The Save Our Safety Net Petition sign now

Do you think our state legislature should reject the recommendations of the Berger Commission?

If you do, sign this petition and pass it along to all you know-- and call our state legislature and governor toll-free at (877) 255-9417.

A little context: fifty-eight years ago on December 10th 1948, the United Nations General Assembly adopted the Universal Declaration of Human Rights (UDHR) that our county's own Eleanor Roosevelt drafted. Article 25 of the UDHR states: "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control."

We should be doing more, not less, for health care here in New York.

Get the facts on the Berger Commission at and (see archives first week of December); direct action site here:

Fact: The New York State Commission on Healthcare Facilities in the 21st Century, otherwise known as the Berger Commission, met behind closed doors for almost a year and a half, then delivered a 231-page report full of recommendations-- giving the state legislature less than three weeks to review and consider them; this is utterly ridiculous.

Fact: If the state legislature does nothing, the Berger Commission's recommendations automatically become law...(they call this democracy?).

Fact: Dr. Alan Sager of the Health Reform Project at Boston University analyzed 1200 hospital closings across the country since 1936 and found that hospital closings constantly failed to generate cost savings and contributed to health care costs, and that such closings, in fact (as common sense would dictate) had a strong negative impact on access to care (see and for more on this; also see Sager's testimony online-- "Closing Hospitals Won't Save Money But Will Harm Access to Health Care").

Fact: The Poughkeepsie Journal itself reported on November 30th that according to Assemblyman Richard Brodsky, Dobbs Ferry Community Hospital (one of the sixteen hospitals targeted for closure by the Berger Commission report across NY) makes enough of a profit to keep the larger hospital that owns it, St. John's Riverside in Yonkers, in the black.

Fact: The Berger Commission targets small community hospitals for closure across the state-- two hospitals in Buffalo, one in Dobbs Ferry, one in Schenectady, and five in New York City-- along with another seven hospitals across NY.

Fact: The Berger Commission report recommends the elimination of over 800 nursing home beds in New York City-- when the same Commission tells us over 3500 nursing home beds are needed in NYC.

Fact: After the 1979 round of hospital closures and bed reductions, the HIV/AIDS and crack epidemics resulted in shortages of hospital beds and overcrowded emergency rooms. The New York Times reported people waiting for two days in the emergency room for a hospital bed.

Fact: Crucial reproductive services could be lost if Kingston and Benedictine hospitals are forced to merge (see

Real health care reform means addressing the profit-driven pharmaceutical and insurance/HMO industries-- saving money for small business, big business and all of us with an efficient single-payer system of health care that covers all of us, as Assemblyman Kevin Cahill, Lt.-Gov.-elect David Paterson, and over 90 other members of our state legislature have called for-- "New York Health"; see

Joel Tyner
County Legislator
[email protected]
(845) 876-2488
Host of "Real Majority Project"
Sundays 9-11 pm WVKR 91.3 FM

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From the December 10th New York Times...

"Beds of State"
by Linda V. Green
(Columbia Business School Professor)

The report issued last month by the Commission on Health Care Facilities for the 21st Century proposes widespread changes in New York State's hospital industry, including the effective elimination of nearly 20 hospitals and the downsizing of dozens more.

The recommendations, which in many cases are aimed at specific numbers and types of beds, are based on the premise that the state has too many hospitals and too many beds. The report repeatedly cites this "excess capacity" as wasteful, inefficient and costly, and asserts that eliminating it will result in better health care.

Unfortunately, the commission's reasoning is wrong.

The primary evidence used to support the report's finding of excess beds is hospital occupancy rates. On average, more than 77 percent of staffed beds statewide are occupied. To support its conclusion, the report compares this number to an "ideal rate" of 85 percent. But the 85 percent target level, which was developed by the federal government in the 1970's, was based on an overly simplistic analysis and has shown to be potentially dangerous.

For example, in 1987 and 1988 New York City had a severe shortage of inpatient hospital beds. Ambulances were routinely turned away from full hospitals and there were times nearly all hospitals were on "diversion." Urgently sick patients waited days for available beds.

The crisis followed two years in which capacity had declined 9 percent as a result of new state regulations that sought to reduce the number of "excess" beds by providing more favorable Medicaid reimbursement to hospitals with occupancy levels of at least 85 percent. According to advocates of this bed reduction, an 85 percent level would allow sufficient capacity for periods when occupancy peaks.

This analysis failed, however, to account for the impact of high occupancy levels on emergency room crowding and ambulance diversions. In fact, the primary reason for emergency room delays is a lack of inpatient beds. When beds are not available, patients requiring hospitalization cannot be moved out of the emergency room. As a result, the emergency room overflows and ambulances must be diverted to other hospitals.

In a 1999-2000 study of ambulance diversions and death from heart attacks in New York City, my colleagues and I found that, on average, three hospitals a day diverted ambulances to other hospitals for periods of approximately five hours each. On days when more than 20 percent of a borough's emergency room hours were spent on diversion, fatalities from heart attacks increased 47 percent boroughwide.

Hospitals are far more crowded and ambulance diversions longer and more numerous in the winter, during the week and in the midday and evening hours. For example, the commission's report for New York City shows that the peak midday average hospital occupancy rates during the flu season vary from a low of 93 percent in the Bronx to a high of 106 percent in Staten Island.

Yet the authors nevertheless conclude that bed capacity in the city is "about right." Their judgment seems patently ridiculous in light of long emergency room delays at many hospitals, even during nonpeak months. It also flies in the face of recent assessments by government officials and medical professionals that hospitals need enough beds to deal with potential surges in demand resulting from avian flu, SARS or even terrorist attacks.

There is cause for concern about beds in other regions of the state as well. Long Island has an average occupancy level of 84 percent, the highest in the state, with three hospitals averaging over 99 percent. In other words, on a typical weekday afternoon these hospitals may be totally occupied, leading to excessive emergency room delays.

Even when some beds are empty, delays can be extremely long and ambulances diverted because patients need particular types of beds. Unfortunately, the beds most urgently needed, intensive care beds, are often the least available. In a study I conducted in 2000 on New York State hospitals, at least 75 percent did not have enough intensive care beds. Based on more recent data, there are four such hospitals in Westchester County alone.

As the commission's report observes, there are substantial variations in hospital use among regions and among individual hospitals within the state. There are surely instances in which hospital closings may be appropriate. Moreover, the report includes many valuable suggestions for changing hospital management and financing.

But the ever-increasing number of hospital patients admitted from emergency rooms, as well as new threats from emerging diseases and terrorism, require a more nuanced analysis of how many beds we really need. If we follow the recommendations proposed by the commission, we may create a hospital crisis even worse than the last one.

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Also from the December 10th New York Times...

"A Little Hospital in the Fight of Its Life"
by Joseph Berger

The experience is familiar. You walk into the emergency room of a big-city hospital-- the kind where patients on gurneys moan in the aisles waiting for flimsily curtained cubicles to become available. You tell the receptionist about your agonies or, worse, those of your child or aged parent, and the first question you're stonily asked is "What's your insurance?"

By all accounts, that has not usually been the case at Community Hospital here, one of 20 hospitals the state's Commission on Health Care Facilities in the 21st Century wants to eliminate. Community's reputation for friendly care stems not from its assembled a humane staff of 150-- though its champions say it has done that-- but more from its size. With 32 beds, it has been in this appealingly fraying Hudson River town for 113 years, and so is as homespun as a village bakery.

Its emergency room has only 15 chairs, and waits are normally under an hour. There's usually only one doctor, and if it's Brian White, patients might recognize him as a rangy local boy of 50 who started as an ambulance medic and worked his way up.

Marie Partenza, who lives practically around the corner, recalled how in the middle of the night four years ago, her husband, John, 77, a retired locker room attendant, suffered cardiac arrest in the emergency room and the staff resuscitated him. They ended up sending him to more sophisticated hospitals to get his pacemaker and defibrillator, but it was Community that saved him.

"If they hadn't done that, John wouldn't be here," she said. "They're not rushed. It's like a small grocery store compared to a supermarket."

What galls supporters is that the commission did not even bother to visit the hospital. Its analysis was done by crunching numbers-- giving hospitals pluses or minuses for factors like low-income clientele and proximity of other hospitals. Its methodology is emblematic of the icy distance that increasingly characterizes modern medical care. No one expected the commissioners to visit all of the state's 235 hospitals, but once they determined which ones were in jeopardy, a visit might have been informative, not to mention polite.

They might have learned that while the nearest emergency room, St. John's Riverside, is only three miles south, in Yonkers, it can take half an hour to navigate those miles during the rush. People who live in the river towns of Irvington, Dobbs Ferry and Hastings have come to depend on Community's being close, like a fire extinguisher.

"Very often, time is of the essence," Dr. White said. "I've seen people walk through that door and in two minutes they were in cardiac arrest. Had they paused to tie their shoe, they may not have made it."

Ronald J. Corti, the chief executive of Community, pointed out that it earned a profit last year of $750,000, which goes to St. John's, its corporate parent, and thus helps provide services for the poor of Yonkers. Fewer than 5 percent of Community's patients are covered by Medicaid, so it barely costs the state anything.

Nevertheless, David Sandman, the commission's executive director, called Community "a prime example of excess capacity," where doctors are pressured to admit patients just to bring in revenue. But the commissioners seem to have given no credit to the human factor and what the hospital social worker, Nancy DiFrancesco, called the personal touch-- something people hunger for in these days of shopping-mall anonymity.

Community makes a profit through new programs like the county's largest breast surgery center, which treats 300 cancer cases a year. There is no price tag for the tenderness women yearn for when the organ at risk is something as tender as a breast. That's why Mike and Mary Jane Sipala of Dix Hills, N.Y., were at Community the other day. Their daughter had just undergone a double mastectomy, an operation she chose to have at Community, rather than at a hospital closer to home on Long Island, to avoid suffering the emotional bruises of a factorylike institution.

"There's nothing in my mind as a mother that says there's anything good about this, but there's a sense of comfort we've found in these doctors," Mrs. Sipala said...

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More from First Week of December Action Alert...

The 'Medical Arms' Race

Mr. Berger continually referred to the medical arms race, where hospitals provide the same specialized, expensive services because they are reimbursed at a higher level. The very hospitals that participate in this race are not touched by the Commission's recommendations. Highly specialized services should be regionalized into fewer hospitals that are good at providing those services to everyone. But when the report addresses regionalization, it is more likely talking about pediatrics and maternity services - services that are more commonly used and are better provided nearer to home. In one example, the Commission recommends closing the pediatric beds at New York Downtown Hospital and regionalizing the service at New York Presbyterian at the opposite end of Manhattan island. To do this right, the hospital would have to guarantee a helicopter ride for everyone, particularly for children and youngsters in need of emergency treatment.

Obscuring the Facts of the Recommendations

In the press conference held by the Hospital Closing Commission to announce the recommendations, Mr. Berger said that nine hospitals would be closed statewide - but in reality it is 16 hospitals. He said five hospitals would close in New York City, but in reality it is seven hospitals that would close. It is also not clear from the Commission's report that its final recommendations differed in varying degrees from the proposals of the Regional Advisory Committees. In the city, the RAC did not recommend the closing of Victory Memorial, Westchester Square, or St. Vincent's Midtown - but the Commission did recommend they be closed. In the case of Parkway Hospital, the RAC recommended waiting two years while the owners reconfigure services to see if that works, but the Commission recommended closing.

Playing Games & Politics With the Recommendations

Despite claims of an objective and non-partisan commission, quite the opposite is true. As one reporter said, the Commission chose the 'lowest hanging fruit' or the hospitals with the least political clout. Several hospitals with similar characteristics to hospitals proposed for closing, were basically untouched in the recommendations. In several places, to make a hospital's situation look worse, the Commission report only included the occupancy rate based on certified or licensed beds, while the occupancy rate based on available or staffed beds was reported for most other hospitals. The hospitals for which the only statistic reported was occupancy rate for licensed beds, appeared more seriously underutilized and therefore, less needed. There were no recommendations for closing hospitals in the Long Island region, perhaps due to the large number of Republican State Senators representing that area.

Economic Impact

Closing hospitals and nursing homes create an economic hardship on patients, communities, and the workers who lose their source of employment. As noted in Alan Sager's report, Closing Hospitals in NYS Won't Save Money but will Harm Access to Health Care, the closings of smaller community hospitals will not save money, and in fact will raise the overall cost of health care because the resulting cost of care in the remaining institutions, large academic medical centers and hospitals will be able to raise their prices dues to less competition.

Some studies have shown that thirty percent of patients displaced by hospital closings do not reappear at surviving institutions for long periods, if ever. When health care is delayed or denied due to lack of access, the overall cost of treatment increases as conditions worsen.

Health care is recognized as an economic engine in every community of New York State. The impact of these closings will be devastating on jobs and ancillary businesses in the communities that are affected. Even the most rudimentary back of the envelope calculation shows us how dire this impact may be. Where 100 beds are reduced, there is an associated number of jobs 3 to 4.5, depending on the size and staffing of te hospital or facility. There is also a ripple effect of the associated neighborhood vendors, commercial businesses, and services in the areas of the closed hospitals that will be long lasting as there will be a long lead time before new markets are developed for those services.

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"Pataki, Spitzer on Board with Hospital Closings: Plan Involves Facility Merger in Kingston"
by Jay Gallagher [Poughkeepsie Journal 11/30/06]

[excerpts here below]

The plan would eliminate about 4,200 hospital beds, slash about 3,000 nursing-home beds and save about $800 million a year.

The plan recommends administrative consolidation for Kingston and Benedictine hospitals in Kingston.

Both the Assembly and Senate have been noncommittal and have scheduled hearings on the matter in the next two weeks. The plan has already sparked strong opposition in some of the communities where the closings are to take place.

The commission report was discussed by Spitzer and Democratic members of the Assembly at a closed-door meeting in Manhattan Wednesday.

But "there was no attempt to come to an agreement," said Assemblyman Richard Brodsky, D-Greenburgh, who said most lawmakers are still trying to digest the report.

Five of the nine hospitals that would close are in New York City. Two are in Buffalo, one in Dobbs Ferry and another in Schenectady. The proposed mergers and consolidations are spread around the state.

"The Berger Commission's plan represents medicine that is worse than the original illness," said Assembly Majority Leader Paul Tokasz, D-Buffalo. A hospital in Tokasz's district would close under the commission plan "I will exert every effort to save St. Joseph Hospital and will urge my colleagues in the Assembly to reject the report," he said

Brodsky, who also has a hospital in his district marked for closure, said, "I don't think anyone knows quite enough yet" to decide whether to try to block the plan. He pointed out the hospital in his district slated to close, the Dobbs Ferry Community Hospital, makes enough of a profit to keep the larger hospital that owns it, St. John's Riverside in Yonkers, in the black. That hospital is a vital part of health care in Yonkers, he said.

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From ...

[note-- see and for more on Dr. Alan Sager!]

On Eve of Final Hospital Closing Commission Meeting, Leading National Expert on Hospital Closings Comes to New York to Weigh in on Likely Impact of Berger Commission

New Report Documents Repeated Failure of Previous Hospital Closings in New York - and Across the United States - to Control Health Care Costs. Report Raises Serious Concerns About Impact of Hospital Closings on Access to Care in Underserved Areas and Communities of Color.

November 19, 2006, New York, NY - One day before the New York State Hospital Closing Commission held its final meeting before issuing its long-awaited "hit list" of hospitals and nursing homes slated for closure, one of the nation's leading experts on hospital closings came to New York to release a summary report on his latest research on the economic and human impact of hospital closings in previous years.

Alan Sager's latest work follows up on his extensive research on hospital closings in 52 U.S. cities and further demonstrates that hospital closings have consistently failed to generate cost savings and have actually contributed to increased health care costs. Even more disturbing is the evidence that hospital closings have had a strong negative impact on access to care and have disproportionately affected poor communities of color.

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More from

Critique of NYS Berger Commission/ACTION ALERT

(Posted on Thu, 7 Dec 2006 23:32:16 -0500)

1. Critique of the Recommendations of the NYS Governor's Commission on Health Care Facilities in the 21st Century (Berger Commission), by the Save Our Safety Net Campaign (SOS-C)

2. ACTION ALERT: Save community and public hospitals in New York State

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1. Critique of the Recommendations of the NYS Governor's Commission on Health Care Facilities in the 21st Century (Berger Commission), by the Save Our Safety Net Campaign (SOS-C)

The Hospital Closing Commission work began in July of 2005, and culminated in the release of its report on November 28, 2006. A stated major goal of this exercise was to decrease Medicaid spending by downsizing and closing hospitals and nursing homes. According to the Greater New York Hospital Association (testimony December 1, 2006 at a State Senate hearing) the Governor's proposed Medicaid budget cuts in 2005 were devastating and in their place major reforms were negotiated. One such reform was to set up this Commission to try to realize savings through the closure of hospitals. However, the theory that closing hospitals saves money has been seriously questioned by noted authorities, including Dr. Alan Sager, Professor at Boston University School of Public Health (Closing Hospitals Won't Save Money But Will Harm Access to Health Care, November 17, 2006, for the Committee of Interns & Residents). In Senate testimony on December 1, the Health Care Association of New York State raised concerns that the costs of closings and mergers might be so high that the state won't save as much as they claim.

An important word: We believe that this plan could have been even worse if not for the work of the Save Our Safety Net - Campaign (SOS-C), a coalition of consumer and community organizations and unions. S0S-C - co-coordinated by CPHS and the Committee of Interns & Residents - through steadfast organizing, outreach, information, model legislative drafting, and more, influenced the outcome of this report. The SOS-C was formed around Principles that address the need for services in low-income, medically underserved, immigrant and communities of color. Maps of locations of hospital closings in the city over the past 40 years show a consistent pattern of closings in underserved communities. SOS-C adopted the motto that the Commission 'Should do no more harm!' The way to address excess capacity is to first address community needs and then determine how and where there are too many beds. SOS-C also advocated strongly for a review of access to health care services for the uninsured, the disabled and the elderly - along with an understanding of the current racial and ethnic disparities in access to care and outcomes of care.

Haven't We Been Here Before? Yes, we certainly have in New York City. In 1979, then Mayor Ed Koch appointed a Task Force to identify hospitals to be closed. The Task Force proposed the closing of 14 hospitals in the city, and bed reductions in a fifteenth hospital. A June, 1979 policy analysis of the Task Force report was prepared by the Coalition for A Rational Health Policy in New York City. Many of the Coalition's arguments are still relevant today regarding the methodology and the kinds of hospitals recommended for closing. In essence, the Mayor's Task Force recommended closing small community hospitals that were often located in, or serving medically underserved communities. The Coalition found that implementing the recommendations would result in serious potential civil rights violations. In addition, the report was prepared in secret, behind closed doors, much in the way that the Hospital Closing Commission operated. Some of the Task Force recommendations were never implemented, but eleven of the hospitals were closed, leaving medically underserved communities more underserved.

We need to learn lessons from history, but apparently have not. Then as now, there are empty proposals for changes in reimbursement, the expansion of insurance coverage, and funding for expansion of primary care. Such unfunded proposals result in communities and the work force losing out twice, with the removal of services from communities that cannot afford to lose them, and the false hope that resources will be made available to make up the difference. History also shows us that meaningful planning needs to consider all angles and possibilities. After the 1979 round of hospital closures and bed reductions, the HIV/AIDS and crack epidemics resulted in shortages of hospital beds and overcrowded emergency rooms. The New York Times reported people waiting for two days in the emergency room for a hospital bed.

Where is the Money Coming From? There are two pots of money being made available to fund some of the recommendations of the Hospital Closing Commission: HEAL which is state funds; and FSHRP which is federal Medicaid dollars. The FSHRP package is the most troubling. The federal dollars come with a heavy price attached. FSHRP is $300 million a year for five years. But in negotiating these dollars, the current Governor made some disastrous commitments. Medicaid and Family Health Plus beneficiaries are seeing an increase in their co-pays; SSI beneficiaries and Seriously and Persistently Mentally Ill (SPMI) adults, as well as people in fourteen upstate counties will be herded into Medicaid managed care. The agreement also stipulates that that State forfeit FSHRP funds if the hospital closing recommendations are not adopted and implemented in their entirety by a date certain. Yet state representatives told the federal agency (CMS) that they did not expect savings in the short-term from the hospital and nursing home closings. Also, federal money cannot be used directly to fund a major share of the state proposal - $650 million over the five years to pay off capital debt when facilities are closed. Instead, the federal government will give the State money to match certain programs, the money will lose its 'federal identity' (in other words, be laundered) and then the state can use the funds to pay capital debt. Most importantly, there is no guaranteed funding in FSHRP to provide alternative health care services such as primary/ambulatory care when hospitals are closed. The State can use the money for this purpose, but is not required to fund primary care.

Final warnings: in order to receive the FSHRP funding the state had to agree to make additional major cuts in Medicaid. Thus to get $1.5 billion over five years, the state agreed to cut $3 billion in Medicaid spending. Much of the FSHRP funding will be used to transfer wealth as bondholders and banks will benefit through the funding mechanism to pay back on capital debt. Because of the restrictive clauses within the FSHRP waiver, the document could very well dictate Medicaid policy in the state for the next five years.

What is Wrong with the Hospital Closing Commission's Recommendations?

First, we need to look at what was wrong with the process. The Commission was set up on three levels: the statewide commission with 18 members, six regions with up to six members each, and six Regional Advisory Committees (RAC's) with up to twelve members each. These bodies were unrepresentative of the population of the state. The process was anything but public and transparent. Aside from hearings held by the Regional Advisory Committees, and brief public sessions held by the Commission itself, the rest of the meetings were behind closed doors in Executive Sessions. The Chair of the Commission allowed a person to attend the closed sessions who had resigned from the New York City Regional Commission because of a conflict of interest. Even the final process is undemocratic - this plan could become law without the legislature ever voting on it. If the legislature does not act during December - a time when the legislature is not in session, the plan becomes law on Governor Pataki's last day in office. The RAC's were the only body within the Commission that heard directly from the public, yet their recommendations are clearly advisory, and as we have seen can be overruled by the Commission itself.

The Commission also relies on 'reforms' that have been tried but do not seem to work, such as achieving economies of scale by developing large networks of hospitals and nursing homes and consolidating institutions. In New York, after much fanfare and public expense, the merger of Mt.Sinai and NYU did not work and has been, or is being dissolved. In California, the merger of medical centers at Stanford and UC-San Francisco, which was projected to save $256 million, actually produced an entity that lost $86 million before it unlinked. The price tag for the merger was $79 million. We should think twice before emulating this policy, yet the Commission proposed many mergers.

The three routes to the 'Hit List' the closing list were primarily hidden from public view. The first is through RAC recommendations. This process was problematic because though the RAC's held public hearings, they used closed door sessions to make recommendations that were not revealed until the final report was released. The second way on the list was even more secretive: hospitals, nursing homes, or networks were allowed to meet with Commission or State Health Department staff to propose deals. The final way was what could be termed clean violence. The Commission adopted six criteria, with twenty- seven metrics. Data for all of these categories were fed into a computer and rated. A list for closing/restructuring was prepared and many of these proposals were included in the final closing list.

The major problems with the Hospital Closing Commission's recommendations and proposed closings/restructurings include:

*targeting small community hospitals for closing while leaving more costly teaching hospitals untouched;

*proposing closures and restructuring in low-income medically underserved communities, with potential racial and ethnic impact;

*failing to consider patient needs and preferences;

*failing to consider the needs of the elderly;

*failing to consider the needs of people with disabilities of all ages;

*obscuring the facts of the proposals, for example, seven, not five, hospitals are proposed for closing in New York City and sixteen, not nine, statewide;

*not addressing the 'medical arms' race repeatedly referred to by Commission Chairman Berger;

*playing games and politics with some of the recommendations;

*proposing privatizing some public institutions with no prior warning;

*failing to consider the economic impact on communities and on workers who lose their jobs; and,

*making recommendations for reforms in the system with no teeth or funding behind them.

Targeting Small Community Hospitals

If this exercise was truly about reducing Medicaid spending the obvious choice for closings would have been large costly hospitals, many of whom duplicate specialty services and drive up the costs. Not one large academic medical center is touched by these recommendations. Instead small community hospitals will be closed and patients will be left to go to the large hospitals - if they can get in the door. Two clear beneficiaries of recommendations to close hospitals are Continuum's Beth Israel Medical Center (with Cabrini closing) and Roosevelt Hospital (with St. Vincent's Midtown closing). It is astounding that with the thousands of hospital beds on the East Side of Manhattan from 14th Street to 96th Street, the only hospital proposed for closing is Cabrini which has 338 beds currently staffed and in service. It is also astonishing that Westchester Square Medical Center was proposed for closing - the least expensive hospital in the Bronx.

Low-Income Medically Underserved Communities With a Racial and Ethnic Impact.

Instead of choosing hospitals to close on the East Side of Manhattan - among the wealthiest zip codes in the country - hospitals are slated to close in primarily underserved communities. Recent reports by the Community Health Care Association of New York State and PCDC and the Health and Hospitals Corporation and PCDC (Primary Care Development Corporation), identify by county around the state and by zip code in the city, the communities with primary care shortages. Some of the hospitals targeted for closing are located in, or serve, those underserved communities. Four of the hospitals in New York City proposed for closing serve a disproportionate percent of people of color as inpatients: Cabrini at 53\%; St. Vincent's Midtown at 65\%; Westchester Square at 57\%; and Parkway at 51\%.

But there are also consolidation recommendations that could be harmful to medically underserved communities. An example is the recommendation that North General Hospital in East Harlem be further consolidated with Mt. Sinai Hospital. These two facilities have different missions and treat different populations - does that get lost in the consolidation. North General, an African American operated hospital, had a large number of African American physicians in leadership positions. The Commission also recommends the consolidation and privatization of four state public hospitals affiliated with state medical schools. The recommendation includes a reduction in the local county funding of these facilities. What happens to the public mission to provide care for everyone regardless of the ability to pay? Does this get lost in the privatizing of the state facility? The same questions could be asked of the recommendation to privatize county nursing homes. What happens to the mission and commitment?

Patient Needs and Preferences Were Not Considered

Many people have expressed a preference for a small community hospital, where they are known and treated in a friendly way. Yet small community hospitals are being targeted for closing. Some hospitals address a special need that cannot be transferred. In Schenectady County, Bellevue Hospital is the only specialty women's hospital in the state. More than 2,000 births take place there, and it provides care for high-risk cases. (Lois Uttley, Merger Watch). Patients come to Bellevue come to from a wider area. The hospital also has a mobile mammography unit that travels way beyond county lines. The Commission recommended a closure of this hospital with the service being transferred to a merged hospital of St. Clare's and Ellis Hospitals. Apparently, the Commission thinks some of the unique services provided by Bellevue can be picked up by other area hospitals.

In Brooklyn, Victory Memorial Hospital provides culturally competent maternity care for Arabic- speaking Muslim women, and this service would be lost with the hospitals closing, as proposed.

The Needs of the Elderly Were Not Considered

In reporting important statistics for hospitals proposed for closing, the Commission ignored the number and percentage of Medicare patients. Yet, Medicare discharges was a metric listed under the Vulnerable Population criteria, one of the six to be considered.

No one disagrees with the concept of de- institutionalizing long term care where possible. However, it is not always possible to care for a loved one in the community, as we know from Friends and Relatives of the Institutionalized Aged (FRIA). It is premature to adopt the Commission's proposal to eliminate 3,000 nursing home beds before substitute community services are planned and, most especially, a source of funding committed. There is agreement with the Commission's recognition that the State needs a variety of non- institutional services. However, without a comprehensive plan of non-institutional services and corresponding funding supports, the proposed elimination of beds will yield only fewer service options for communities. The Commission's report on nursing homes bed need is contradictory and inconsistent in several areas. In addition, the basis for closing for closing some facilities and keeping others is unclear, as evidenced by the decision to close Split Rock Nursing Home in the Bronx, a community identified as a high need, 97\% occupancy nursing home county. The reasoning for this decision is inexplicable.

Although the Commission's official report proposed closing 3,000 nursing home beds, it established a pernicious system for the future by permitting 'voluntary' rightsizing, without public transparency or comment. As a result of such voluntary efforts to date, over 800 nursing home beds will be eliminated in New York City, an area identified by the Commission as in need of 3,666 beds. There is no justification for inconsistently permitting the elimination of beds in the face of such a finding by the Commission. Where then will the needed nursing home beds come from? This is particularly of concern since New York City is bracing for a staggering increase in its older old population, the very group that will need long term care services.

The Needs of People with Disabilities of All Ages are Not Met

The elderly are not the only population overlooked in this report. People with disabilities of all ages have the same need for community-based services, plus affordable housing, as elderly people do, before nursing home beds are closed. They also tend to have longer average lengths of stay than nondisabled patients, because they may need more community- based services for their discharge plans. In addition, people with disabilities often need physical accommodations in order to use health care facilities. More hospital outpatient clinics have accessible services than individual physicians' offices. There is no legal obligation for individual medical offices to make extensive changes to become accessible, if the changes represent a large part of their budget. Hospitals and nursing homes, as large institutions, are mandated to have accessible examining tables and X-ray machines, and to have ASL interpreters available to deaf patients, for example. Patients who have mental illness, mental retardation, and/or substance abuse problems also get physically sick and injured. When they do, they are (on average) more expensive to treat than other patients, and for that reason they have traditionally been unwelcome at many hospitals. The hospitals that accept people with emotional and cognitive disabilities pay a financial price for doing so. If you close such a hospital, there is no guarantee that a surviving hospital that has no interest in treating this population is going to step up to the plate and change its attitudes and policies. Many people with visible and invisible disabilities have trouble traveling to medical appointments. When hospitals or their services are merged or closed, as the Berger Commission suggests, usually some patients have to travel further as a result. This is even more of a burden on sick people with disabilities than on patients without disabilities.
Proposing Privatizing Public Institutions

That the Commission would potentially recommend to privatize public institutions was never publicly discussed. For many other issues, there were presentations in the public sessions of the Commission meetings, versions of which were also available, on the Commission's web site. It is not clear where the privatizing recommendations came from, however we do know that Governor Pataki continually proposed legislation that would privatize the state hospitals affiliated with the states medical schools - Stony Brook in Suffolk county, Downstate in Brooklyn, and Syracuse. The legislation was never enacted, so this recommendation could be viewed as another way to circumvent the legislative process. The Commission recommended merging SUNY Upstate and Crouse Hospital into one hospital into a new entity that would not be public. Concerns were raised by The New York State AFL-CIO, as Crouse Hospital recently emerged from bankruptcy while SUNY Medical Center has an average occupancy rate of 80\% and is financially sound. For a commission claiming to be concerned about access to care for the uninsured and underinsured, privatization of a public institution and the loss of the legal mission to provide care regardless of the ability to pay, could be seen as a contradiction. A fourth county hospital, the Erie County Medical Center is proposed for consolidation with a non-profit hospital and a dismantling of the public benefit corporation that runs the public hospital. The Commission also recommended review of the viability of the 44-county run nursing homes...

The Empty Policy Recommendations

Separate and apart from the closing/consolidation/restructuring recommendations, the Commission proposed a series of policy recommendations. However, these recommendations are non-binding, separate from the rest of the report, and have no funding attached. Yet, several of the policies are too central to a successful system to be deemed afterthoughts. In fact, they should have been in place prior to any review and recommendations for closing. The lack of designated funding for them, however, decreases the likelihood that any of them will be realized.

Many of the policy recommendations are not new, they have been proposed in the past many times but never fully funded and thus never fully implemented. Funding is never available to fully implement them. The most important of the recommendations - to expand primary care capacity, review reimbursement policy, and enact universal health coverage - could initially be costly, but ultimately save money and certainly lead to an improved health care delivery system. But since we do not believe that the closing recommendations will save money and actually might be more costly to the system as patients are moved into more costly hospitals, there will not even be funds available to reinvest. HEAL and FSHRP dollars are not specifically targeted for the expansion of services.


It is sad that an undertaking this sizeable and costly, involving so many people, was executed so poorly. The basic premise for the Commission and the focus given to it can be likened to 'putting the cart before the horse.' Planning from a community-based perspective is essential when such an important undertaking is initiated. Clearly that was not asked of, and not done by, the Hospital Closing Commission. It is another very important missed opportunity - although not the first missed opportunity. As was noted in this critique, there was a similar undertaking in New York City in 1979, with many of the same mistakes.

Mr. Berger, the Chair of the Commission, understood the difference in 1973 when he wrote: 'It is at the public, consumer level that we find the essential insight into individual health care preferences, requirements and needs. And it is here, also, that we find a focus on the human goals and purposes of the health care system rather than on the needs of facilities and institutions.' (Health Care Needs and the New York City Health and Hospitals Corporation. State Study Commission for New York City, Stephen Berger, Executive Director, April 1973. Page 176.) In recent testimony, the Healthcare Association of New York State wrote: 'Should the report continue to move forward toward final adoption, it is essential that communities impacted by closure or conversion recommendations continue to be afforded genuine opportunities to state their case to their Legislators, the Commissioner of Health and even the courts, before and after any potential implementation activities commence. To do otherwise would diminish the responsibility of the Legislature and the next Commission to preserve and protect the public health.' We agree!

The Commission's recommendations are quite complex. We are given a very short time to analyze what it took them 18 months to prepare. This critique is partial as there is much more that we need to understand before we completing an analysis. We believe that it is imperative that the Legislature endorse a delay in approval of these recommendations. Do not be lured or fooled by those who are eager to have in hand the federal dollars through FSHRP. It is not a federal gift, but rather a burden that should be re- negotiated.

To recap some of our major points:

* A stated major goal of this exercise was to decrease Medicaid spending by downsizing and closing hospitals and nursing homes. Yet noted authorities have shown that closing hospitals, particularly small community hospitals, does not save money.

* Many hospitals have been closed over a period of years, particularly in New York City, leaving medically underserved communities more underserved.

* Proposals are made - as in this instance - to expand primary care and fix Medicaid reimbursement but the hospitals close and the rest does not happen. Proposals are made but the funding does not follow.

* 'Reforms' continue to be proposed that have not worked in the past, e.g. achieving economies of scale by consolidating hospitals and developing networks.

* Communities that are losing under these recommendations are primarily underserved with primary care shortages. These recommendations continue the pattern of closing hospitals in low-income, medically underserved, immigrant and communities of color.

* The needs of major communities and populations were ignored in the development of the recommendations for closing/rightsizing.

* The Hospital Closing Commission process did not work: the composition was not at all reflective of the population of the state; much of the work was done in secret closed door meetings, although at least one person with an acknowledged conflict was allowed to be present.

* The Regional Advisory Committees were the only body that heard from the public yet there were recommendations were treated as advisory and overruled at times.

* Community hospitals are targeted although they are less costly and often more supported by their communities - while large academic medical centers are left untouched, or actually benefit from their poor cousins closing.

The New York City Regional Advisory Committee made several important recommendations that we believe should be embraced. The RAC wrote: 'We are also calling for a major new model of a community hospital. We do see the value of our community hospitals and they should not be abandoned or unnecessarily targeted for closure. Included in our thinking is the need for safety net and critical access hospitals.' (Page 11).

'Decisions about hospital closure or restructuring must take into account the existing unmet need as well as the capacity of other area primary care providers to take up the slack and ensure the City's public health. The existing primary care capacity must be preserved - hospital closures or restructurings should not undo the expansion of the primary care delivery system achieved over the last decade.' (Page 30).

'The RAC believes it is incumbent on the State to invest in preserving ambulatory care resources within each community where hospital-based resources are to be downsized. Such investments should be offset over time by reductions in Medicaid spending for more expensive (and often preventable) emergency and inpatient care. Therefore, HEAL NY funds should be considered to enhance primary care capacity in 'Stressed/Serious Shortage' areas served by hospitals for which the RAC has recommended closing.' (Page 31).


* The legislature must vote to delay any approval or forward movement on this plan while a dialogue is set up about the meaning and impact of the recommendations.

* The new Governor and the legislature must re-negotiate the Terms & Conditions of the FSHRP waiver to ensure appropriate spending in the health system and to undo the requirements that set the policy and parameters of the Medicaid program in the state for the next five years.

* The legislature and new Governor should immediately begin consideration of re-starting community-based health planning in New York State that involves all key stakeholders, including the community. Efforts should focus on rebuilding the safety net infrastructure needs to ensure the health of our communities.

* The legislature and new Governor should immediately determine the primary care health care needs of all designated shortage areas and work with those communities to develop plans, and funding, to address those shortages.

* The legislature and the new Governor should immediately begin a process of ensuring that community-based long term care services are in place prior to any reductions in nursing homes.

[This critique was written by Judy Wessler, Commission on the Public's Health System, with contributions from: Ngozi Moses, Brooklyn Perinatal Network; Lois Uttley, Merger Watch; Amy Paul, Friends and Relatives of the Institutionalized Aged, Linda Ostreicher, Center for the Independence of the Disabled in New York; Carol Pittman, New York State Nurses Association, and Moira Dolan, District Council 37, AFSCME. Julie Rowe, of the Opportunity Agenda provided editorial assistance.]

2.ACTION ALERT: Save community and public hospitals in New York State

As you all know, the state's Hospital Closings Commission s recommendations are out, and have already been approved by Governor Pataki. Time is running out for the Legislature to intervene if the recommendations are to be blocked. There is a possibility that the Legislature will be considering the recommendations next week during the special session on Dec. 13-14 and there has been some discussion about passing a resolution to allow for more time for review before a final determination is made.

To help build support for a time extension and ultimately an outright rejection of the recommendations - we are asking folks to do several important things right away:

1) Go to the SOS-C website at for updated information and action alerts.

2) Go directly to SOS-C s "Get Active" website at to send a fax and e-mail to the Pataki, Spitzer and the Legislature demanding additional time and public hearings. It takes less than a minute to do. Please pass this action alert along to everyone you know to try to generate as many faxes to the Legislature as possible before the special session starts next Wednesday.

3) Plan on attending one of the public hearings scheduled for next Monday, December 11th with the Assembly Health Committee on the Berger Commission s report. Further details are available at

4) Plan on joining unions, community groups, the SOS-C and others on the State Capitol Steps on Wednesday December 13 at Noon in Albany to call on the Legislature to stop the clock and shoot down recommendations that will deny many of New York State's Communities of essential health care services and important sources of jobs and economic security.

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