Decades of Shrinking Hospital Capacity ‘Spelled Disaster’ for New York’s COVID Response

On Feb. 6, the state’s Public Health and Health Planning Council approved Mount Sinai Beth Israel’s plan to construct a 70-bed hospital and new emergency department in the East Village, replacing its existing 700-bed facility two blocks away. The changes were in response to shifting healthcare trends, the hospital said, including an increase in outpatient services that’s resulted in fewer hospital stays. “There are too many inpatient beds, particularly in Manhattan,” a public presentation about the plan explained, noting that Mount Sinai Beth Israel has sustained $100 million in operating losses each year for the last six years. 

The same week the hospital’s downsizing was approved, Gov. Andrew Cuomo was setting up a state-run hotline to answer the public’s questions about the Novel Coronavirus; it would be another few weeks before New York saw its first confirmed case of COVID-19. In the time since, as the number of sick and dying skyrocketed, the city and state have scrambled to increase hospital capacity: Officials have made use of a Navy hospital ship, set up field hospitals at the Javits Center and in city parks, and evacuated college dorms for potential medical use. Some patients have been transferred out of city hospitals to others as far away as Albany.

Mount Sinai Beth Israel’s plan is merely the latest in dozens of hospital mergers, downsizings and outright-closures across New York in the last several decades. More than 40 hospitals in the state have shuttered since 2000, including more than a dozen in the city, accounting for what advocates say was the loss of nearly 21,000 hospital beds statewide during that time. Today, New York’s hospital network has about 53,000 beds. After climbing for weeks, the state saw its hospitalization rate dip slightly for the first time Tuesday, Cuomo told reporters.

The pandemic has cast a harsh light on those losses, many of which were at the behest of the state and which involved community hospitals that either shuttered, pared back inpatient services or were taken over by bigger providers. The closures were often based on the belief that more care could now be offered outside the hospital setting, and that “it’s too costly to keep unused hospital beds open,” says Lois Uttley, of the nonprofit healthcare advocacy group Community Catalyst.

“I think the assumption behind all that downsizing now has been called into question,” she says. “Now we need to ask: How much are we spending to convert the Javits Center to a hospital, to rent hotel rooms to house patients? The idea that we were saving money by getting rid of hospital beds now doesn’t seem like it was wise.”

What’s more, experts say, is that the decades of shrinking hospital capacity has made it harder for New York to respond to the current crisis. As of Tuesday, more than 29,000 coronavirus patients were hospitalized in the city, according to Health Department data.

“We would not be in dire straits, calling and having navy ships come into the city,” if many of those now-shuttered facilities had been kept afloat, says Anthony Feliciano, director of the Commission on the Public’s Health System. “I do think we would have had enough beds, at least, to be more prepared.”

Unused capacity

In response to the pandemic, several health advocacy groups are calling on the state to reopen some of the hospitals that were shuttered in recent years, as well as issue a “moratorium” on future closings or downsizings. This includes Mount Sinai Beth Israel’s plan as well as another at Montefiore’s Mount Vernon Hospital in Westchester County; Montefiore filed a proposal with the state last year to construct what it calls a “hospital without beds” to replace the actual 121-bed facility, the only full-service hospital in the city, advocates say.

That plan is still pending state approval, records show, but advocates say Montefiore had already begun scaling back services before the pandemic struck. In a letter to Cuomo sent March 18, a group of Mount Vernon elected officials accused Montefiore of moving forward with the hospital closure before the plans for its new facility were even approved by the state’s Department of Health, leaving Mount Vernon Hospital “dormant and deactivated” as other regional hospitals scrambled for beds.

“Montefiore systematically removed medical services and resources from Mount Vernon Hospital, leaving residents without a functional hospital in the midst of the pandemic,” the scathing letter, signed by two state senators and an assembly member, reads. Later that month, Mount Vernon Mayor Shawyn Patterson-Howard told the Journal News that 40 of the hospital’s beds were coming back online in response to the crisis, and that she was pushing to get the rest restored.

Mischa Gaus, a union representative with the New York State Nursing Association, says only about 60 beds were being utilized at Mount Vernon Hospital as of April 9, while another Montefiore facility — Westchester Square Hospital in the Bronx — had zero beds in use at the start of this week despite having the capacity for 140. Montefiore eliminated in-patient services at Westchester Square when it took over the facility in 2013, though Cuomo has named it among the sites providing the state with extra beds for COVID patients.

“Montefiore could have opened these beds in both Mount Vernon and Westchester Square by seeking additional temporary nursing staff. We asked management to staff up before the crisis hit. They chose not to,” Gaus told City Limits. 

Meanwhile, he says, Montefiore’s other locations, including the Weiler campus in the Bronx just a short distance away from Westchester Square, are struggling to find space for patients. 

“They’re using every square inch, including waiting rooms and other areas that are not used for patient care,” he says. “Why are you doing that when you have vacant space?”

Montefiore declined to say how many beds are currently in use at Mount Vernon or its other facilities, saying the number changes by the hour, and it did not respond to questions about whether it has reactivated beds at Westchester Square in response to the crisis.

“Montefiore Mount Vernon is open and ready to serve the community in the face of this health crisis,” the company said in a statement, adding that it is “looking at every available option for beds to meet the needs of the communities we serve. This includes Montefiore Mount Vernon and the resources available there, as well as every location across our health system.”

Neither the state Department of Health nor Cuomo’s office responded directly to questions about whether any hospital closures or downsizings will be halted indefinitely as a result of the pandemic, as advocates have urged. On March 22, Cuomo issued an executive order requiring all New York hospitals to increase their capacity by at least 50 percent, and the state has adopted a so-called “flex and surge” system so facilities across the state can coordinate in the sharing of staff, beds and equipment. 

“Our current focus is on slowing the rate of infection and community spread of COVID-19. The Department continues to carry out the state’s surge and flex plan in support of the lifesaving work of more than 200 hospitals statewide,” Health Department Spokeswoman Erin Silk told City Limits in a statement. “Our goal of access to quality health care for all New Yorkers is unwavering and will continue well after this crisis is abated.”

In Brooklyn, a state plan to consolidate services among three struggling hospitals—Interfaith Medical, Brookdale and Kingsbrook Jewish—is reportedly being put on hold in order to respond to pandemic patients, and a number of beds that were previously dormant were brought back online, The CITY reported in March. Mount Sinai Beth Israel has similarly reopened three unused floors, advocates say, though the hospital did not return requests for comment to confirm this. Mount Sinai has also publicly stated it would make Rivington House, a former AIDS nursing home downtown that’s being converted to a substance abuse center, available for the state’s use in the pandemic. 

‘Devastating to this community’

Advocates say the plans for Mount Vernon are illustrative of larger trends taking place across the healthcare industry, as hospitals move towards offering fewer in-patient services to reduce costs, what Gaus calls part of “the corporate healthcare model.”

“They have been prioritizing same-day surgery and other profitable services and trying to abandon lower-income communities, where patients are predominantly people of color,” he said. “Montefiore is not unique in this strategy but they are the ones attempting to close a hospital during a pandemic.”

Like it did with Westchester Square, Montefiore took over Mount Vernon Hospital when it was in bankruptcy, in 2013. The new facility Montefiore wants to replace the hospital with would be located at another location which critics say is harder to access without public transportation, and while it would offer an array of services—like pediatrics and adult primary care, as well as an “off-campus” emergency room—there would but no beds for overnight stays. 

Instead, those in need of inpatient care would be stabilized and then “seamlessly transferred” to another hospital, according to an outline of the plan on Montefiore’s website, which notes that Mount Vernon’s “inpatient census” had remained low in the six years since Montefiore took over operations, with fewer than 50 beds in use on any given day. 

“More complicated care can now be provided in ambulatory settings, which results in better community-based care and reduces the need for hospitalizations,” the outline reads. 

The state is providing $41 million in grants for Montefiore to build its new Mount Vernon facility. But critics who’ve been fighting for months to stop the closure argue those funds should be used instead to restore Mount Vernon Hospital and allow another hospital provider to take it over if Montefiore won’t do so.

“It would be devastating to this community of roughly a hundred thousand residents and the surrounding neighborhoods, and the surrounding city,” if the hospital closes, says Robin Mack, a consultant with New York State Nurses Association on its campaign to save Mount Vernon Hospital.

Shuttering it would leave already overburdened facilities nearby to pick up the slack, she adds. 

“It is creating a health desert in the southern tier of Westchester County.”

Decades of downsizing

Her worries echo past hospital closures in New York City, where the shuttering of community facilities put additional strain on surviving nearby hospitals, particularly those in low-income communities that served larger populations of the uninsured. After Mary Immaculate and St. John’s hospitals in Queens closed their doors in 2009, Elmhurst Hospital saw a “staggering” uptick in patients, City Limits reported at the time. A similar ripple effect took place in Lower Manhattan after St. Vincent’s Hospital closed in 2010. 

“If you need to go by ambulance from southern Queens to find an emergency room when Jamaica Hospital is jam-packed, how far do you have to go? Or if you have to go into Manhattan in an ambulance — how long does it take at rush hour?” says Alan Sager, a professor of health law, policy and management at Boston University, who studies hospital closures. In 2006, he produced a report examining New York’s hospital closures and found they did little to save the state money. 

Sager says the trend towards closing and consolidating hospitals has been taking place across the country for 40 years. It accelerated in New York starting in the early 2000s, particularly after then-Gov. George Pataki convened a commission to restructure the state’s health care system to reign in spending and root out waste. That panel—dubbed the Berger Commission after its chairman, Peter Berger—recommended the closure of five city hospitals and the merger and downsizing of at least five others. 

Many of those recommendations were carried out. But in the years since, experts say, New York has continued to shed hospital beds, far more than the Berger Commission even suggested. It has “spelled disaster” for the system’s ability to respond to the current crisis, says Elisabeth Benjamin, vice president of health initiatives at the Community Service Society (a City Limits funder.)

“The hospital closures kind of went on steroids, and there were real policy reasons for why and how that happened,” she says. Those reasons include the state’s move in 1997 to deregulate hospital reimbursement rates, which left health care providers to negotiate their own prices with insurance companies. 

“That’s bad, because the most powerful hospitals were able to command really good reimbursement rates and the least powerful hospitals were not,” says Benjamin.

This was exacerbated by other policies. For years, the state distributed public funds intended to cover the costs of treating uninsured patients, known as the Indigent Care Pool, to both public and private voluntary hospitals instead of targeting the institutions that truly served the most vulnerable populations. That distribution formula was changed in the most recent budget agreement so it will be less favorable to wealthier hospitals going forward, Benjamin says.

More recently, Medicaid reimbursement cuts that were enacted in 2012 also disproportionately impacted smaller safety net hospitals, but left larger systems relatively unscathed, City Limits reported previously. 

The combined result of these policies left many of the city’s small or medium-sized hospitals struggling to stay afloat, while power shifted to about a dozen or so larger hospital systems like New York-Presbyterian, NYU Langone, Northwell and Mount Sinai.  

For many low-income neighborhoods, that means that “care gets more expensive and farther away,” says Sager.  

“It’s a joke to imagine that a small number of major teaching hospitals that are geographically concentrated…can serve an enormous, spread-out city like New York.”

Changes needed 

That’s in some ways the argument that proponents of hospital closures and downsizings have made in the past. 

“Brooklyn and the rest of New York will always have enough high-quality hospitals to care for the patients who need them,” Stephen Berger, who led the Berger Commission less than a decade earlier, wrote in a New York Post op-ed in 2013. At the time, advocates—including then-Public Advocate Bill de Blasio—were staging protests against the closing of Brooklyn’s Long Island College Hospital.  

“Sometimes hospitals simply reach a point where their survival is no longer financially tenable and their services are no longer essential,” Berger explained. New Yorkers need “to overcome their reliance on hospitals and embrace the rapidly shifting health-care landscape,” he writes, saying that low-income communities “desperately need more primary care, not more inpatient beds.”

And while experts agree that access to primary care is vital, the idea that closing hospitals will somehow shift more resources towards preventative services often “doesn’t happen.”

“That’s more rhetoric,” says Sanger. 

“Primary care is essential, but it isn’t a replacement for the hospital,” he added. “After we fail to prevent illness or accident, we need treatment.”

The key, he said, is for health systems to be better prepared, looking comprehensively at the needs of the communities it serves, during both “ordinary times and in emergencies.”

“It’s hard to keep an empty hospital open, but it is possible to mothball it instead of closing it,” he says. This would entail keeping underutilized facilities intact, but not operating unless they’re needed in times of crisis. 

“You drain the pipes, you turn off the heat and you check the roof twice a year make sure there are no leaks,” he explained. “If you do need the surge capacity, it can come back quickly.”

A recent analysis by the Association for Neighborhood and Housing Development found that of the 18 city hospitals that closed in the last two decades, more than 40 percent have been replaced by residential developments. Feliciano, of the CPHS, says the city should do a better job of leveraging its land use policies to ensure health care needs are not ignored when development is proposed. 

He and other advocates are also pushing for the state to reform its process for approving hospital closures, mergers and downsizings, what he describes as a “very laissez faire” approach that focuses more on unused hospital beds than “any social needs of the communities” affected.

“Closures are approved without any public hearing, without any public debate,” and just require the approval of the State’s Health Department, says Uttley, of Community Catalyst. More stringent oversight is only triggered under specific circumstances, such as when health care providers want to add beds to a hospital, change ownership or undertake more expensive renovations. 

In those cases, providers must file a Certificate of Need, and their plans must be reviewed and approved by the state’s Public Health and Health Planning Council (PHHPC). But that council’s two dozen seats “are dominated by the executives of hospitals and nursing homes” according to Uttley, meaning many projects are rubber-stamped without adequate input from the community. 

Advocates are pushing for the passage of state bills that would reform that process, including one that would require the Health Department to issue a report on the potential community impact of every hospital closure it receives an application for, and would be required to incorporate public feedback when doing so. Another bill would add two new seats to the PHHPC and require they be filled by representatives from healthcare consumer advocacy groups, not industry insiders. That bill passed both the State Senate and Assembly in February, but has yet to be signed by the governor.

Experts say it’s now more important than ever for New York—and the nation—to really examine and address the gaps in its healthcare planning. 

“How do we fund hospitals at the necessary level to keep adequate surge capacity available?” says Uttley.

“What did it cost us as a state to construct in a big hurry all these emergency hospitals? We’re not going to be able to maintain those forever. The Javits Center will at some point go back to being a convention center.”