Last November, however, Circleville’s voters chose another direction, one that, in other places, has resulted in an economic hit to the community—mostly in the form of job losses and stagnant wages—as well as a lowered quality of care. At the urging of city and county leaders, and Berger’s administrators, residents voted to allow local politicians and the hospital’s board to begin a process to turn Berger, one of the last publicly owned and operated hospitals in the state, into a nonprofit private corporation. Following that, Berger would most likely be integrated into a larger regional system, probably the Columbus-based nonprofit Ohio Health, with which Berger has an ongoing relationship. The hospital and the local leaders campaigned hard for that approval, but not because it was the ideal future they envisioned. They feared that Berger wouldn’t survive any other way.

Hospitals have been struggling—especially independent public and/or nonprofit hospitals located in smaller cities and rural towns. Last year, for example, the National Rural Health Association, a nonprofit, estimated that 673 rural facilities (with a variety of ownership structures) were at risk of closure, out of over 2,000. And with the new tax legislation, and events like the merger of the drugstore chain CVS and the insurer Aetna, the turmoil looks to get worse. In response, stand-alone nonprofit hospitals have been auctioning off their real estate to investors, selling themselves to for-profit chains or private-equity firms, or, like Berger, folding themselves into regional health systems.

The implications of those moves can be profound, as consolidation can hurt hospitals and the smaller cities and towns they’re located in. Not only are community hospitals vital to many places’ social fabric and image of themselves, but they are often the largest local employers now that manufacturing jobs have faded. “When I started here in 1999, we were coming off losing multiple thousands of jobs to globalization,” Tim Colburn, Berger’s CEO, says. Berger is now the biggest employer in Circleville, generating an estimated $50 million a year of economic activity in the area, including wages, the purchase of goods and supplies for the hospital, and follow-on spending, such as when hospital visitors eat in local cafes.

Fairfield Medical Center (an independent nonprofit hospital) in nearby Lancaster, Ohio, is the largest employer there. Bryan Hospital (also an independent nonprofit) is the largest employer in Bryan, Ohio, in the northwest corner of the state. The same is true of hospitals in many communities across the country: Health care in the U.S. accounted for $3.2 trillion in spending (about $9,900 per person) and 17.8 percent of GDP. Whereas a good local hospital was once seen as a way to attract employers, such hospitals have now become the primary employers. “And I don’t say that with any pride,” says Phil Ennen, the president and CEO of Community Hospitals and Wellness Centers, which includes Bryan.