Tough questions came from the audience Monday night in San Andreas as the executive director for the only hospital in Calaveras County indicated the best option going forward is to continue partnering with the Dignity Health system.

About 30 people came to the Calaveras County Library off Mountain Ranch Road to hear the first public disclosures of a proposal from Dignity Health. That proposal became public at 6 p.m. Monday when the meeting started but neither Mark Twain Health Care District or Dignity Health distributed copies of the proposal at the meeting.

People will get another chance to hear both presentations at 7:30 a.m. Wednesday at the same library, said MTHCD executive director Randy Smart. The sessions are for information only. The board is expected to make a decision later this month or early next year.

Voters will then be allowed to have their say.

Some in the audience asked about the merger announcement last week between Dignity Health and Catholic Health Initiatives, another multi-state system.

"Why are you interested in rural hospitals when they're so hard to run and there are so many at risk of financial ruin?" Dr. David Goodman, a physician who works at the MTHCD clinic in Copperopolis, asked Dignity Health representatives.

Goodman asked if the motivation is altruism and charity, or if there is a business strategy.

Gary Spaugh, a Dignity Health consultant, said, "We are engaged with communities and we are connected to Calaveras County. We don't cherry pick and abandon communities. We're committed."

Karl Silberstein with Dignity Health said, "We're a nonprofit, we're not in this to make money."

Susan Atkinson, a member of the MTHCD board, told the Dignity Health representatives,"There is a huge image problem for this hospital. Eighty percent of our people don't use it. People up here do not appreciate large corporate branding. They're tough people. They want appointments and help with billing problems. How are things going to change going forward with Dignity Health?"

Spaugh responded, “We have to move forward with cooperation, collaboration and support and that begins with the community. We have to support our hospital.”

Early in the meeting Monday night, Smart outlined what it would take for MTHCD to run Mark Twain Medical Center and its five clinics in Calaveras County independently, and he said consultants between 2015 and this year painted a dark picture.

The costs of taking the hospital and its clinics could add up to $69 million, Smart said, citing consultants Quorum Health Resources and Carl Gerlach.

Furthermore, Calaveras County's population is not growing, the median income in the county is 14 percent below the state average, and a disproportionate number of people rely on Medicare and Medicaid, Smart said.

"Right now it seems pretty far fetched" to consider taking the hospital and its clinics independent, Smart said.

That was the situation before 1989, when the hospital and the district ran alone. The hospital was independent from 1951 to 1989, when it entered its current partnership with Dignity Health. The lease expires Dec. 31, 2018.

"Regardless of who runs the hospital, if the community does not support it, we're done," Smart said. "If you lose the hospital you lose the five clinics and you lose more than 300 jobs. That's a county issue."

Dignity Health partners with Mark Twain Health Care District to run Mark Twain Medical Center.

The board for Mark Twain Medical Center, the third-largest employer in Calaveras County, is in the midst of deciding whether to run the hospital independently or lease the hospital and other medical facilities to Dignity Health.

Mark Twain Medical Center has a workforce of 324 employees and 35 doctors, and its payroll approaches $30 million a year.

Adventist Health considered making a proposal to partner with MTHCD when it's lease expires, but the multi-facility system dropped out in November, a decision that was announced publicly last week.

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