By Candace Miller, president and CEO, Jackson General Hospital; Lifetime West Virginian
I am proud to say I was born and raised in Mason County, West Virginia and have lived my entire life in this great state. That said, I bring a unique perspective to a hot topic back under the microscope this legislative session regarding certificate of need. I spent my entire career in healthcare working out-of-state (in Ohio) until July of 2024 when I “came home” to work for WVU Medicine in Ripley, West Virginia. I gained over twenty years of healthcare experience working in multiple hospital settings ranging from a small critical access hospital in Southeast Ohio to an exceptionally large health system in central Ohio. Colleagues would jokingly ask if I had to get my passport out to cross the state line (insinuating I came from a different country rather than a different state), to which I routinely shrugged off the comment and continued about my workday. Little did I know…… in comparison, healthcare in West Virginia does feel more like a different country than a different state. Let me explain.
During my first week working in West Virginia, I began to learn about certificate of need (CON). Coming from a state that only utilized certificate of need for inpatient beds and knowing that Ohio hospitals were registered for far more inpatient beds than they could physically stand up and/or staff, certificate of need was rarely, if ever, discussed. My first opinion was that it was more bureaucracy and red tape. It did not take long for me to realize the difference between our market and theirs (being Ohio). Simply put, West Virginia is built different.
When we break it down by the numbers, West Virginia has big challenges when it comes to creating a healthcare “free market.” The US Census Bureau shows we have fewer people per square mile, fewer people in the labor force, fewer people who have graduated high school, fewer people with computers, and fewer people with internet access. Advocates to eliminate the certificate of need conveniently leave out data points as discussed below when making an argument to create a free market in healthcare.
| West Virginia | Ohio |
| Seventy-two hospitals, of which 21 are critical access | 250 hospitals, of which 33 are critical access |
| State census 1.8 M | State census 11.8 M |
| Population per square mile 74.6 | Population per square mile 288.8 |
| Civilian labor force 16+ 53.5% | Civilian labor force 16+ 63.1% |
| Graduated high school 88.6%; bachelor’s 23.3% | Graduated high school 91.6%; bachelor’s 30.9% |
| Household w/computer 90.1%; broadband 84.4% | Household w/computer 93.6%; broadband 88.8% |
In addition to these numbers, there is also a significant difference in the payer mix from state to state. West Virginia’s majority payer mix is Medicare and Medicaid whereas in other states commercial payers make up the majority. Why is this important? Just like our state’s payer mix, most West Virginia hospitals rely on government programs to keep from losing money each year. For my hospital in Ripley, West Virginia, we rely on our critical access hospital designation, 340B funds, Medicare, and Medicaid reimbursement, along with certificate of need to keep the doors open!
As I shared earlier, I come from a healthcare system in central Ohio that made $6 billion last year, with a 14% net operating income. WVU Medicine stands as the largest healthcare provider in West Virginia, comprised of twenty-five hospitals, and our 2% net operating income budget for 2025 will be a challenge. It takes smart healthcare leaders to stretch dollars and provide high quality healthcare in a market that barely allows for a breakeven budget. I raise these points to say a typical false narrative heard in support of eliminating CON is that money-grubbing healthcare systems are motivated to keep CON for protectionism. This is simply not true.
Breaking down the apples to oranges a little further. Advocates to eliminate CON will state it increases cost of healthcare because of supply and demand. This is only a true statement when demand is present. Our state needs more jobs to bring more people to live in West Virginia. Advocates to eliminate CON will state it prevents hospital growth. This is only a true statement when the market to grow in is profitable. Our state needs more jobs to bring more people to work in West Virginia. Advocates to eliminate CON will state it increases mortality. This is only a true statement when the social determinants of health are equal between two areas. Our state needs to put programs in place to increase the number of high school and postsecondary graduates along with making access to broadband internet more readily available to reduce mortality through healthier living.
Just last week, the last remaining anchor store at the Charleston Town Center Mall announced it will close its doors this spring. There is a free market for clothing department stores in West Virginia so why is it that in the capital of our state, our only shopping mall has lost its last department store? One cannot blame online shopping because only ninety miles away in central Ohio, shoppers can visit two giant shopping centers, Easton Town Center Mall, or Polaris Parkway. I am not one to speculate, however I am sure the 1 million population sitting inside Columbus’s 270 beltway along with the 1.1 million jobs helps support the shopping business. As I shared earlier, I have lived in West Virginia my entire life, worked in Ohio my entire life, and I can honestly say West Virginia is built different. Please join me to protect the certificate of need in our state. Without it, just like shopping centers, those of us in rural West Virginia will be resorting to online options (when our internet works) or driving ninety miles for access. Those big health systems in metropolitan areas making a 14% net operating income on commercial insurance will not be coming to us.
