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Decades of Hospital Closures Led to This Disaster

The United States has been closing vitally needed hospitals for decades. Now, with a pandemic afoot and triage tents popping up in Central Park, we need to stop holding our hospital system hostage to the whims of the market.

People stand in line to be tested for the coronavirus at Elmhurst Hospital on April 1 in New York City. (Stephanie Keith / Getty Images)

By the middle of this week, nearly fifty thousand residents of New York City were confirmed to have the coronavirus. The actual number of coronavirus cases is of course much higher, as testing has been elusive. But the crisis is visible: over a thousand New Yorkers have died. The Federal Emergency Management Agency (FEMA) has sent the city eighty-five refrigerated trucks to be used as mobile morgues.

Hospitals are overwhelmed. The volume of calls for ambulance rides has nearly doubled. Nurses are comparing the situation to “battlefield triage.” In response, the city has transformed the Javits Convention Center and a tennis stadium into ad-hoc hospitals. A Navy hospital ship has docked at Pier 90 and opened its doors to overflow patients.

In Central Park, an evangelical Christian organization erected a field hospital with the blessing of the city and at the request of Mt Sinai. The organization, Samaritan’s Purse, is run by Franklin Graham, who’s known for his homophobic extremism. Mayor Bill de Blasio promised that the facility wouldn’t discriminate.

When you’ve reached the point where the mayor is assuring the public that the makeshift tent hospital in the city’s park won’t deny treatment to those condemned to an eternity in hell by the founder of the charity organization supplying the beds, something has gone terribly wrong.

Of course, desperate times call for desperate measures. But these times didn’t have to be so desperate to begin with. Typically if one hospital is overcrowded, a patient can be transferred to another hospital in the vicinity. But all of New York City’s hospitals are overcrowded. This wasn’t inevitable: New York City has lost nearly twenty hospitals, and tens of thousands of hospital beds, in the last two decades. In 2000, New York City had 73,931 hospital beds. Now it has 53,000, a reduction of nearly thirty percent.

The problem is not unique to New York City. Across the country, in rural and urban environments alike, hospitals are shuttering. A report by Morgan Stanley analysts “found that 8% of U.S. hospitals were at risk of closing and another 10% were considered weak.” At least thirty US hospitals entered bankruptcy last year alone.

The technical reasons for distress in the hospital system are complicated, but the fundamental cause of mass closures is that hospitals, even so-called nonprofit and public ones, are run as businesses. They are by and large expected to cover their own operating costs with payments extracted from patients and insurers or wheedled out of a patchwork of government programs in exchange for services — like a store covering its overhead with revenue from paying customers. This is a different model than, for example, our K-12 education system, which is funded through taxes and guarantees an education to all school-age children in every community. Hospitals instead have to play by the rules of the market, and if they can’t keep up, they’re shuttered, leaving entire communities without access.

Due to the pressures of the market, hospitals do the same kinds of things all businesses do to increase their profit margins. They hire as few workers as they can and pay them as little as they can reasonably get away with. They cut corners on space and equipment in order to lower overhead costs. They lobby for deregulation, which can be dangerous to patients and workers, to save money. They downsize, restructure, close locations, and merge with other businesses to simplify operations and maximize revenue streams. And sometimes they just fail.

Contrary to free-market dogma, the relationship between supply and demand is far from automatic. People everywhere need hospitals, but because hospitals are compelled to behave like businesses, fewer Americans have access to them with each passing decade. In 1971, the United States had roughly 1.5 million hospital beds. In 2017, that number had plummeted to about 931,000. In the same period, the US population grew from about 207 million to about 327 million. Fifty years ago there was one hospital bed per 138 Americans. Now there is one hospital bed per 351 Americans.

Hospital closures are especially common in rural areas. Since 2015, more than 150 rural hospitals have closed, forcing people to drive sometimes hundreds of miles — or even be airlifted by helicopter — to receive medical care. More than six hundred rural hospitals are currently categorized as vulnerable to closure. Many of the rural hospitals that remain are bare-bones and unprepared for an influx of sick patients. For example, in south-central Washington State, not too far from the early coronavirus hotspot of Seattle, the seventeen-bed Klickitat hospital says that a coronavirus surge would bankrupt it within a month.

As the chaos in New York City reveals, urban areas are struggling with hospital closures too, especially in poor neighborhoods. One particularly egregious case is the Hahnemann University Hospital in Philadelphia. Operational for 178 years, the hospital served primarily black and Latino working-class Philadelphians — which was a problem, because Medicaid and Medicare have lower reimbursement rates. Essentially punished for serving the poor, its financial troubles soon became overwhelming, and it was sold to an absentee private equity executive named Joel Freedman, who shuttered it despite community outrage and protests.

Now Philadelphia, like New York City, is facing a need for more beds due to the coronavirus pandemic. The city offered to buy the hospital from Freedman to reopen it, but Freedman turned his nose up at the city’s bid. He offered to rent it to them for an astronomical price instead, which the city called “unreasonable.” As Akela Lacy reports, Freedman is probably holding onto it in order to take advantage of a new stipulation in the coronavirus stimulus package just passed by Congress. It is speculated that the building will eventually be developed into luxury condos. Meanwhile, as a pandemic sweeps the nation, the working-class residents of Philadelphia are left in the lurch.

The decline of US hospitals is a protracted crisis that has been unfolding quietly for decades. Now we have a public health crisis on our doorstep, and we don’t have enough beds, space, equipment, staff, or hospitals to heal the sick. The crisis is suddenly acute and visible to all. After the tents have come down from Central Park, the question will remain: should hospitals be left to the whims of the market?

It would seem that if we view health care as a social right, something all people ought to reasonably expect from a functioning society, then the answer is a resounding no.