Something for the community to think about

Forty-eight years ago, while I was covering in the John C. Fremont Hospital Emergency Room, I worked on four patients whose cases illustrate a gnawing worry I have for this community.

The first was a thin and muscular 35 year-old who came to the ER with chest pain. He was a competitive runner in excellent condition, so heart attack seemed unlikely.

But examination and testing revealed that it was, indeed, a heart attack. I could have kept him at JCF, monitoring his heart as it went through the phases of losing blood supply to his heart muscle, the muscle dying and scar formation during the healing of this injury. But the damage to his heart would be permanent.

So instead, I rode in the ambulance with him to Merced where more specialized care was available, in hopes that the damage to his heart could be limited and the impact to his running would be minimal.

The second patient was a young mother-to-be who came in sometime in the late 1970s. At that time, we were still delivering babies at JCF. Most of the time, it was an uncomplicated and happy event.

But Medi-cal progress for obstetrics by that time included fetal monitors and the availability of board-certified obstetricians and pediatricians with neonatal training in facilities equipped for emergency C-section surgeries. We didn’t have any of that at JCF.

I was working with this woman whose cervix was dilating as labor progressed. But then, in spite of labor pains, her cervix stalled and failed to dilate further. Delivery would not be possible until her cervix was fully dilated.

Patiently, we waited, encouraging her and monitoring the fetus’ well being by listening to and counting fetal heartbeats. With a stethoscope. As I said above, there was no fetal monitor at JCF.

After some hours of unproductive labor, I became worried that the fetal heartbeat was slowing. Someone in there was getting tired, as was their mother. Since we had no option for urgent C-section, the fetus was, I felt, in danger with the prolonged, unproductive labor.

I made some calls and finally found an OB-GYN in Merced who was willing (reluctantly) to take over her care. I rode in the ambulance with the patient(s), trying to listen for the fetal heartbeat.

But all I could hear in the stethoscope was the roar of the ambulance tires. During the entire trip to Merced, I didn’t know if the fetus was still alive — if it would become a baby. A normal baby.

The OB-GYN was professional and cared for the mother and, ultimately, healthy baby. But she was not happy to be doing this on a patient she had no opportunity to see during pregnancy.

I said that this was “a patient.” Actually, this occurred several times with all the doctors in Mariposa at the time. It was hardly a happy experience for the mother-to-be.

We were playing Russian roulette delivering babies with no emergency OB back-up immediately available. Eventually, we set up a system of pre-natal care in Mariposa and delivery in Merced for the sake of every woman and baby.

Third and fourth cases: After a joyous high school event (prom or graduation, don’t recall which), the car in which four Mariposa kids were riding failed to make a curve. The ambulance brought in two badly injured girls.

One was moaning in pain, barely conscious. It was obvious that she was hemorrhaging internally. The second girl was unconscious and my quick exam suggested similar internal bleeding.

We started IVs — but this would be helpful for only a little while. I moved quickly between the two, looking desperately for progress, but both needed surgery to stop the bleeding.

While the nurses did what we could, I had to call surgeons in Merced to get someone to accept the girls as patients, then get the ambulance and helicopter rolling. All this took longer than I wanted.

It took too long. For both.

We have since constructed an entire EMS system involving 911 Medi-cal dispatch, first responders, professional ambulance service (both ground and helicopter) and trauma centers. Such patients now may often bypass JCF and go directly (quickly) to a trauma center.

Saves time. Saves lives.

Certainly, there have been many patients I’ve cared for in the JCF hospital, but these were not cases of such critical nature, nor did they require more complex specialized care.

Over the ensuing 48 years, there have been put in place many improvements in Medi-cal care here in Mariposa County. But what has not changed is that it’s still in the patient’s best interest, in critical care cases, to bypass small rural hospitals for larger, more fully equipped facilities.

Moreover, the forces that control the money in health care are squeezing rural hospitals. Over 153 rural hospitals have closed since 2010. Nine of them were in California, including in Sonora, Madera and Dos Palos.

Almost always, the cause is financial insolvency. And that pressure is increasing. I see nothing on the Medi-cal horizon which suggests that will change.

This estimate is based on my knowledge of the forces on Medi-cal care exerted at the federal and state levels, behavior of insurance companies and the research done by the University of North Carolina’s Sheps Center which specializes in studying rural American hospitals.

The JCF Healthcare District provides many valuable services to this community: Clinics, emergency room, laboratory, X-ray and imaging, skilled nursing facility, respiratory services, physical therapy, in-patient (hospital). We need to protect those services — or at least the most frequently used services — from being lost.

Data from JCF financial report of June 2025 shows that, in the first six months of 2025, the clinics provided an average of 90 patient-days each day. That’s six times as many as the in-patient (hospital) in the same period. The ER provided 41 a day, three times the in-patient.

As we can see from these patient utilization statistics, the clinic and emergency room services of the healthcare district are far more often used than the in-patient (hospital) service.

Additionally, out-patient services generate more than twice the revenue that the in-patient service does per the JCF financial report.

Moreover, the district reports an operating loss of $5,479,000 for the year ending June 2025. This is alarming in the face of similar rural health care facilities facing financial distress and closing nationwide and in California.

Add to that the realization that Medicare and Medi-cal are a lifeblood to this district. They provided 45 percent of district revenue in June.

But those two programs are under attack. The Trump administration and Republican congress just recently adopted the “Big Beautiful Bill” law. Many experts predict that this law will reduce reimbursement to Medi-cal facilities for patients with Medicare and Medi-cal for years to come.

There is no doubt in my mind that the JCF Healthcare District is facing financial threat. And all the services provided by the healthcare district could be lost if the district doesn’t respond appropriately — and aggressively — to this threat.

Ours is a health care district where out-patient services provide more than twice the revenue of in-patient (hospital) services and where the community utilizes out-patient service more than six times as much as in-patient.

We are already showing an operating loss. We must be honest with ourselves and ask if we can afford a new hospital without risking financial ruin and loss of all the services or should we focus on having an upgraded, well-staffed clinic operation and 24 hour emergency service of some sort?

This health care district is yours. We should be asking ourselves — and the JCF board — some serious questions:

1. What is the district administration doing to mitigate the impending decrease in Medicare and Medi-cal revenue? (And using grant or loan money to cover losses does not cut it. Those are not long-term funding sources.)

2. Which JCF Healthcare District services make money or break even, and which are perpetually incurring losses?

3. How much would it cost to build a modern, comfortable clinic building?

4. How much to build a new in-patient hospital?

5. How much to operate and maintain a new in-patient hospital?

6. Measure “O” generated only $ 3,708,000 over the past 12 months (JCF figures). Where would the money for a new hospital come from?

7. What is the administration’s plan to avoid financial insolvency/bankruptcy of the health care district, which could well result in the community losing all of the Medi-cal services the district has provided?

8. Should the JCF board bring in some administrators of successful rural hospitals for some new ideas?

Dr. Charles Mosher, M.D., M.P.H., was Mariposa’s county health officer from 1988-2014. Prior to his work at Mariposa County, Mosher served in the Peace Corps, worked for the state of Georgia and served for 11 years with the Merced County Health Department. He can be reached at author@greaterstory.com.