At a time when Obamacare is being blamed for a range of economic woes, local heath care executives say the new law is part of a powerful mix of forces revolutionizing their industry and constricting budgets.
Some executives attribute recent layoffs at several North Coast hospitals to the Affordable Care Act's cuts in Medicare reimbursements, along with cutthroat competition and advances in medical technology.
Employment at U.S. hospitals peaked in April at 4.84 million. But hospitals have been cutting jobs this summer and fall, shedding 9,000 jobs in May and an additional 4,400 jobs in July, according to the U.S. Bureau of Labor Statistics.
The layoffs started on the North Coast in July, when St. Joseph Health in Sonoma County, which runs both Santa Rosa Memorial Hospital and Petaluma Valley Hospital, said it would eliminate 26 jobs at Memorial and 11 in Petaluma.
In August, Ukiah Valley Medical Center notified employees that 18 positions would be eliminated or left unfilled, though five of the affected employees were to be switched to different positions. Another five employees had their hours reduced, according to an internal hospital memo detailing the cuts.
A little more than a week ago, Healdsburg District Hospital announced that it would cut its workforce by 8 percent, letting go of 30 employees.
The next ax is expected to fall in Sebastopol, where Palm Drive Hospital executives are embarking on a painful effort to "right-size" the hospital from 37 inpatient beds to 14 beds.
The hospital currently is exploring which positions, and how many, will be affected. Officials are focusing on jobs associated with inpatient care, which covers a large swath of positions at any hospital, said Palm Drive CEO Tom Harlan.
"The uncertainty having to do with Obamacare is a factor" driving the hospital's assessment, Harlan said.
In addition, hospitals are keeping fewer patients overnight as advances in technology and medicine continue to transform the industry, leaving them with an increasing number of empty beds.
"What we're taking out is the people who are really in reserve to staff all these empty beds," Harlan said. "We're calling it 'right-sizing.'"
At Healdsburg District Hospital, patient visits declined 10 percent during the first 10 months of this year, to 7,061.
Meanwhile, like most hospitals in the country, the Healdsburg hospital is anticipating a big hit from future cuts to Medicare, which is used by 52 percent of its patients to pay for their care. Another 18 percent of the hospital's patients are covered by Medi-Cal, the federal Medicaid program in California.
State hospital advocates say the federal government's reimbursements for those programs are a fraction of the actual cost of care, and that percentage is poised to get smaller.
"If revenue is going to come in at what the government is paying, we have to keep our expenses in line," said Nancy Schmid, CEO at Healdsburg District Hospital. "Inpatient volumes are going down, and they have been going down since 2008. ... Volumes went down, the staffing didn't go down. Staffing went up."
Add to that a hospital industry that is becoming increasingly competitive and troublesome for smaller district hospitals, as larger health care systems like Kaiser Permanente and Sutter Health continue to dominate the market.
That has smaller district hospitals more aggressively shifting their focus away from traditional inpatient services to whatever it is they do best, such as wound care services at Healdsburg District Hospital or stroke services at Palm Drive Hospital. A focus on certain outpatient services is becoming critical.