America is broken, but sometimes it takes looking at the smallest shattered pieces to realize how broken. That is the sad lesson at the core of Brian Alexander’s The Hospital. An Ohio native, Alexander spent two years reporting in Bryan, a small town in the state’s northwest corner where the jobs, benefits, and even the grocery stores have gone away, leaving a nonprofit hospital as the community’s soul and, unwittingly, it’s economic engine. This is not an uncommon predicament in the hollowed-out industrial parts of the country whose cities no longer feature steel mills and auto factories but competing knee-replacement centers.

No one knows the depths of the problem more than Phil Ennen, CEO of Bryan’s Community Hospitals and Wellness Center and the central figure in The Hospital. Ennen is a charismatic and tempestuous executive who finagles and cajoles CHWC into making a three-percent profit — just enough so that a corporate hospital chain based in nearby Toledo or Fort Wayne, Indiana, won’t swallow it up. Now in his fifties, he’s been at the hospital for almost his entire adult life, watching the town crater economically until CHWC is all that remains of its identity.

Alexander expertly lays out Ennen’s multiple challenges. He is in competition with big-city hospital chains that get volume discounts on the purchase of surgical equipment. Then there are the personnel issues. Doctors are retiring, and Bryan isn’t exactly a destination for a young couple. So he recruits a young Muslim doctor whose patients are grateful while still asking why she wears that thing on her head.

Ennen is even fighting a losing war with components of American capitalism that should have skin in the game of keeping CHWC open and independent. Most striking is the hospital’s relationship with Menards, a home-improvement center that is Bryan’s other significant employer. Menards has been given tax breaks and free road improvements. They’ve paid back northwest Ohio by offering a miserable health plan that leaves CHWC writing off Menards workers’ medical debts.

alexander the hospital cover

“The Hospital,” by Brian Alexander

One of Menards’ employees is Keith, an overweight diabetic with a recently dead wife and a child. Keith is the kind of American rarely written about in these kinds of books, because there’s no redemption arc: He eats crap, watches a lot of television, and lets his diabetes spin into chaos by not taking his insulin on a regular basis. But Alexander makes clear that Keith is a man, no better or worse than most, who like many Americans has been dealt a bad hand from birth. He’s been born into a era when all the decent-paying, working-man jobs have gone away, replaced by slots at Menards or Taco Bell, for wages meant to provide teenagers with gas money, not to pay rent and feed children. And he doesn’t skip his insulin out of indolence (OK, maybe a little) but because he can’t afford it.

The end result: Keith loses toes, limbs, and an eye. Even if you don’t care about him as a human, you should be horrified by what this costs all of us. A lifetime of cheap insulin might run $25,000; Keith’s multiple surgeries have cost significantly more.

The only sane conclusion is that America’s dysfunctional health care system needs holistic change, not just a Band-Aid. Decades of social inequality have left rural Ohioans without jobs or a beater car to get to one of the few remaining grocery stores. They spend their food stamps on the Pepsi and potato chips pushed at dollar stores that have multiplied across the country like retail locusts. (For many, the nearest actual grocer is 12 miles away). Nutrition is nonexistent, health deteriorates, and a doctor visit is postponed because of shitty insurance. Everything spirals until another American shows up in the ER with catastrophic issues. The Hospital proves that Phil Ennen or any other executive do-gooder can’t solve America’s health care problem. It has to be solved by all of us, or it will remain everyone’s problem.

“This is more than not being able to go to a doctor,” Alexander says via Zoom from his San Diego home. “We’re a sick nation. The whole approach has to change or the sickness just will get worse and worse.”

You dedicate the book: “To the memory of Bruce Alexander, writer, who kept waiting to see a doctor until his Medicare kicked in.” Tell me about him.
He’s my older brother. He earned a living as a technical writer, but he was a very talented writer of one-act comedy plays, and he had some movie script ideas. He reached an age where he thought, if I’m ever going to be able to do this, I’m just going to have to jump in. So he left his job and his health insurance to do it full-time. He was about 60. He figured there are three, four years before retirement age, and I can make that, and Medicare will kick in at 65.

A year later, he’s tells me “God, I was out trying to surf, and I felt these weird chest pains.” And then he’s riding a bike and telling me, “I couldn’t even ride the bike very far today, these chest pains are getting more severe. I can’t wait until the Medicare kicks in and I’ll get checked out.”

He lived up the road in San Clemente, and one week he didn’t return emails. I thought, “Well, that’s Bruce. He’s probably in Vegas for three days.” Then a guy that runs a theater that he was working with called me up and said, “Bruce was supposed to be at a meeting today, and he wasn’t there.” I got in the car, ran up to his apartment, and broke in, and there’s Bruce. He had been dead for five or six days. Blocked arteries. If we had a different health care system, my brother would be alive today. I was already working on the book, but it made it all matter more to me.

I’m so sorry. Before we get to Bryan, you lay out some historical characters responsible for the health care predicament the United States is in. One of them is Morris Fishbein, a leading figure with the American Medical Association in the 1930s and 1940s. How did he help turn the country against a system of universal health care that was beginning to take root in Europe?
He was a real asshole. He was the most recognizable doctor of his time. He had a column and gave speeches. Anyone who suggested government control of health care, he would start talking about socialism and communism, the Soviet-ing of medicine. He was just advocating for doctors and their profits. He’d say, “It’s no longer the doctor-patient relationship, it’s now this triangle between the government, the doctor, and the patient.” Of course, it’s now a triangle between doctor, patient, and an insurance company that has a profit motive. I think we chose the worst one.

You wrote about dying Ohio industries in your first book, Glass House, so I suspect you had some idea what you were getting into with this topic.
I did, but it was even worse then I thought. We’ve replaced people making things with people spending money on our bodies to keep them going in a welfare kind of relationship, and often when it is already too late. There becomes this real erosion of pride and community when you don’t make anything any more. But no one wants to say anything, because the hospital is now the only job engine. The golden egg is now being laid by health care.

I talk about the situation in Toledo, where a company named ProMedica said, “We’re going to tear down your old steam plants and build you a beautiful campus with maybe a loft district.” Jeep or Chrysler is never going to do that. So a city like Toledo doesn’t have a lot of interest in reforming a system that just rebuilt their downtown.

What happens in the United States [is] you have places like Pittsburgh, where the University of Pittsburgh Medical Center is the largest landowner and the largest employer in Pittsburgh. So the hospitals are beautiful and state-of-the-art. The care is going to be much better, but now we have people with $5,000 and $10,000 deductibles, and they can’t afford to go these beautiful hospitals until it is almost too late.

I’m guessing that is what Keith’s plan was like.
Yeah, that’s why someone like Phil was so mad at Menards. It takes about 30 to 35 percent of your wage to cover [Keith], his wife, and kid. And that’s with a high deductible. Keith was making choices of whether to buy food and pay rent or putting off his health needs. And it didn’t have to be that way. It could have been, “Hey, Keith, you’ve just been diagnosed with diabetes, and you’re in your twenties. That can be a bad road for you, but you could have a lot of years left to go. We’re just going to give you insulin and the test strips. And we’re going to have a little coaching, because we kind of know you, Keith.” If we had done that well, Keith at this moment would be working and paying taxes and contributing to the GDP. He would not have to cost the taxpayers close to a million dollars and have some doctors say it will be a miracle if he lives to be 50. But we want to approach from the American idea of punishment: “Keith ate the wrong stuff. Keith’s parents were obese.” This is all true, but we want to attribute everything to personal sin. We don’t want to recognize the social, economic, and cultural factors. The lack of good jobs. The lack of affordable medical care.

Millions of people are placed in these kinds of situations where, as, as touchy-feely as it sounds, a lot of time, their only comfort is a really big pizza and mac and cheese and watching racing on his giant TV. There is a reason people are living this way, and to just blame them gets us nowhere. People know this. Experts know this, but we want to blame people and say they did it to themselves.

You really lay out how all of this feeds on itself. The lack of jobs leaves people with no money for a car. So they can’t get to a real grocery store and end up going to dollar stores because it is the only place they can walk to. And the dollar stores only have to offer a minimum of vegetables because they have a strong lobby, and there is a giant markup on chips and soda. It all suggests that American capitalism is unworkable, at least if you care about others.
You’re right; this is more than not being able to go to a doctor. We’re a sick nation. We have people walking into stores with AR-15s and shooting people. The whole approach has to change or the sickness just will get worse and worse. Donald Trump wasn’t the sickness, he is just a symptom. But no one gets anywhere saying America is sick, so we just ignore it. We could have Canada’s system tomorrow, or the UK system. We could do it tomorrow. But if you still had this rampant and outrageous inequality that we currently have, with the erosion of our sense of community, it’s not going to solve the problem. 

Despite the obscene deductibles and high premium costs, so many of the people you talk to for the book don’t think Medicare for All is the answer, even those who would benefit the most. One of the people you write about finally gets on Medicaid and gets care for her sons, but when you ask her about universal health care she is against it.
Yeah, she said, “No, once the government takes over that means they decide who gets taken care of.” I wondered if she knew that is what is happening now. Look, Republicans have done a real good job; it shows the effectiveness of this 40-year campaign to instill distrust of government. It’s two generations now, and younger people don’t know that there was ever a time when it was any different. When [Republicans] are in charge, they screw up the post office to prove their point. In Bryan there is a beautiful park and pool [with a sign] that says, “Built by the WPA, 1934.” Now? No one knows what that means.

You had to revisit some of the book because it was reported before the Covid-19 pandemic. Did that change much of the book?
Sadly, not really. It just accentuated all the fault lines I’d been writing about. To me, the pandemic just blew all that up. Hospitals were unprepared because they’re trying to run very lean — “How do we get return on investment?” They’re using all the dark arts of business to turn a profit. Essentially they’re not humane missions of mercy, they’re turning to the Harvard Business School for how they’re supposed to be doing right as a business. That doesn’t work in a pandemic, and we saw it in the shortage of PPE equipment and screwed-up availability of ventilators. But you know what worked? “We as a government are going to finance a bunch of vaccines, and we’re going to give you the vaccine for free.” That is what worked.