When people talk about jobs in Ohio, they often talk about the ones that got away.
"Ten years ago, we had steel. Ten years ago, we had coal. Ten years ago, we had plentiful jobs," says Mike McGlumphy, who runs the job center in Steubenville, Ohio, the Jefferson County seat.
Today, the city on the Ohio River is a shell of its former self. And health care has overtaken manufacturing as the county's main economic driver.
1 in 4 private sector jobs in the county are now in health care. The region's biggest employer by far is the local hospital. Trinity Health System provides about 1,500 full-time jobs and close to 500 part-time jobs, more than Jefferson County's top 10 manufacturing companies combined.
Still, unemployment in Jefferson County stands at 7 percent, 2 percent higher than the state overall. And health care leaders worry that the Republican proposals to repeal and replace the Affordable Care Act could take many health care jobs away.
Specifically, they're concerned about the rollback of Medicaid that is central to both the House and Senate bills. Ohio was among the states that expanded Medicaid under the ACA, adding 700,000 additional low-income or disabled people to the rolls.
The Congressional Budget Office estimates that the Senate bill, the Better Care Reconciliation Act, would cut Medicaid spending by $772 billion over the next 10 years, whereas the House bill, the American Health Care Act, would cut the program by $880 million over the same period.
At Trinity Health, 1 in 5 patients are on Medicaid, slightly lower than the state average. Joe Tasse, the hospital's acting CEO, warns that cuts to Medicaid could imperil jobs as well as the hospital's bottom line.
"It would be pretty devastating," he says. "If Trinity Hospital were to fail, this region economically would fail."
Tasse says under the AHCA, Trinity could stand to lose $60 million over 10 years. He says that's the equivalent of a thousand or more hospital jobs.
His fears are backed up by the liberal-leaning Economic Policy Institute, which projects that more than 81,000 jobs in Ohio could be lost within five years under the AHCA, resulting in a 0.7 percent drop in the state's overall employment.
A big challenge, Tasse says, is that departments such as emergency care and obstetrics, which have high rates of Medicaid patients, are also among the most costly to operate. Given the 24/7 nature of the care they provide, they can't cut back on staffing on days when demand is slack.
"An OB department is really an emergency department for women and obstetrics," said Tasse, pointing out that most births are not scheduled. "If you want to have that service and provide it for your community, you have to incur that cost. There's really not a way around it. Unless you want to tell the women, 'Hey, we're closing our service,' which many hospitals have had to do. 'Here's your bus ticket or here's the car ride that you have to take to deliver.'"
Trinity's obstetrics and emergency care departments are now also dealing daily with the opioid crisis. At Trinity, 1 in 5 babies are born prenatally exposed to opioids, adding complications and cost. In the emergency room, nurses are seeing so many overdose cases that they are set up to meet patients in their cars at the entrance, armed with the antidote drug naloxone.
Under federal law, hospitals are required to treat anyone seeking emergency care. So if Medicaid were cut back, Tasse says they wouldn't turn patients away at the door. They would scale back in other ways.
"Where we've tried to move patients to preventive [care], identifying health problems earlier — that would all go away," he says. He'd expect more patients showing up in the emergency department, "sicker [and] more expensive."
ROBERT SIEGEL, HOST:
If there are big Medicaid cuts coming, then they are likely to hit small and rural hospitals especially hard in terms of both the job they perform and also the jobs they provide. I recently visited rural Ohio, and when people there talk about jobs, they often talk about the ones that got away. Steubenville just across from West Virginia on the Ohio River is a shell of its former self.
MIKE MCGLUMPHY: Ten years ago, we had steel. Ten years ago, we had coal. Ten years ago, we had plentiful jobs.
SIEGEL: Mike McGlumphy directs the Jefferson County Community Action Council, which runs the local job center.
UNIDENTIFIED MAN #1: Now, I got my stellar resume right here.
SIEGEL: Today, unemployment in the county runs about 2 percent higher than the statewide average for Ohio. That means in Jefferson County, it's about 7 percent these days. Fracking and pipeline construction in the region have brought some jobs back.
MCGLUMPHY: Our demand occupations in this area would be truck driving because of the oil and gas industry that came into the area. Welding's another demand, anything medical.
SIEGEL: Anything medical - it's common in rural counties that one of the biggest, if not the biggest, employer is the local hospital. The jobs pay well, but they require expensive training and education. A job driving a truck might pay $33,000 a year while a registered nurse would make about 48,000. But...
MCGLUMPHY: A truck driving job - to get a commercial driver's license is $5,000 and four weeks. A nursing job could be up to 18 months and $12,000 to $16,000. So there's your big difference.
SIEGEL: Mike McGlumphy says some of the pipeline-related jobs come and go when the pipeline work is done. But those health care jobs - they account for about a fourth of all private sector jobs in the county, and most of them are going to stay put right in Steubenville at Trinity Health System, the local hospital. Joe Tasse is the acting CEO.
JOE TASSE: If Trinity Hospital were to fail, this region economically would fail.
SIEGEL: Joe Tasse's mission is to manage a community hospital, not to provide jobs. But that's just what a rural hospital does.
TASSE: We're an employer. We're an economic engine in this community. And everybody's talking about, where are we going to get jobs? We go into coal. We go into alternatives. We're doing this. We're doing that. Well, what about what we're providing already? We met one of our state senators here 'cause he was talking about - yeah, we need economic stimulus; we need to work on the infrastructure and so on and so forth. I said, well, what about - we're here?
SIEGEL: Two-thousand people work at Trinity. The top manufacturing employer is a company called TIMET, which makes titanium alloy products. It employs 500.
Let's say the news out of Washington this year is that the Medicaid expansion is going to be rolled back and that Medicaid might further be cut or block granted in some way that it wouldn't grow from year to year to keep up with needs. What's your plan? How do you respond to that?
TASSE: You mean after we've had our acute myocardial infarction?
SIEGEL: Meaning a heart attack. For Joe Tasse and Trinity, Medicaid covers about 20 percent of their patients. Cut back on Medicaid...
TASSE: It would be pretty devastating.
SIEGEL: Roughly 1 in 4 Ohioans is covered by Medicaid, which is for people with low incomes or disabilities. Ohio, like most states, expanded eligibility under Obamacare. With federal funding, that added over 700,000 people to the program statewide. Some of the most Medicaid-dependent departments at Trinity are also among the most expensive to operate.
DEB LOUK: I am Deb Louk. I'm the clinical manager of the emergency room. I've been with Trinity about 40 years altogether.
SIEGEL: In the days of the mines and the mills, Deb Louk remembers industrial accidents being common in the ER. Today what's a lot more common is an opioid overdose.
LOUK: Because it seems like we're having more mental health opiate addictions - younger children, even adolescents with some of these issues going on.
SIEGEL: How often do you admit someone who fits that description?
LOUK: Basically on a daily basis.
SIEGEL: Medicaid accounts for about 30 percent of the ER's patients.
(SOUNDBITE OF INFANT CRYING)
SIEGEL: An especially costly service for a rural hospital is obstetrics. At Trinity's OB department where we met this 3-day-old named Hunter, who was staying until his jaundice cleared up, Medicaid patients account for 50 percent of the births. The department's running at about 500 births a year. As CEO Joe Tasse explained to me, a small hospital can't cut back OB staff on days when demand is slack.
TASSE: An OB department is really like an emergency department for women and obstetrics. I mean if you think about it - right? - babies don't come - you know, like, you don't necessarily schedule them. If you want to have that service and provide for your community, you have to incur that cost. There's really not a way around it unless you want to tell women, hey, we're closing our service, which many hospitals have had to do. And here's your bus ticket, or here's the car ride that you have to take to deliver.
SIEGEL: Another complicating cost of obstetrics - 1 in 5 babies at Trinity is born having been exposed prenatally to opioids. So if Medicaid were cut back, what would happen?
You still wouldn't turn them away at the door of the hospital, would you?
TASSE: Well, what would happen would be - where we've tried to move patients into more of the preventive and identifying health care problems earlier, that would all go away. So now you're going to see more patients showing up in the emergency department. They're sicker, more expensive. And we sort of slide back to what we've been trying to work ourselves out of.
SIEGEL: If a significant share of Trinity's patients lose Medicaid coverage, Trinity would lose revenue and probably jobs.
TASSE: Because I mean we're business, too. I mean we've got 2,000 employees. We've got to pay those salaries. If you can't pay the salaries, what do you do?
SIEGEL: Last year, Trinity Health did something. The hospital joined a national network - Catholic Health Initiatives. That gives them more leverage in the medical marketplace. It is a measured step in the direction that many small and rural hospitals are weighing - becoming part of a larger hospital system.
SIEGEL: More than 150 hospitals were represented at the annual meeting of the Ohio Hospital Association in Columbus earlier this month.
UNIDENTIFIED MAN #2: 'Cause, you know, when you're in a semi-rural area, finding primary care is a little bit difficult.
SIEGEL: The hospital CEOs assembled had Washington on their minds. A few of them spoke with me about their work, their hospitals and Medicaid. One of them was Ray Chorey, the CEO of Southeastern Ohio Regional Medical Center in Cambridge, Ohio. He talked about that high cost of obstetrics.
RAY CHOREY: Where you're a rural hospital, I think one of the first services that you see cut when you're at the point where you're financially strapped, you're close to bankruptcy - the first thing that will get cut will be childbirth services.
SIEGEL: His hospital still does obstetrics despite some alarming numbers.
CHOREY: Four-hundred-fifty to 500 babies a year - 70 percent of them are born to Medicaid families, and 1 out of 8 is addicted.
SIEGEL: Meaning they were exposed to opioids before birth. Medicaid pays less for the same hospital service than Medicare or private insurance pays, so that depresses revenue at Southeastern Med. Faced with problems like that, a great many small hospitals have chosen to align with bigger health care systems. Chorey's hospital has a relationship with one called Ohio Health, but Southeastern Med remains independently and locally owned. As Ray Chorey says, that's not the trend.
CHOREY: In 2014, there were 40 independent community hospitals in Ohio. In April of 2015, that number had dropped to 30. And today there's maybe 20 to 25 independent hospitals.
SIEGEL: Consolidation means a loss of local jobs in, say, administration if a big hospital system takes over a small one. A representative of one big Ohio hospital told me this pointedly not for attribution. We have too many hospitals; the big ones should be buying out the little ones. No obstetrics department - bring back more midwives. The rural hospital is an institution whose time has passed. But Ray Chorey from Cambridge, Ohio, says there are virtues to being local that go beyond medical services.
CHOREY: As you start looking at the other major players in the community's infrastructure - primarily the banking industry has gone away, and larger industries in Ohio have gone away - there's this increasing look at the hospital for leaders to go out and become active in the community, to improve the overall quality of life within the community.
SIEGEL: Leaders on issues like the current opioid epidemic. As hospitals streamline through mergers and acquisitions accelerated perhaps by Medicaid cuts, one question is whether those small cities and rural areas will lose something more than just jobs in delivery rooms and administration. Do they also stand to lose part of their sense of community?
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ARI SHAPIRO, HOST:
As the Senate continues to work on its health care bill, we want to know what questions you have about the Republican efforts to repeal and replace the Affordable Care Act. Are you worried about what these proposed changes could mean for you or your family, or are you hopeful for what these changes could bring? If you have questions about what's in the proposal and what it will mean for you, email us at firstname.lastname@example.org. We may put you on the air later this week. That email address again - email@example.com. Please put health care in the subject line. And while you're getting in touch with us, feel free to send some birthday messages to my co-host here. Robert Siegel turned 70 today.
SHAPIRO: Happy birthday, Robert.
SIEGEL: (Laughter) Thank you.
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