The U.S. population has grown every decade since its founding, resulting in an increasing need for healthcare. Yet hospitals are closing at a record pace, especially in rural areas. 700 healthcare facilities are at risk of closing around the U.S. in the near future.

The Valley has also witnessed the struggles that hospitals have faced, but here it has been a struggle for decades, with the closure of Northside, Southside, Woodside, Tod Children’s, and Youngstown Osteopathic, to name a few.

In this 21 News in-depth examination, we look at what many are calling a badly broken and dysfunctional healthcare system. We speak with experts on the challenges the industry is facing — including factors affecting the quality of health care and detail local efforts to help provide the quality care our Valley deserves.

 

HEALTHCARE ON LIFE SUPPORT?

In the past 15 years, 21 hospitals have closed in Ohio, including two right here in the Valley — Trumbull Regional Medical Center and Hillside Rehabilitation in Warren.

In November of 2024, Becker’s Hospital Review, a leading organization covering hospital analysis and news, detailed hospitals across the country at risk of closure. On that list, Ohio has five hospitals at risk, with two facilities at immediate risk of closing in the next two to three years. In Pennsylvania, it’s predicted that 13 hospitals are at risk of closing, with seven at immediate risk of closing in the next two to three years.

“Many hospital systems, not only in Northeast Ohio, but in Ohio in general, and across the nation, are financially struggling,” said Dr. Brian Harte, president of Cleveland Hillcrest and Mentor hospitals and president of the Cleveland Clinic’s East Submarket of the Cleveland Clinic’s Northeast Ohio Market.

“And so, I think the question is, really, what are we going to see five years from now in the healthcare landscape?” he added.

The Ohio Hospital Association, a nonprofit representing hospitals and health systems, reported that 51 percent of Ohio hospitals broke even or lost money last year. In rural areas, those numbers plummet to 72 percent of hospitals that only broke even or lost money. And taking it one step further, looking at Ohio hospitals operating with a two percent or less operating margin, those numbers jump to 67 percent for Ohio hospitals and 88 percent for rural hospitals.

Dr. Harte said on the financial strain hospitals face, “Health care expenses rise faster than household inflation, technology, pharmaceuticals, etc. Layered on top of that are the workforce challenges that have led to fairly significant labor inflation and on the revenue side, about 70 percent give or take, depending on the hospital, of our patients come with government payers, principally Medicare, Medicaid and those are critical resources for our patients and for our health care system. But that, that revenue, that reimbursement has also not kept up with inflation, so health care is getting squeezed on both ends.”

And it’s the patient who suffers when there’s a lack of health care. The World Health Organization looked at the rate of hospital beds per 1,000 people.

In 2020, the U.S. averaged 2.74. Based on our local population, that would average 3.1 beds in Mahoning County, 2.1 beds in Columbiana and only 1.2 beds per 1,000 in Trumbull County.

Lena Esmail, CEO of QUICKmed, said there is a problem she is looking to fix right here in the Valley.

“I think that we have a disenfranchised population, but we also have an access to care issue across the whole Valley, so that the access to care issue is not an issue of socioeconomic status or class, it’s just options. So, you have those that might have transport, transportation issues, but then you might also have those that just, we live here and we don’t have access to care,” Esmail said.

CONTRIBUTING FACTORS

So, how did we get to this point? Why can’t the Mahoning Valley — and, for that matter, the nation — sustain a “healthy” healthcare system?

Some of the answers are obvious — higher costs and fewer workers. Then there’s less help from the federal government and an issue of private owners squeezing the profit from hospitals.

Regardless of the reason, the strain on our local healthcare system is real.

HIGHER COSTS

But why do hospitals fail? The first reason is the cost of doing business.

Like any business, healthcare systems require funding to remain operational. So as prices rise, so do the pressures. The American Hospital Association states that the costs of labor, treating chronic conditions, and hospital equipment are all continuing to grow faster than inflation.

Adding to the cost, people are getting sicker and more are inclined to seek treatment.

Chronic diseases, for example, are becoming more prevalent in the U.S.

John Palmer, Director of Public Affairs for the Ohio Hospital Association, said “When you think about kidney disease, cancer, cardiovascular disease, asthma, these are pretty serious and when you think about 15 percent have three or more of those, that is concerning which puts a lot more a need and demand on the healthcare system to help provide those services.”

Between 2010 and 2019, emergency department visits related to heart failure increased by 127 percent. The spending to treat these patients increased by 177 percent. Chronic diseases, like Type 2 diabetes and acute renal failure, are also rising — both by double digits.

During the COVID-19 pandemic, people who were sick began waiting to receive care. By the time they went to the doctor’s office, many needed more advanced treatment. And a sicker patient costs more for both the hospital and the patient.

Sarah Hohman, Director of Government Affairs for the National Association of Rural Health Clinics, said, “They weren’t going to the doctor for that normal preventive or primary care services that they were used to.”

Hohman added, “And so in the wake of COVID, time and time again, I hear from facilities that they are seeing, again, patients that are sicker, more complex. Because their care went untreated for several years.”

Then there’s the cost of drugs. Drugs cost hospitals $144 billion dollars in 2024.

But you may be thinking... but they bill me for those medications... so how can they be losing money on them? Which brings us to reason number two — Medicare and Medicaid reimbursements. Hospitals are losing money on government reimbursements.

Medicare and Medicaid reimbursements are lagging behind inflation. This is especially stressful for rural healthcare facilities.

The National Association of Rural Health Clinics advocates for rural healthcare across the country. One of their biggest concerns is the cuts to Medicaid.

The group advocated against the $1 trillion cuts to Medicaid outlined in the Big Beautiful Bill, which was signed into law by President Trump in July.

As a result of these cuts, the Congressional Budget Office estimates that 10 million people will be at risk of losing their insurance over the next decade, including more than 162,000 people in the Valley.

MEDICARE AND MEDICAID CUTS

Liz Williams, a senior policy manager for KFF, a leading health policy organization in the U.S. and works on their program on Medicaid and the insured, said, “Most people are eligible for Medicaid because of their low income. And so I think definitely if you are in an area where people are around the federal poverty level, I think that means there’s a lot of folks that could be impacted by these cuts.”

And these cuts could be felt particularly deeply here, where Mahoning, Trumbull, and Columbiana counties all have a higher poverty rate than the state and the nation as a whole.

And when someone is looking for care without coverage, it is the providers who lose out.

“As more of those folks lose access to healthcare through their insurance coverage, that doesn’t mean that they stop showing up to the doctor’s office or to their local emergency department. It just means that those facilities don’t receive payment to care for those individuals,” says Sarah Hohman, Director of Government Affairs with the National Association of Rural Health Clinics.

The Big Beautiful Bill, which significantly reduces federal healthcare spending, allocates $50 billion for the Rural Health Transformation Program. This program is designed to help offset the cuts to Medicaid, but according to KFF, it only covers 37 percent of the estimated loss of Medicaid funding. The goal for the five-year initiative is to help sustain rural healthcare, where states will receive the funds and can decide how to best spend them.

“The way that this fund is designed, there [are] a lot of unanswered questions to start, and it’s certainly not a one-to-one in terms of making up the difference between what the estimated losses are going to be from a coverage and therefore revenue perspective,” said Hohman.

KFF analysis shows Medicaid spending in rural areas is estimated to decline by $155 billion within a decade. Hohman said the cuts are concerning.

“This is a particularly large cut, the largest we’ve seen, and so, there’s a lot of concerns on whether they’ll be able to keep their doors open,” added Hohman.

Those cuts are leaving some U.S senators worried about the future of hundreds of hospitals. That includes hospitals like East Liverpool, one of 11 rural hospitals in Ohio cited as being at risk in a study from North Carolina.

The impact of these cuts goes beyond rural healthcare. KFF says the cuts affect every hospital that treats Medicaid enrollees.

“Medicaid accounts for about one-fifth of all healthcare spending. So, it’s a major payer in the health system. And a $1 trillion sort of in cuts from the program over ten years could have an impact on sort of how everybody accesses care,” said Williams.

Then there’s Medicare, which is the healthcare insurance for senior citizens. In Ohio, 22 percent are enrolled in Medicare.

Over the past five years, an increasing number of senior citizens on Medicare have opted for more comprehensive coverage and selected supplements, such as Medicare Advantage. The difference between the two is that traditional Medicare is administered by the government and hospitals are often reimbursed at a lower rate. Medicare Advantage utilizes private health plans and is often reimbursed at a lower rate.

Hohman said, “They get their cost to treat an average patient is, that’s what they receive every time a traditional Medicare beneficiary walks in the door. When it comes to Medicare Advantage, they are not receiving their cost based style reimbursement. And so they are consistently getting reimbursed at less than cost or significantly less than cost.”

LESS WORKFORCE

Higher costs, less reimbursements, and reason number three — fewer workers. As we’ve been reporting, more and more health care workers are leaving the field. This is a problem that feeds itself. Workers leaving means longer hours and quicker burnout for those left behind. A problem that intensified during the COVID pandemic.

The National Center for Health Workforce Analysis found that 49 percent of surveyed healthcare workers felt burned out, and 43 percent felt overworked.

In Ohio, the problem is compounded by an aging workforce. There are efforts to recruit a younger workforce.

“We’re seeing a lot of baby boomers that are going to be approaching retirement and are retiring. And so there is going to be a lot more collaboration happening between our hospitals and educational institutions as well. Community colleges, higher education,” said Palmer.

PRIVATE EQUITIES

A more obscure reason hospitals struggle is that private equities own them, or, put more simply, investors out to make money.

Here’s how one private equity group affected hospitals in our area.

In 2017, Steward, aligned with Cerberus Capital Management, bought four local hospitals, Northside Medical Center, Trumbull Memorial, Hillside Rehabilitation and Sharon Regional Health System.

Almost immediately, Cerberus sold the real estate of the hospitals to Medical Properties Trust and began distributing funds to pay shareholders.

Cerberus broke away from Steward five years ago, but the separation had lasting effects.

The Private Equity Stakeholder Project is a nonprofit watchdog organization that focuses on the impact of these private groups on American life, including healthcare.
https://pestakeholder.org/reports/the-pillaging-of-steward-health-care/

“You look at some of the real estate services, like at Steward, where the real estate is sold out from under the hospital and then they have to make rent payments, you know, where they didn’t have to before, on top of all the debt they have to pay from the private equity deal,” said Chris Noble, Private Equity Stakeholder policy director.

Private Equity groups do not buy hospitals with the hope of closing, but keeping them open is often not a top priority. And that gets complicated.

Many companies are not interested in purchasing hospitals unless they own the real estate, which limits the selection of potential buyers.

“The business model creates a risk of hyperfocus on making a profit, and we just feel like that’s against the public interest and you know, keeping communities healthy,” said Noble. “If you’re talking about cutting services that aren’t as profitable, especially when we talk about those rural hospitals, where else are they going to get services except for the hospital that’s around them.”

And there’s nothing illegal about what these private equities are doing.

“I have not seen any in Ohio, unfortunately. It does not mean they will become part of that trend soon. There have been states in the Midwest, such as Indiana, you know our neighbor, that has passed its own Enhanced Merger Review Notice Law. So I’m confident as this trend continues to go, maybe states like Ohio might participate as well,” said Noble.

In 2024, Indiana enacted a new law — the Enhanced Merger Review Notice — which requires companies looking to merge or acquire healthcare facilities to provide the state’s Attorney General with 90 days of written notice for review.

Ohio has no such similar law.

In fact, a tool compiled by a corporate law firm that assists in such acquisitions finds that Ohio is one of the majority of states with no effort whatsoever to gain stricter oversight of these mergers.

FUTURE PLANS FOR HEALTHCARE

There’s an old saying... When one door closes, another opens.

In the Mahoning Valley, the closing doors have been those of hospital entrances, such as at Insight Trumbull. However, across our community, new doors are opening to clinics, urgent care facilities, and outpatient care centers, all designed to fill the gaps and keep healthcare close to home.

In many communities across the Mahoning Valley, construction crews are hard at work building new emergency departments, modern outpatient centers, and state-of-the-art specialty healthcare units.

Each project fills a gap left behind by closures — and each one is a door of opportunity for patients.

“It is not just an option anymore to work together to improve and to maintain the quality of healthcare that we have in the Valley; it’s mandatory,” said Esmail, QUICKmed.

MERCY HEALTH EXPANSION

In Champion Township, Trumbull County, the newest investment comes from Mercy Health, a freestanding 30,000-square-foot emergency department offering a full suite of ancillary services, including diagnostic imaging and laboratory work.

“We’re continuously evaluating and reevaluating what the needs are in our various communities and how we can meet those needs,” said Dr. John Luellen, President of Mercy Health Ohio, saying this site was chosen after studying where services are currently being provided, and where gaps in services exist.

“We saw the Trumbull County community growing in the future. We’ve actually seen that come to fruition now, but at the time, the thought was that we’re going to need to be able to expand our services,” Dr. Luellen said. “We’re going to need to expand into a void that exists where services aren’t being offered,” he added.

Mercy Health remains one of the biggest healthcare providers in the Valley, operating three hospitals and 52 practice locations across Mahoning, Trumbull and Columbiana counties. In the three counties, they employ more than 390 doctors and see more than 900,000 patient visits per year.

Dr. James Kravec, Mercy’s Chief Clinical Officer for Lorain and Youngstown and System Medical Director Graduate Medical Education at Bon Secours Mercy Health, said, “As you look at the last year or so, we’ve added, through Mercy Health Youngstown, which will be 17 new beds. And we’ve added new beds... a new unit, I should say, at St. Elizabeth Boardman and St. Joseph Warren, so really four new units, entire units of patients that we’ve added to our community in just the last 24 months.”

Also under construction is a 16-bed, state-of-the-art neuro intensive care unit at St. E’s Youngstown. Dr. Kravec says it will be used to care for the most complex neurological and neurosurgical patients.

Kravec said, "this was a very large investment of over $13 million and we’re proud to invest that back into our community with new physicians, new nurses, new technology, be able to take care of our patients here at home and couple that with our new interventional radiology suite taking care of patients as well, that’s going to just bring be able to treat more patients in our community."

SOUTHWOODS HEALTH GROWTH

In Boardman, Southwoods Health has built a reputation on its world-class surgical and specialty care. Today, their mission is bigger than any one location and has no plans to sit on the sidelines after the closings of the Trumbull County hospitals.

"We took a deep dive, took a look at what was needed up there. And the first thing we did about six months ago was we made sure that the physicians that were there and wanted to stay there had a chance to stay there. So, we put out a life preserver to those docs. Proud to say that we have now over 20 docs, primary docs that we either employ or that are our partners," said Ed Muranksy, founder and CEO of the Surgical Hospital at Southwoods in Boardman Township.

Muransky has long had a vision of expanding services beyond the sprawling campus on Market Street. Having a healthcare void in our Valley is simply unacceptable to Muransky.

The company is in the midst of a $20 million expansion at the Boardman campus, which includes the addition of four operating rooms, updates to clinical areas, and a new endoscopy area.

"When the demise occurred, I said, we have to create up there what we have in Boardman, so there’s going to be a women’s breast care center there that you could go all the way from mammography to ultrasound to breast biopsy all in the same day. Women deserve that. People have been using it in Boardman. We’re going to have that [in Trumbull County]," Muranksy said. "We’re going to have our own pain management clinic. We have our general surgeons in our gastro center that’ll be up there. We have our orthopods and spine surgeons that are up there. So what we proved, as we move urologists up there and spine surgeons, that if you have the general practitioners there, people will stay and be loyal to the community," Muransky added.

And Muransky says that’s important — he believes keeping healthcare local will keep jobs and the funds from these services right here in the Valley.

"If we could keep healthcare here, everybody wins...," Muransky said.

"If we employ local people, and if we don’t realize that we need some more mental health or some rehabilitation cases like Mercy is doing up on the North Side, those patients are going to find their way someplace else. Those jobs are going to find their way someplace else. So, if you take a look at what Mercy employs, we’re now over 1,500 local jobs," Muransky said. "You know, to me, if you could continue to do that and add another three or 400 in Trumbull County, give people of Trumbull County the access to physicians in Trumbull County and to stay here for healthcare. I think everybody wins," he added."

SALEM REGIONAL LOCAL NEEDS

In Columbiana County, Salem Regional Medical Center is using independence as a strength, making its decisions based on local needs.

Dr. Anita Hackstedde, the president and CEO of Salem Regional Medical Center, said their focus is on what is best for the people they serve.

Dr. Hackstedde said, "We’re lucky enough to be an independent hospital. So, our decisions are made by the folks who live here, work here, and our patients here."

She said, "We’ve done a huge turnaround to value-based medicine, and so we want to show value for what we do in hospitals, having to reach outside their own walls and take care of the community as a whole."

That means expanding outpatient services to improve access and affordability.

"Hospitals are expensive, very expensive. And so, what we’re trying to do is offer imaging at lower cost that what you pay at a hospital, surgery at lower cost that what you pay at a hospital," Dr. Hackstedde said.

An example of this is the SRMC Surgery and Outpatient Pavilion at Firestone Farms, which features state-of-the-art medical imaging, a surgery center, and an infusion center.

"This was truly an outpatient area, so having independent diagnostic testing, like medical imaging. Having our physician practices here, our surgery center, we have an infusion center for non-chemo drugs that need to be infused. So really looking at everything, short of having to stay overnight in the hospital," Dr. Hackstedde said.

CLEVELAND CLINIC APPROACH

The Cleveland Clinic may be best known worldwide for pioneering specialty care, from heart surgery to neurology; however, here in the Mahoning Valley, its approach begins much closer to home: primary care.

Dr. Brian Harte, the president of Cleveland Clinic’s Hillcrest and Mentor hospitals, says their vision is to grow carefully and strategically — focusing on accessibility and quality over sheer size.

"I think it was precipitated, actually, when Steward and Trumbull started having their disruption and a number of physicians, principally primary care physicians, who some of our leaders, both here at Hillcrest Hospital and at the Cleveland Clinic, knew and had good both personal and professional relationships with, started talking to each other, and it seemed like this was a good fit for us," Dr. Harte said. "It gave us the opportunity to serve patients in close to Mahoning County, close to Youngstown, principally with primary care, although we’re also starting to introduce a limited number of specialists in the offices, gave us an opportunity to expand our footprint and provide access to our care," he added.

By adding family doctors and pediatric care to communities like Austintown, Warren, Kinsman, and Niles, the Cleveland Clinic is working to strengthen the patient-doctor relationship — the foundation of its growth strategy.

Dr. Harte said, "We recognize that the patient’s most important relationship is with their primary care physician. And so, for us to grow, and we do want to grow carefully and judiciously, but we do want to grow, one of the best ways to do that is to introduce primary care physicians into the community, because there’s not enough of them, and the demand is remarkable."

"Our vision is, quite simply, to be the best place in the world in healthcare to receive care and the best place for us on the caregiver side to provide that care when, when it comes to looking about, looking around, about how we grow, whether it’s through new facilities or whether it’s through acquisitions, I think we a number of calculations come into play. One of them is, where is, where are their populations that we’re not serving, and how can we improve access to those, to those communities," Dr. Harte said.

QUICKMED FILLING IN GAPS

While some providers are building new hospitals or adding specialty units, QUICKmed has taken a different approach — growing rapidly into a network of urgent care centers designed to alleviate the pressure on crowded ERs.

"The plan started 2017-2018 when Northside Hospital was closing. So, what we knew at the time was that Northside Hospital basically discharged about 90% of their patients. So, we knew, well, this operates a giant urgent care so that’s when we knew we needed urgent cares in the community," said Lena Esmail, CEO of QUICKmed

So Esmail did just that... filing paperwork with the state in October of 2019 to open her first QUICKmed location in Liberty, and expansion soon followed.

Today, QUICKmed has 15 locations across Ohio with the goal of incorporating more primary care into the walk-in clinic experience.

"I think that historically, the way that urgent care is practiced is a treat and street type mentality. You’re here, I’ll fix your immediate problem, and then I send you back out. And what we’re looking at now is really focusing more on the continuity of care with our patients so that we can convert those patients into primary care patients," Esmail said.

Esmail continues to take the business further than just urgent care, expanding into women’s health and mental health, filling two of the most pressing gaps in local healthcare.

"We do have a women’s health practice in our Austintown location. We’ve expanded all of our locations offer mental health services now, so we are slowly but surely expanding into specialty services that we deem of need, and it can vary from location to location," Esmail said.

"One of our driving factors in opening our women’s health practice was when we lost two active, full-time practicing ob-gyns at the time. So, we absorbed their patients, because the majority of their patients were Medicaid, and they would have had to wait months and months to get in to be seen, just because there wasn’t, there weren’t enough clinicians that accepted Medicaid that had openings. So, we said, we can at least fill in the gynecology part of that gap. We’re not going to deliver babies, but we can at least do the gynecology part. And that’s been really impactful. And we see a lot of volume of women that are very grateful that we offer that service," she said.

Esmail says that collaboration — not competition — will be key to maintaining the Valley’s strong healthcare.

"I think everybody has to do their part. You know, I like to say you can’t, you can’t compete where you don’t compare. And you know, I think that we all do our own little niche in terms of what we do best. I mean, nobody is trying to replicate Akron Children’s [Hospital] here in the Valley. Nobody should," Esmail said.

"I think Mercy has a very strong and reputable methodology to the treatment of patients on every scale. Southwoods does amazing with their surgeries and their surgical candidates. I think that when you look at landscape of the healthcare in the Valley, we do a really good job, I think, not stepping on each other’s toes, but being able to work really well together in order to fulfill the needs of our Valley.

"And I think that as long as we continue to have that mentality, then we can continue to grow and flourish throughout the landscape without sacrificing care," Esmail said.

Different approaches, different specialties, but one mission — to ensure that in a region where hospital doors have closed, care for people of the Valley isn’t shut out.

 

Watch the full interviews conducted for this show: