as she kept working, shaving off bits of skin, “it’s okay to get help on all different levels. We have some resources at the hospital across the street. And at Parkview, too.”
“I see what you’re sayin’,” Keith said, which was what he said when he had no intention of following advice but didn’t want to be rude.
Keith’s life revolved around doctors. A Parkview doctor scheduled a colonoscopy for him, though Keith didn’t understand why, given everything else that was wrong with him. But Keith wanted to be cooperative, so he complied.
His eyes began to ache again. His left one, the worst of the two, throbbed. So he made an appointment with the same doctor in Toledo. Bobbi drove him there early one morning. Keith sat, slumped over, in the waiting area of St. V’s, his red-checked flannel pajama pants baggy around his legs and a brown hooded jacket draped over his torso. Once they called him, the surgery didn’t take long. The ophthalmologist installed a bolus of silicone oil in Keith’s eye to replace the gas he’d tried last time. The staff told Keith to “take it easy,” but he wasn’t sure how much easier he could take it. He spent most of his days in the recliner, hopping to the front door to greet Caleb when he came home from school.
As the drama over Ennen’s resignation played itself out at the hospital, Keith and Bobbi moved, one carload at a time, up to Hillsdale. Keith wasn’t so sure he wanted to go. All of his doctors were in Bryan, and he liked the way the schools treated Caleb. He’d taken up with Bobbi because she was willing to help. She did help, too, but now she wanted to move back up to Hillsdale, into a Section 8 apartment because it had a decent washer and dryer and was closer to her family. Keith gave in. They left just ahead of a shut-off notice from Bryan Municipal Utilities.
A month later, Keith opened the door to his new apartment. He was wearing just a pair of long, sagging gym shorts—no shirt. Sallow skin hung from his waist. His face was drawn. He squinted at the April sun as if emerging from a long slumber in a cave. The amputated foot looked worrying: unbandaged, scabbed, with signs of pus in spots. A new wound had appeared above the ankle on his lower calf. He didn’t know how he’d gotten it. Maybe the move. The vision in his good eye had grown fuzzy. Toys lay scattered everywhere, and potato chips had been ground into the carpet. Bills—some opened, some not—sat in a pile.
The job Bobbi had hoped to get by moving up to Hillsdale didn’t pan out, so she took one at Clemens, a hog-processing plant near Coldwater. She started at $12.50 an hour. She didn’t last long. Every day her body ached; every morning she woke with back pain, the result of the physical intensity of meatpacking. She eventually got a job at a McDonald’s.
Keith was just so stressed. That was easy enough to believe. A few days before, he’d thought he was dying. His heart seemed to be knocking itself out of his chest, and his chest hurt, too, and the room swirled a little. Bobbi took him to the Hillsdale hospital’s ER, but they didn’t find anything. When it happened again the next day, the symptoms worsened, so he called an ambulance. Hillsdale ran more tests but again drew blanks. Frustrated, Bobbi drove him to a hospital in Jackson, Michigan. They ran tests, too, keeping him for four hours and concluding that Keith was probably experiencing severe anxiety. “I think I might need a counselor,” he said. “I might be depressed.”
Soon after, the day Pete Buttigieg announced he’d be running for president and Tiger Woods won the Masters, Keith spent most of the day in bed. He asked if I’d drive up to Hillsdale to take him to a hospital. When I arrived, Keith was up, and sitting so close to a computer screen that his nose almost touched it. He was trying to watch a movie. A cartoon played on the big TV, the boys screamed, and Bobbi heated frozen pizza in the oven. She handed a styrofoam plate with two pieces on it to Keith. “I know it’s not salad,” he said.
Keith was now almost entirely blind in his left eye. He could no longer see shapes—only a small amount of light. Despite the uselessness of his left eye, it still caused him pain. It kept him awake. He wanted to visit the doctor in Toledo, “but that’s twenty bucks,” he said, referring to the gas money. They were broke until Caleb’s Social Security check arrived in four days.
Keith looked at me. As if to answer an unasked question, he said, “I admit it, Brian. I do cry at night more. I know you’re worried about me. But I ain’t gonna do anything to myself. I have too much to live for. I have Caleb and Bobbi and Gabe.”
On April 23, 2019, Keith called to ask if I’d give him a ride to see the ophthalmologist in Bryan. The pain in his eye had gotten worse, and he couldn’t stand it anymore. I picked him up in Hillsdale and we drove south into Bryan, to the chain ophthalmology outlet, where an assistant measured the intraocular pressure in Keith’s eyes. His right eye tested at 18 millimeters of mercury. Between 10 and 20 is considered normal. His left eye measured 53.
“You need to go to the Kellogg Eye Center up in Ann Arbor,” Dr. Mandar Joshi told Keith.
“Okay,” Keith said. “I’ll make an appointment.”
“No,” Joshi said. “You need to go right now. Get in your car and go.”
We drove the ninety minutes to Ann Arbor and checked into the ER at the University of Michigan Medical Center. Since I’d met Keith, he’d had two amputations, three eye surgeries, and one colonoscopy. He’d been in six hospitals. The question arose as to how all of that might have been prevented if—way back, when he was first diagnosed—his insulin and his care had been free to him: just a benefit of being a taxpaying American citizen. There would have been costs for every taxpayer, of course. But those costs would have been a fraction of the Medicaid tab Keith had racked up—and would continue to rack up. And Keith would still be working and paying taxes himself.
Sana Qureshi, a petite New Yorker in her first year of an ophthalmology residency at Michigan, walked into the exam room and greeted Keith with an open smile and a gentle manner. She took his intraocular pressure and explained the situation to Keith in a way he hadn’t heard quite the same way before, telling him that he had a very small chance—15 percent, tops—of regaining any sight in his left eye. His goal should be to protect his right one.
We were in for a long night. He sat, worried and despondent, on the edge of an exam table, waiting for Qureshi to return.
“I wish I woulda made a lot of different choices in my life,” he said. “Before, in my life, I was in control. I had money, marriage, a lotta things.” In the months since I’d first met him, Keith often talked about “control,” as if he were controlling his own life the way he controlled an RC car. Most of that control had slipped away. He sighed. He was compliant. Really, he’d always been compliant—at least in terms of the big picture. “You have to accept how things are, because you can’t change it all,” he said. “Ya gotta work with the hand you’re dealt. My dad always said that. That wise old trucker.”
Keith wound up being admitted to the hospital. The next day I called to check on him, and he said, “Doin’ good, buddy. Doin’ good.”