The New Company Towns: Monopolistic hospital systems now dominate the economies of many cities--and shape public policy far beyond the scope of medicine.

• Date: 01 April 2023
• Author: Alexander, Brian

Hospital City, Health Care Nation: Race, Capital, and the Costs of American Health Care

by Guian A. McKee

University of Pennsylvania Press, 392 pp.

On the morning I wrote this essay, I received a text message. It contained a scan of a letter written by the president of Community Hospitals and Wellness Centers, a hospital in the rural town of Bryan, Ohio. CHWC featured in my book, The Hospital: Life, Death, and Dollars in a Small American Town. Much of the tension in the book centered on whether CHWC would be able to survive as an independent community hospital in an era of stampeding consolidation.

For the past 20 years, CHWC, fearing the loss of local control, cuts to services, and higher costs, had been trying to stave off being gobbled up by a big health system. Could it succeed forever? In the letter, the CHWC president gave the hospital's employees the answer to that question: No. The hospital was exploring a "relationship" with just such a system, rumored to be Parkview Health, based in Fort Wayne, Indiana.

Guian A. McKee, an associate professor of presidential studies at the University of Virginia, provides many important services in his new book, Hospital City, Health Care Nation. The most important is delivering an exquisite accumulation of detail that explains not only how the swallowing-up of small hospitals like CHWC has become inevitable, but also why it matters.

McKee's focus is urban cities--specifically Baltimore, Maryland, home of Johns Hopkins Hospital--not rural towns like Bryan. But in both Baltimore and Bryan, as in many other American communities large and small, hospitals have become leading, if not the leading, employers. Many have also evolved into quasi-government actors practically colonizing large swaths of urban landscapes while, at the same time, often battling to avoid public scrutiny. So the fate of the hospital can dramatically affect the fate of the town or the urban neighborhood.

Johns Hopkins is based in the neighborhood of East Baltimore, which, during America's great deindustrialization, became majority Black and majority working class and poor. In the post-World War II era, the hospital quickly became both an economic engine and a remodeler of the neighborhood. It became a health care provider and a source of low- and middle-wage jobs for neighborhood residents. As McKee shows us, Hopkins was a prime mover in local urban renewal projects, motivated to help itself, mainly, even as it said, and perhaps...