Editor's note: Since this story was originally published in our Winter 2020 issue, the COVID-19 pandemic has put even more strain on rural healthcare systems. The folks featured here have packed up the camp where they spent months protesting a monopolistic healthcare merger, but they're still fighting to keep clinics, NICUs, and trauma centers open. Now they're working to organize a hospital authority that would allow community oversight of their healthcare system. You can find out more by checking out Rally For The Valley.

Leaning forward in her lawn chair, Dani Cook says, "The problem they're running into is that the truth always stands."

She pauses a minute, looking around at her comrades sitting in front of Holston Valley Medical Center in Kingsport, Tennessee, mostly older folks between the ages of 50 and 80. It's a chilly October day, and the five protesters are arrayed around a small folding table, sitting in various mismatched lawn chairs brought from home.  On the table are items that will get them through the day: a deck of cards, a sketchbook, a box of doughnuts. Dani sits in the middle, prepared with pictures, documents, and a lifetime of stories about the Kingsport health system. "And my story's not gonna change," she adds, "because it's the truth."

The crew is small this morning––a group of five people who range in age from Deacon Farris, who is in his 80s, to Dani Cook, who is the youngest at 46. Dani is a grandmother and a self-described disabled veteran. Like everyone in the group, she's local to Kingsport, a small city just south of the Virginia line. They're protesting Ballad Health, a nonprofit health-care provider based in Johnson City, that formed in February 2018 from a cost-cutting merger between two indebted local health systems.  They've been actively occupying the medical center since last April, when Ballad Health announced the closure of the Kingsport neonatal intensive care unit or NICU. 

Dani Cook takes a selfie on the 188th day of the protest she launched in response to Ballad Health's austerity cuts. (Photo from Dani Cook's Facebook)

Dani started the Ballad occupation due to her grandchild, Bella.  Running through pictures on her phone, she describes how Bella was born at 1 pound, so fragile you could see her heart through her skin.  If the NICU had been any farther from home, Bella would have died. Welling up with tears, Dani says the nurses whose care and attention saved Bella inspired her to come sit in front of the hospital. She is standing up for patients, but also for these workers, mostly women, who dedicate their lives to the health of their community.

The protestors say the NICU closure, along with other changes and austerity measures that stemmed from the merger, have led to  an immensely downgraded workplace and a lower quality of care for patients.

The state of rural health care must be a factor in any conversation about rural economic justice, but the outlook isn't good.

The occupation is planted at the hospital entrance, directly in front of the parking garage, unavoidable from any direction. Signs line the opposite side of the road, placed carefully on public property by the sidewalk:  "BALLAD HEALTH PUTS PROFIT OVER PEOPLE."  

Over the mountain, a group of recently laid-off coal miners had just shut down a railroad in Kentucky. They were blockading a train loaded with coal they had mined before their employer, Blackjewel, filed for bankruptcy and left them without compensation.  The miners had the weight of history behind them, the deep and bloody history of coal mining in Appalachia, made famous by armed battles between miners and their bosses. National media flocked to the scene, excited by the reignition of old battles. The coal miner, ever a prop in the struggle between the right and the left, became once again a symbol of the economic hardships faced in Appalachia. And it's true, the coal industry is crucial to understanding of the region. But it's not the full picture.

Deacon Farris holds a sign criticizing Sen. Rusty Crowe at the Ballad Health protest site. (Photo from Dani Cook's Facebook)

In this part of Southern Appalachia, if you want to make a decent living, coal mining is one of a small number of career options. Another is health care, namely nursing, accessible through a community college degree. As the coal industry dwindles, health care is taking its place as one of the biggest  well-paying, blue-collar, private-sector industries in Appalachia. The state of rural health care must be a factor in any conversation about rural economic justice, but the outlook isn't good. The Ballad Health merger is a prime example of how privatization and consolidation are leading to worse health services across the South.  

In February 2018, the executive board members of Mountain States Health Alliance and Wellmont Health Systems unanimously voted to approve the merger that created Ballad. They cited hundreds of millions of dollars in debt as rationale. As a new regional monopoly, Ballad Health is now the only option for Southwest Virginia and Northeast Tennessee, a mountainous area with 1.2 million people and that's roughly the size of New Jersey. Ballad Health employs 14,000 people, making it the largest employer in all 29 counties it serves. Ballad's logo is omnipresent throughout Kingsport and its greater service area; it shows up at storytelling festivals, school events, Pride festivals, on billboards, and in newspapers. Ballad Health is now one of the largest hospital systems in the country.

To hear Bill Greene tell it, the merger idea came to him during a frustrating hospital visit, when a Mountain States facility wouldn't check on any of his Wellmont-held medical records. Greene, a prominent and wealthy banker, floated the idea to Mountain States Health Alliance CEO Alan Levine during a golfing trip. From there, they organized a small group of influential business people and elected officials, a group they nicknamed the "hole-in-the-wall gang."

An ambulance sits parked outside an Eastman Chemical Company plant in Kingsport, TN. An Eastman executive was among those who pushed for the merger that created Ballad Health.

The group includes the president of East Tennessee State University; the senior vice president of Kingsport's largest employer, Eastman Chemical Company; the CEO of the Bank of Tennessee; and others.  Levine would eventually become CEO of Ballad Health. The hole-in-the-wall gang refined the merger plans over three years of small meetings. In order to accomplish a merger of this scale, the "gang" enlisted state Sen.  Rusty Crowe (R-Johnson City), the chair of the Tennessee Senate Health Committee and a former paid consultant for Mountain States, who is now a contractor for Ballad Health.

The Ballad merger created a monopoly which, under normal circumstances, is illegal. But, thanks to a federal law passed in the 1990s, states can approve something called a Certificate of Public Advantage(COPA). A COPA allows healthcare providers to form a monopoly  as long as state regulators determine that "the likely benefits of the proposed Cooperative Agreement outweigh the likely disadvantages that would result from the loss of competition." But what that actually entails isn't specified. The Federal Trade Commission generally blocks health-system mergers on the grounds that they diminish the quality of service for patients and allow the price of services and workers' wages to be set at the corporation's whim. The FTC opposed the Ballad merger, but Tennessee and Virginia lawmakers collaborated on a COPA that took the decision away from the federal agency.  It was the first COPA merger to ever cross state lines, and yet there's much about Ballad's oversight that will be shielded from public view. In early 2018, Johnson City Press reported that, at Ballad's request, Crowe crafted a bill to make some of the information Ballad reports to the state Department of Health confidential. Public outcry led lawmakers to narrow the scope of information that's kept secret. The new law ultimately made eight types of information confidential (instead of fourteen) including operating budgets, certain contracts, and complaints.  

"You hate coming in and knowing you could be the only one on the floor."

The motivation for the merger was evident almost immediately as Ballad's board set in motion an austerity regime for the hospital system.  In 2018, four urgent-care clinics in Tennessee were shuttered and 150 employees laid off. The board decided to merge two Level I trauma centers, which provide the most comprehensive care to severely injured patients and reduce the risk of death by 25 percent. The board also merged  two NICUs into one. For Kingsport, that meant the local trauma center was downgraded from Level I to Level III, and the NICU was removed completely. These services are now provided only in Johnson City. The majority of patients must drive an average of an extra hour to reach emergency care.  These cost-cutting measures have directly resulted in loss of life, since many patients live in small, isolated hollers where communication with emergency medical services is already difficult. These measures, according to the hospitals' leadership, free funds for other public health initiatives.  Dani says that Ballad board members have told her that communities "don't need a NICU on every corner."

According to Cook and the other protestors, Ballad hospitals are now deeply untenable workplaces. A retired nurse, who will remain anonymous, joins the group around noon.  After handing out small breakfast tacos to the group––"She always comes with food," says Dani. "Don't even try to say no"––she begins to describe the outlook for health-care workers in the region.

Protestors erected an encampment at Holston Valley Medical Center in April 2019.

The arc of the health industry, says the nurse, who worked at Holston Valley Medical for 15 years, has bent toward long hours, less pay, and chronic understaffing.  Now, she says, "You hate coming in and knowing you could be the only one on the floor." A night nurse may see up to 25 patients on a given night, a situation that was once unusual and is now routine.  

"Overworked, understaffed, underpaid," concludes the nurse, munching on her taco and turning her face toward the  sun. 

Until last summer, new nurses were hired at $18 per hour, significantly lower than the Tennessee average of $28.87. while being saddled with more work than starting nurses are generally capable of.  Dani notes that nurses hired last May were asked to train new staff just a few months later. Though nurses and support staff got a modest pay raise last year, Modern Healthcare reported in September that morale was still low because new bonus and overtime policies left workers feeling shortchanged. The retired nurse I spoke to believes the increasing workload has outweighed any gains. She recalled one notable night on the floor when an RN called for help with a patient who was struggling to breathe; with insufficient training to complete a simple but life-saving task, she shouted, "I need a nurse!"

Harried, overworked nurses are now asking the protesters for help with patients.  Dani has acted as volunteer patient liaison and advocate more than once, finding that without her intervention, several uninsured, homeless and/or mentally ill patients would have been turned out onto the street.  Despite being told not to interact with the protest, nurses are beginning to stop by, quietly and usually at night. In no uncertain terms, Ballad has said that if they are caught, they will be fired. In Tennessee, a right-to-work state, firing workers for exercising First Amendment rights is legal.

In many rural areas, but especially rural Appalachia, health-care projects like the Ballad merger are being touted as economic development mechanisms, mostly in terms of creating quick, relatively high-paying jobs for local people.  A large part of Ballad's public outreach strategy involves partnerships with local arts nonprofits, a move with precedent by coal companies, large factories, and other industries that use charitable giving to maintain a facade of good community relations. A partnership with the International Storytelling Center spawned a "youth board" to encourage patients to "tell their health-care story."  Dani noted that because Ballad Health and the companies represented by members of the hole-in-the-wall gang are so powerful, local press rarely covers the community response to their actions—which, overwhelmingly, has been negative.

Signs along a sidewalk at Holston Valley Medical Center bear messages opposing Ballad Health's austerity cuts.

Health-care consolidations, care level downgrades, and closures are hardly the picture of economic development, and it's no coincidence they're happening in states like Tennessee, one of 14 states where lawmakers blocked Medicaid expansion.  Rising insurance premiums and Medicaid cuts in the state have directly contributed to rural hospitals' myriad financial troubles. Uninsured residents do not use the hospital when needed, resulting in fewer, more expensive visits that many are unable to pay off, which spirals hospitals into debt. In Ballad's coverage area in Tennessee and Virginia, up to one in four people live in poverty, and up to 12.5 percent  of people are uninsured, nearly double the national average.

There's a movement forming in Appalachia: a movement for just and accessible health care.

Michele Johnson, executive director of the Tennessee Justice Center, advocated for Medicaid expansion and says it would have delivered real economic benefits. "We know that Medicaid expansion would have created 15,000 new jobs," she explained in a phone interview. Instead, the state lost billions of taxpayer dollars,  "because the governor and legislators feel it's not politically needed. … [The Ballad merger] is a symptom of this larger issue of making health care a political game."

What's happening here is health-care rationing––tightening care access for the poor, the geographically isolated, and historically marginalized communities with very little political power.  Meanwhile, business leaders who jump between Chambers of Commerce, seats in government, and nonprofit boards reap the benefits. During his first year as Ballad CEO, Levine received a compensation package of more than $1.4 million dollars. And because the merger was structured in an unusual way––with Ballad existing first as an entity independent of Wellmont and Mountain States––Levine's team was able to sell hospital bonds that sparked a feeding frenzy for investors. 

Though Ballad Health is a particularly egregious example, closures and consolidations have happened in North Carolina, Ohio, and Missouri, among other majority-rural states, often with similar results. As usual in neoliberalism, the profits go into private hands, and the costs remain public.

But if Dani and the Ballad occupation are anything to go by, there's a movement forming in Appalachia: a movement for just and accessible health care.  The protestors, along with their supporters in Kingsport and throughout Tennessee and Virginia, have sat with congressmen, organized forums, gathered about 23,000 signatures on a petition, and turned out hundreds of people to hospital board meetings. Next they're planning to push for the formation of a hospital authority that would ensure public oversight and force Ballad to listen to the people it serves.

The Ballad occupation in Kingsport is contending with the power of the Appalachian business elite and their feudal tendencies. Dani and her cohort believe that with the privatization, regionalization, and consolidation of health care, other public services in the region are to follow.  As Dani says, when businesspeople want to do something extralegal, they can perfectly well "change the damn law"—a succinct summary of the hole-in-the-wall gang's strategy with Sen. Rusty Crowe.

Since the fall, the occupation has both enjoyed increased support and faced increased political repression. National media coverage has favored the occupation.  But Kingsport city council members introduced an anti-camping ordinance specifically, Dani fears, to pressure the protesters to leave. These fears were confirmed when Kingsport city police delivered citations to every protester present in front of the hospital.  As this story goes to press, the legal situation remains unresolved, with protesters facing potentially heavy fines.  

Dani goes on Facebook Live almost every night to share her news of the day in what she calls her "podcast," which often garners several thousand viewers. As the protest stretches on, she asks for help keeping the senior citizen occupiers warm at night and declares her intentions: She will stay as long as there is work to be done.  As long as there's no NICU for grandbabies like hers, no trauma center for old folks like Gary and Deacon, no safety net for folks who live out in the hollers, they will be there—educating the public, sleeping outdoors, organizing, and above it all, taking care of one another.

Caitlin Myers is a writer and organizer splitting her time between Knoxville, Tennessee, and Whitesburg, Kentucky. Caitlin writes primarily about economic justice as it relates to labor, health, and the privatization of public services, and she loves to explore the many ways in which communities take power back.