Coalition Power

Ashley Saupp and her husband, Sean Collins, were shocked when they learned in June 2023 of the planned closure of the nearby Burdett Birth Center where their three-month-old son, Ben, had been born. Burdett, located within Samaritan Hospital in Troy, New York, was targeted for closure by its parent health system, St. Peter’s Health Partners (SPHP), because of reported financial losses and staffing issues. System executives said pregnant people could travel to the system’s hub hospital in a neighboring county, or to other hospitals in the Capital District (which includes Troy and Albany).

“I was just outraged and astounded that a place where I had experienced such a joyful birth would be closed,” recalled Saupp, who works for the Albany Social Justice Center. In an interview, she explained that “It would leave all of Rensselaer County without any maternity service at all and pose a real hardship for so many pregnant people who depend on having this center here and can’t easily travel elsewhere. It would also eliminate the only midwife-led maternity service in our area, one that has the lowest C-section rate of any area hospital.”¹

More than half the patients Burdett serves rely on Medicaid, in a city with a poverty rate that is double the surrounding county and national levels (23.3 percent for Troy, compared to 11.2 percent for Rensselaer County and 11.5 percent for the nation). Troy also has higher percentages of residents who are Black and/or Latinx, speak languages other than English at home, or have disabilities—all groups that already tend to face barriers to accessing care; in addition, 22 percent of Troy residents don’t own private vehicles, leaving them to rely on bus service. While Burdett is a short bus ride from downtown Troy, the nearest alternative maternity service in Albany requires two bus rides and an hour’s travel, and the buses don’t run overnight. Burdett also serves residents of far-flung rural areas of Rensselaer County, as well as adjacent and largely rural Columbia and Washington Counties, neither of which has a maternity service. Public transportation from those areas to Albany is nonexistent, and most are not served by ride-sharing services.²

Word spread quickly in the community; local families, midwives, and doulas, as well as community organizations such as the local YWCA, joined with Saupp and Collins to start the Save Burdett Birth Center Coalition (SBBCC). They began to turn out hundreds of concerned neighbors and healthcare workers at rallies and community meetings, posted Save Burdett lawn signs throughout the county, and took over billboards along local roads.³ Collins, who is the president of the Troy Area Labor Council and a union organizer, mobilized support from unionized workers at other area hospital maternity wards to testify that their hospitals could not absorb the 800-plus births a year that would be displaced from Burdett. (Burdett and Samaritan workers are not unionized and were afraid to speak out.) The president of the Troy Firefighters Union testified that the city’s emergency medical service was already stretched thin and could not take on transporting people with pregnancy emergencies to other counties.⁴ A first-in-the-nation health equity impact assessment required under a new state law and a community-led version of the assessment both revealed serious consequences for medically underserved people that could not be easily mitigated.⁵

Eleven months later, SBBCC won its campaign. In April of 2024, SPHP executives withdrew their closure plan and accepted a $5 million state grant to help secure the future of the maternity service for at least five years.⁶ The coalition’s victory is one model of how healthcare workers and community residents are banding together with public officials to fight a tsunami of hospital downsizing and closures across the nation, and sometimes succeeding.

This article will examine the causes and consequences of recent hospital closings, downsizings, and sales across the nation and describe some of the community, union, and government actions being taken to protect patients and hospital staff. It will draw on the work of the SBBCC and efforts in other communities in highlighting important steps that can be taken to fight closures.

Where and Why Is This Happening?

The current wave of hospital downsizing and closing comes after more than two decades of consolidation in the health industry. Events of the last four years—disruptions caused by the COVID-19 pandemic, worsening staffing challenges, and serious deficits that some hospitals reported in 2022 and 2023—are prompting drastic actions. For example:

• In Lower Manhattan, residents who had depended on Beth Israel Medical Center for decades were horrified when its parent Mount Sinai Health System announced in late 2023 that Beth Israel would close after more than 100 years because of financial losses.⁷
• In central Brooklyn, the announcement in January of 2024 of the planned closure of financially troubled SUNY Downstate Medical Center* provoked outrage among the medically underserved residents who utilize the hospital and among the workers who care for them.⁸
• In eight states, patients and staff of 30 hospitals acquired by the for-profit health system Steward Health Care^† watched nervously in the spring of 2024 as the system filed for bankruptcy. It already had shut hospitals in Massachusetts and Texas.⁹ In June, a bankruptcy court judge allowed Steward to keep running the hospitals while seeking buyers for them, after Steward received an emergency loan.¹⁰
• In California, residents across large swaths of the state have limited access to obstetrics services, as 29 hospitals stopped delivering babies over the last three years and another four maternity wards were slated for closure in early 2024.¹¹

Particularly affected are rural hospitals—nearly 200 have been closed or converted to other uses since 2005¹²—and urban hospitals serving primarily low-income neighborhoods. Patients are scrambling to navigate changed and unfamiliar health delivery systems, while hospital staff are forced to accept new positions at facilities farther away from home, with less seniority and less desirable hours.

Meanwhile, systems that acquired many hospitals over the last two decades are offloading some to buyers, including private equity firms. And the promises that health system executives made as they acquired hundreds of community hospitals are now being broken. In short, we are witnessing the other shoe dropping.

Promises, Promises: Two Decades of Hospital Consolidation

Over the last 20-plus years, there have been more than 1,800 hospital mergers and acquisitions through which hundreds of community hospitals joined health systems that have been growing bigger and bigger.¹³ American Hospital Association data show that more than two-thirds of all hospitals in the nation are now part of a health system.¹⁴ That wave of consolidation also reduced the number of hospitals from 8,000 to just over 6,000.¹⁵ Overall, these trends have meant that the era of the independent community hospital is fast coming to an end.

Of the nation’s 10 largest health systems, the current leaders are the for-profit HCA Healthcare, which operates 184 hospitals, and the Veterans Health Administration, with 172 hospitals. Another four of the top 10 are for-profit systems: Lifepoint Health, with 124 hospitals; ScionHealth, with 94 hospitals; Community Health Systems, with 71 hospitals; and Tenet Healthcare, with 61 hospitals. Three systems are operated by Catholic-affiliated organizations: CommonSpirit Health and Ascension, each with 140 hospitals; and Trinity Health, with 101 hospitals. The remaining top-10 system, Advocate Health, has 61 hospitals and is a nonprofit combination of two smaller systems.¹⁶

In my more than 25 years of working with community coalitions across the nation and grappling with more than 135 proposed hospital mergers, I have observed executives of these systems make promises both to the hospitals they were acquiring and to the communities that depended on these local hospitals. Among the most frequent was the promise that the merger or acquisition would provide financial stability to ensure the hospital’s future. Joining a big system, local hospital boards were told, would help with acquisition of electronic medical systems and negotiations on complicated value-based contracts. System executives also pledged better access to needed capital to renovate aging facilities.

For example, when New York’s Mount Sinai Health System sought and received state approval in early 2020 to replace the aging Beth Israel Medical Center it had acquired in 2013 with a smaller but up-to-date facility nearby, executives proclaimed, “The new MSBI facility will be a full-service hospital consisting of inpatient beds, an adult and pediatric ED, radiology functions, operating rooms (OR) and IR suites, including neuro-IR and cardiac catheterization. The new hospital building will serve as a neighborhood hub of critical care, treating patients in need for lifesaving treatment when suffering strokes, heart attacks, aneurysms and trauma.”¹⁷ That facility was never built. Instead, Mount Sinai announced its planned closure of Beth Israel three years later, citing financial losses.¹⁸

What “Quality Improvements” Mean for Patients and the Community

Quality improvements have been another big selling point, with systems claiming their centers of excellence could improve quality at facilities throughout the system. But those better health outcomes often have failed to materialize, according to a recent summary of relevant research.¹⁹ Instead, consolidation-related closures and rerouting of care frequently impose additional barriers to access for already vulnerable patients. And reorganization of health system service delivery patterns have often meant that patients must travel farther from home to unfamiliar hospitals and physicians.

Many of Beth Israel’s patients are elderly and/or disabled and have low incomes. The largest proportion of patients come from two zip codes in the Lower East Side and East Village; in one, a quarter of the residents have incomes below the poverty level. More than half speak a language other than English at home, and 48 percent have only a high school education or less.²⁰

As the Mount Sinai Health System moved to rapidly close services at Beth Israel in late 2023 and early 2024, even without closure approval from the New York State Department of Health, patients with serious conditions were rerouted away from the hospital’s emergency department and sent to other hospitals in the system, located far uptown. One patient with a ruptured appendix who was experiencing sepsis had to wait an hour for an ambulance to another hospital.²¹  Another Lower Manhattan resident who sought care after suffering broken ribs and a collapsed lung in a fall at home was initially treated at the emergency department, but then was transferred to a Mount Sinai hospital nearly 100 blocks uptown because of inadequate staffing at Beth Israel, according to an affidavit filed in a lawsuit over the proposed hospital closing. At that transfer hospital, he received little treatment and was sent home with no follow-up nursing care ordered. He ended up at Bellevue Hospital, where staff found that blood had accumulated in his lungs and abdomen, and he eventually died, according to the affidavit filed by his wife. “It is my belief that my husband’s two weeks of suffering and his death would not have happened had Beth Israel Hospital been in full service,” she said.²²

Who Benefits from Greater Efficiency?

When advocating for mergers and consolidations, executives often make promises of improved efficiency and subtle suggestions that shared administrative costs and other measures would lead to lower prices. Mergers can decrease costs at the acquired hospital by 4 to 7 percent, one study has found.²³ Consolidation of certain services at a system’s “hub” hospital (often an academic medical center) can reduce duplication of services across member hospitals and can help bring down the system’s operating costs. But those efficiencies do not necessarily lead to lower prices for patients or for payers (and the hubs almost always mean patients having to travel farther).²⁴

In fact, numerous studies have documented price increases associated with hospital consolidation, especially in places where a single hospital system gained control of more than half of the healthcare provider market, thereby reducing competition.²⁵ In addition to acquiring hospitals, these large systems have been increasing their market share and bargaining power by practicing vertical integration—acquiring or opening local urgent care centers and physician practices that are affiliated with (and sources of referrals or transfers to) system hospitals, as well as ambulatory surgery centers where many procedures once done in hospitals have migrated.²⁶ Three-quarters of hospitals and more than half of physicians are now affiliated with one of 635 health systems.²⁷

The main beneficiaries of all these mergers and acquisitions turned out to be the systems themselves and their top executives. By growing larger, the systems gained greater market share and increased their bargaining power with health insurance companies, which have also been consolidating.²⁸ And as the systems have grown, so has their top executives’ compensation, especially as the systems rebound from pandemic woes. For example, Sam Hazen, CEO of HCA Healthcare, the nation’s largest system, saw his overall compensation grow to $21.3 million in 2023.²⁹

Broken Promises, Shuttered Services

Over the last few years, the same systems that had rapidly acquired community hospitals began to downsize, shut, or sell them. When systems are looking to improve the bottom line, maternity care is often the first service to be closed because, as healthcare analytics firm Kaufman Hall reports, “obstetrics and delivery services are one of the leading money losers of all hospital offerings.”³⁰ One cause of these losses is low Medicaid reimbursement rates for labor and delivery.³¹

Two of the largest Catholic health systems, Ascension and Trinity, have been under fire this year for proposed or completed closures of maternity services at hospitals they acquired. Ascension has closed more than a quarter of the maternity units it had in 2012, shutting them at a faster rate than the national average. Many of the closings were in areas where people of color and people with low incomes depend on the local hospital.³² And two recent cases involving Trinity illustrate how the system’s promises to community residents have been broken.

Johnson Memorial Hospital in Stafford, Connecticut, was in serious financial difficulty when it joined the Trinity Health system in 2016. Executives promised the move would help bolster the hospital, which had twice filed for bankruptcy. Hospital President and CEO Stuart E. Rosenberg said, “This alliance preserves a critical community asset, allowing us to continue providing healthcare to the community, as well as serving as a significant contributor to the local economy. As part of Trinity Health–New England, our employees and patients can be assured of continued access to the hospital’s 103-year legacy of providing uninterrupted health care services.”³³

However, labor and delivery services were closed during the first year of the pandemic, with temporary state permission; when that permission expired, Trinity Health–New England refused to reopen it.³⁴ AFT Connecticut Vice President John Brady spoke out in opposition to the closure: “While we recognize that continuing labor and delivery at Johnson Memorial Hospital may not be profitable, it must be balanced against the needs of the residents of the area, and Johnson Memorial Hospital should understand that it has a responsibility to provide basic healthcare services in the area.” Trinity was fined $394,000 by the state of Connecticut for refusing to reopen the labor and delivery service and is appealing that fine.³⁵

The Fight for Burdett

Trinity is also the national parent system of the health system that tried to close the Burdett Birth Center at Samaritan Hospital in Troy—St. Peter’s Health Partners. SPHP gained control of Samaritan Hospital and nearby St. Mary’s Hospital through a 2011 merger. It then merged the two hospitals’ maternity services into a separately incorporated facility (Burdett), created on the second floor of Samaritan Hospital to avoid having maternity care come under the Catholic religious restrictions imposed throughout the rest of the previously secular Samaritan Hospital. Hospital executives promised that this maneuver would protect the continued provision of postpartum tubal ligations and contraceptive counseling, which are not permitted in Catholic hospitals.³⁶

That promise was broken in 2020, when SPHP said financial challenges and loss of obstetricians necessitated the closing of the separately incorporated center and reabsorption of its maternity services into Samaritan Hospital.³⁷ Although advocates were dismayed at the loss of services not allowed under Catholic restrictions, they were reassured by the system’s promise that the move would preserve the provision of maternity care in Rensselaer County.

But in June of 2023, SPHP executives broke that promise, too, and announced that Burdett would have to close. This was the last remaining maternity service in Rensselaer County, also serving pregnant patients from adjoining largely rural counties. SPHP said the birth center was losing $2.7 million a year.³⁸

Burdett is a great example of the ways that patients and healthcare workers have been fighting back against plans to close or downsize local hospitals, and sometimes succeeding—at least in the short term. They have taken their concerns to local, state, and federal officials, looking for new policy approaches and funding to protect access to care in communities threatened by hospital closures.

In New York state, I and other healthcare advocates cheered the arrival of a new health equity impact assessment requirement we had fought for, which went into effect in June of 2023—just in time to help save Burdett.³⁹ It requires a hospital to commission an independent assessment of how medically underserved people—a category that includes people with disabilities, women, LGBTQIA+ people, immigrants, people who have public insurance or are uninsured, older adults, and rural residents—would be affected by proposed hospital changes, especially reductions or eliminations of services. It also requires a mitigation plan to address identified negative effects. The law amended the state’s existing Certificate of Need process.

Burdett was the subject of the first such assessment, and the first potential test of the new law.⁴⁰ SPHP initially tried to evade the assessment requirement by filing the Certificate of Need application to close the center two days before the law took effect. But SPHP then agreed to the assessment voluntarily after intense public criticism. Concerned that this first-ever assessment commissioned by the system might be inadequate, SBBCC accepted my offer to help them conduct their own community-led assessment, which it sent to the state Department of Health and posted on the coalition’s website.⁴¹ The coalition’s assessment included conducting a community survey, interviewing people who had given birth at Burdett, studying the demographics of the affected community, examining the lack of affordable 24/7 options for transportation to other area hospitals, and hosting a community forum attended by more than 200 people. The written assessment concluded,

Closure of the Burdett Birth Center would worsen health inequities, causing much harm to medically underserved people in Rensselaer County and adjacent communities. The closure would compound an existing maternal health equity crisis by eliminating a birthing site where pregnant women of color, LGBTQIA+ birthing people, and low-income people say they feel safe, listened to, respected, and not coerced into unneeded medical interventions.⁴²

Also included were quotes from people interviewed about their birthing experiences at Burdett. For example, Jordyn Smith of Troy said,

As an African American woman, I have been failed countless times by the healthcare system. I have anxiety and fear when it comes to hospitals. My number one goal was to be heard and to bring my baby safely into the world. I had an amazing natural water birth at the Burdett Center in 2020. This community needs this center and its healthcare workers. Birthing safely shouldn’t be a middle- or rich-class privilege. It should be for all.⁴³

The assessment commissioned by the health system, while much less comprehensive than the community coalition’s, also found significant negative effects and prompted delay of the center’s closing by at least six months while the hospital and its parent system attempt to address those impacts.⁴⁴

State Health Commissioner James McDonald issued a cease-and-desist order directing the health system to stop trying to shut down Burdett without his written approval of its closure plan.⁴⁵ State Attorney General Letitia James also stepped in, holding a public hearing in Troy⁴⁶ and ordering her Charities Bureau to investigate whether the nonprofit system was appropriately stewarding its charitable assets. The local newspaper, the Times Union, editorialized against the closure,⁴⁷ and the local Catholic bishop denounced it.⁴⁸ A bipartisan group of local and state public officials jointly testified against the closure at a community forum SPHP executives were forced to hold in February 2024 under state closure guidelines.⁴⁹

The local state Assemblymember John T. McDonald III (brother of the state health commissioner) led efforts by public officials to save the birth center. He secured a five-year, $5 million grant for the Burdett Birth Center in the state budget that was approved in April of 2024. Faced with intense community opposition, the escalating attorney general investigation, and no action on their closure plan by the state health commissioner, SPHP officials opted to accept the grant and withdraw their closure plan.⁵⁰

Although the state attorney general’s office dropped its investigation into the proposed Burdett closing, it continues to investigate the financial relationships between Samaritan Hospital and both SPHP and its national parent, Trinity Health, including why Samaritan sent $98 million in unexplained “equity payments” to the Trinity Health system and its affiliates between June 30, 2019, and June 30, 2022. An affidavit filed in late July questions whether SPHP and Trinity are exercising undue control over Samaritan Hospital that is inconsistent with Samaritan’s charitable mission, which includes providing hospital care to indigent people in Rensselaer County. SPHP and Trinity have filed a lawsuit seeking to quash the investigation.⁵¹

Fighting to Save Hospitals and Services—Together

New York’s new state budget also contained funds to stave off the proposed closure of SUNY Downstate in Brooklyn. Members of United University Professions (UUP), an affiliate of the AFT representing state workers, worked with state legislators to fight an effort by the governor and the state university system to close SUNY Downstate. The budget appropriated $300 million in capital funds and $100 million for operating expenses to keep the facility running while an advisory board develops plans to evaluate the hospital’s future.⁵² But the budget did not directly provide any funds to save Beth Israel Medical Center, although there is a pot of money available for health facility “transformations.”

Neither the proposed closing of SUNY Downstate nor the plan to shut Beth Israel Medical Center required a health equity impact assessment. Closures of entire hospitals, as opposed to elimination of maternity wards or other services, are carried out through submission of a formal notice and a closure plan to the state department of health, not a Certificate of Need application subject to a health equity assessment. Advocates and healthcare worker unions are supporting a new piece of legislation (S8843A/A1633B⁵³) to remove that exemption and strengthen community engagement and state review of proposed hospital closures. An amended version of the bill passed both houses of the state legislature in June; as of early September (when this article was finalized for publication), it had not yet been sent to Governor Kathy Hochul for her consideration.⁵⁴

Following the model of the SBBCC, the Community Coalition to Save Beth Israel conducted its own health equity impact assessment. The coalition circulated a community survey to which nearly 1,000 Lower Manhattan residents responded, conducted in-depth interviews with some of those respondents, reviewed demographics for key Lower Manhattan zip codes served by Beth Israel, and assessed capacity at the nearest alternative hospitals. The coalition’s assessment, Lower Manhattan Lifeline: What Beth Israel Medical Center Means to Local Residents, was sent to the state health commissioner and released to the public at a January 2024 press conference with state legislators representing the affected areas.⁵⁵ Key findings of the community’s study included:

Hundreds of low-income people, frail elderly, and people with disabilities—many of whom have relied on Beth Israel for their entire lives—report they are worried about losing the closest hospital they can turn to for care, especially in emergencies. They are unsure where else they could go, how to get there, or whether their insurance would be accepted. Those who have visited two of the potential alternative hospitals—Bellevue and NYU Langone—report long waits in the emergency department, even without the closure of Beth Israel.

While lower Manhattan has its share of well-off people, the top two zip codes from which Beth Israel patients originate (10002 and 10009) have some of the city’s poorest residents and high percentages of people of color. In zip code 10002, the median household income is only $46,000, and a quarter of the residents live in poverty.⁵⁶

The state Department of Health (DOH) issued a cease-and-desist order to the Mount Sinai Health System over its continuing efforts to close Beth Israel Medical Center without written approval of its closure plan.⁵⁷ The department cited the hospital for repeatedly violating that order and then sent back its closure plan as “incomplete.”⁵⁸ Meanwhile, volunteer lawyers from the Community Coalition to Save Beth Israel sued Mount Sinai and won a temporary restraining order against continued closure efforts that also required the system’s “best efforts” to restore services it had already closed.⁵⁹

In late May, Mount Sinai submitted an updated closure plan for Beth Israel to the state DOH. It included promises to create an urgent care center on the campus of neighboring New York Eye and Ear Infirmary that would be open seven days a week and to provide an unspecified amount of support to expand Bellevue Hospital’s emergency department to accommodate some of the patients who would be displaced if Beth Israel closed.⁶⁰ In late July, the DOH granted conditional approval to the closure plan, although the temporary restraining order against the closure remained in effect because of ongoing lawsuits.⁶¹ This action came days after Mount Sinai claimed staffing shortages were making it unsafe to continue to operate the facility,⁶² and the same week that a news outlet revealed Mount Sinai had spent $72,000 on lobbyists in a final push to get approval for closing the hospital.⁶³

In neighboring Connecticut, the State Office of Health Strategy has been aggressive in its review and, in some cases, rejection of proposed hospital downsizing, including planned closures of maternity units. Last year, it rejected Nuvance Health’s plan to close the maternity unit of Sharon Hospital, located in a rural corner of the state—a decision Nuvance is appealing.⁶⁴

Other states that have strengthened review of health provider consolidation include Oregon, where a new law gives the Oregon Health Authority (OHA) jurisdiction over proposed health industry mergers, acquisitions, and affiliations. OHA can reject such transactions if they would not increase access to services in medically underserved areas, improve health outcomes, or reduce patient costs. And in Minnesota, a new statute allows the state attorney general to seek court action barring or unwinding a transaction if it will “reduce delivery of health care to disadvantaged, uninsured, underinsured, and underserved populations and to populations enrolled in public health care programs.”⁶⁵

Efforts to address hospital closures and downsizing at the national level have also focused on the need for higher Medicaid payment rates, increased reimbursements for specific undervalued services such as labor and delivery, and special funding to preserve rural hospitals and urban safety net facilities. A 2021 congressional action created a new “Rural Emergency Hospital” designation that offered financial incentives to keep rural hospitals open, but also allowed them to cut most inpatient services.⁶⁶ Advocates, union representatives, and hospital officials have all been trying to persuade recalcitrant states to expand their Medicaid programs, with funding provided under the Affordable Care Act, to help support financially ailing rural hospitals. They cite the experience of Montana, which expanded Medicaid and has not seen its rural hospitals closing.⁶⁷

Some hospital finances are improving in 2024 as patients begin to seek care they delayed during the pandemic.⁶⁸ But hospital downsizings and closings have continued as hospitals struggle with inflation, increased labor and pharmaceutical costs, frequent coverage denials from Medicare Advantage plans, and other problems. Communities, healthcare workers, and sympathetic local, state, and federal officials will need to work together to preserve essential access to hospital care across the nation.

Lois Uttley, MPP, is a health policy and advocacy consultant and educator with 30 years of experience working with advocates and policymakers to protect community access to healthcare. She was formerly the director of the hospital MergerWatch Project and creator of the Hospital Equity and Accountability Project at Community Catalyst. She teaches in the graduate health advocacy program at Sarah Lawrence College.

*To learn more about the role AFT affiliates played in the successful fight to save SUNY Downstate, see “Fighting for Healthcare Access in Central Brooklyn” in the Spring 2024 issue of AFT Health Care: aft.org/hc/spring2024/kowal_kube. (return to article)

^†For a detailed review of Steward Health Care’s troubles, and the broader impact of private equity on healthcare, see “How Private Equity Has Looted Our Hospitals” here. (return to article)

Endnotes

1. A. Saupp, personal email to L. Uttley, May 2, 2024.

2. Save Burdett Coalition, “Community-Led Health Equity Impact Assessment Report,” docs.google.com/document/d/1Qu_kWwmonKaEttAeHFUPn3Ql4rP5VdIpOj_dnXAQyCQ/edit.

3. S. Simmons, “Residents and Advocates Made Their Voices Heard Over the Proposed Closure of Burdett Birth Center,” WAMC Radio, February 29, 2024, www.wamc.org/news/2024-02-29/residents-and-advocates-made-their-voices-heard-over-the-proposed-closure-of-burdett-birth-center.

4. Save Burdett Coalition, “Community-Led Health Equity Impact.”

5. New York State Department of Health, “Health Equity Impact Assessment: Closure of Maternity Services at Samaritan Hospital,” docs.google.com/document/d/1iMGOPL8kALJjgnz1F3KzmUCYwrzbQ9khBOrU6VhBTmo/edit; and Save Burdett Coalition, “Community-Led Health Equity Impact.”

6. E. Quinn, “Burdett Birth Center Dodges Closure, Thanks to Grant from NYS Budget,” CBS 6 News, April 29, 2024, cbs6albany.com/news/local/birthing-center-to-stay-at-samaritan-hospital-following-state-funding-promice-st-peters-health-samaritan-hospital-troy-brunswick-rensselaer-county.

7. L. Anderson, “On Life Support: Beth Israel Hospital Sudden Closure Sparks Outrage,” Village Sun, November 30, 2023, thevillagesun.com/on-life-support-beth-israel-hospital-sudden-closure-plan-sparks-outrage.

8. R. Greenberg, “State to Shutter SUNY Downstate Medical Center in Brooklyn,” Spectrum News NY1, January 31, 2024, ny1.com/nyc/brooklyn/health/2024/01/31/state-to-shutter-suny-downstate-medical-center-in-brooklyn.

9. S. Vogel, “Steward Bankruptcy Likely as Massive Debt Remains, with Few Options Left,” Healthcare Dive, April 16, 2024, healthcaredive.com/news/steward-health-care-bankruptcy-risk/712899; and S. Vogel, “Steward’s Bankruptcy Documents Reveal Sprawling Debt, Planned Hospital Fire Sale,” Healthcare Dive, May 7, 2024, healthcaredive.com/news/stewards-bankruptcy-documents-reveal-sprawling-debt-planned-hospital-fire/715245.

10. G. Zokovitch, “Steward Health Granted Emergency Relief to Keep Hospitals Afloat During Bankruptcy Process,” Boston Herald, June 13, 2024, bostonherald.com/2024/06/13/steward-health-granted-emergency-relief-to-keep-hospitals-afloat-during-bankruptcy-process.

11. K. Hwang, “Why Nearly 50 California Hospitals Were Forced to End Maternity Services,” CalMatters, April 17, 2024, kqed.org/news/11983217/why-nearly-50-california-hospitals-were-forced-to-end-maternity-ward-services.

12. Cecil G. Sheps Center for Health Services Research, “192 Rural Hospital Closures and Conversions Since January 2005,” University of North Carolina, www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures.

13. A. Sloan and C. Kessler, “How Effective Is the Government’s Campaign Against Hospital Mergers?,” ProPublica, October 28, 2022, propublica.org/article/ftc-campaign-against-hospital-mergers.

14. American Hospital Association, “Fast Facts, U.S. Health Systems,” 2023, data from “AHA Annual Survey Database, FY2021,” aha.org/system/files/media/file/2023/04/Fast-Facts-US-Health-Systems-Infographic-2023.pdf; and American Hospital Association, “Fast Facts on U.S. Hospitals, 2024,” aha.org/statistics/fast-facts-us-hospitals.

15. H. Levins, “Hospital Consolidation Continues to Boost Costs, Narrow Access, and Impact Care Quality,” University of Pennsylvania, Leonard Davis Institute of Health Economics, January 19, 2023, ldi.upenn.edu/our-work/research-updates/hospital-consolidation-continues-to-boost-costs-narrow-access-and-impact-care-quality.

16. C. Behm et al., “100 Largest Hospitals and Health Systems in the US 2023,” Becker’s Hospital Review, December 15, 2023, beckershospitalreview.com/rankings-and-ratings/100-largest-hospitals-and-health-systems-in-the-us-2023.html.

17. Community Coalition to Save Beth Israel and NYEEI, Lower Manhattan Lifeline: What Beth Israel Medical Center Means to Local Residents (New York: January 2024), 5, assets.nationbuilder.com/stpcvta/pages/2479/attachments/original/1706820330/Beth_Israel_HEIA_report.pdf?1706820330.

18. L. Anderson, “On Life Support: Beth Israel Hospital Sudden Closure Plan Sparks Outrage,” Village Sun, November 30, 2023, thevillagesun.com/on-life-support-beth-israel-hospital-sudden-closure-plan-sparks-outrage.

19. C. Damberg, “Health Care Consolidation: The Changing Landscape of the U.S. Health Care System,” testimony submitted to the US House of Representatives Committee on Ways and Means, Subcommittee on Health, May 17, 2023, rand.org/pubs/testimonies/CTA2770-1.html; and N. Beaulieu et al., “Changes in Quality of Care After Hospital Mergers and Acquisitions,” New England Journal of Medicine 382 (2020): 51–59, nejm.org/doi/full/10.1056/NEJMsa1901383.

20. Community Coalition to Save Beth Israel and NYEEI, Lower Manhattan Lifeline.

21. M. Kaufman, “A Barebones Beth Israel Continues Sending ER Patients Elsewhere,” Politico, March 13, 2024, politico.com/news/2024/03/13/beth-israel-sends-er-patients-elsewhere-00146554.

22. J. Neber, “Looming Beth Israel Closure ‘Responsible’ for a Patient Death, Lawsuit Alleges,” Crain’s New York Business, March 13, 2024, cdn.crainsnewyork.com/health-care/lawsuit-alleges-planned-beth-israel-closure-responsible-patient-death.

23. M. Schmitt, “Do Hospital Mergers Reduce Costs?,” Journal of Health Economics 52 (March 2017): 74–94.

24. NCCI Insights, “The Impact of Hospital Consolidation on Medical Costs,” National Council on Compensation Insurance, July 11, 2018, ncci.com/Articles/Pages/II_Insights_QEB_Impact-of-Hospital-Consolidation-on-Medical-Costs.aspx.

25. M. Evans, “The True Cost of Megamergers in Healthcare: Higher Prices,” Wall Street Journal, April 24, 2024, wsj.com/health/healthcare/the-true-cost-of-megamergers-in-healthcare-higher-prices-5c58e8db.

26. Damberg, “Health Care Consolidation.”

27. K. Contreary et al., “Consolidation and Mergers Among Health Systems in 2021: New Data from the AHRQ Compendium,” Health Affairs Forefront, June 20, 2023, healthaffairs.org/content/forefront/consolidation-and-mergers-among-health-systems-2021-new-data-ahrq-compendium.

28. American Medical Association, Competition in Health Insurance: A Comprehensive Study of U.S. Markets (Chicago: 2023), ama-assn.org/system/files/competition-health-insurance-us-markets.pdf.

29. A. Condon, “Executive Compensation at HCA, CHS, Tenet and UHS,” Becker’s Hospital Review, April 16, 2024, beckershospitalreview.com/compensation-issues/executive-compensation-at-hca-chs-tenet-and-uhs.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=7919J8449278D1R.

30. K. Kaufman and E. Swanson, “The Numbers Behind the Numbers,” KaufmanHall, February 21, 2024, kaufmanhall.com/insights/thoughts-ken-kaufman/numbers-behind-national-hospital-flash-report.

31. A. Ollstein and M. Messerly, “‘It’s a Crisis’: Maternal Health Care Disappears for Millions,” Politico, August 1, 2023, politico.com/news/2023/08/01/maternal-health-care-crisis-00109106.

32. A. Hertzler-McCain, “Catholic Bishops Silent as Ascension Hospital System Shrinks Maternity Care,” National Catholic Reporter, April 10, 2024, ncronline.org/news/catholic-bishops-silent-ascension-hospital-system-shrinks-maternity-care#:~:text=Ascension%20closed%20labor%20and%20delivery,units%20that%20existed%20in%202012.

33. T. Jensen, “Johnson Hospital Acquired by Trinity Health–New England,” Patch, December 1, 2015, patch.com/connecticut/ellington-somers/johnson-hospital-acquired-trinity-health-new-england-0.

34. K. Gooch, “Trinity Hospital Appeals $394K Fine for Closing Birthing Unit,” Becker’s Hospital CFO Report, January 23, 2024, beckershospitalreview.com/finance/trinity-hospital-appeals-394k-fine-for-closing-birthing-unit.html.

35. H. McQuaid, “Johnson Memorial Hospital Makes a Case for Closing Maternity Ward,” CT News Junkie, July 12, 2023, ctnewsjunkie.com/2023/07/12/johnson-memorial-hospital-makes-a-case-for-closing-maternity-ward.

36. D. Sanzone, “Newly Formed Not-for-Profit to Oversee Area Hospitals Following Merger,” The Record, October 3, 2011, troyrecord.com/2011/10/03/newly-formed-not-for-profit-to-oversee-area-hospitals-following-merger; and S. McDonough, letter from Northeast Health to Centers for Medicare and Medicaid Services officials describing the need for the creation of the independent Burdett Care Center, August 1, 2011, on file with L. Uttley.

37. R. Swidler, Petition to Charities Bureau, New York State Department of Law, to Merge the Burdett Care Center, Inc. into Samaritan Hospital of Troy, New York, St. Peter’s Health Partners, March 2, 2020, scribd.com/document/658461013/St-Peter-s-Health-Partners-2020-petition-to-absorb-Burdett-Birth-Center.

38. R. Silberstein, “Planned Closure of Samaritan’s Birthing Center Would End Maternity Care in Troy,” Times Union, June 15, 2023, timesunion.com/health/article/st-peter-s-looking-close-troy-s-burdett-birth-18151908.php.

39. New York State Department of Health, “Health Equity Impact Assessment,” health.ny.gov/community/health_equity/impact_assessment.htm.

40. L. Qi, ” Fight to Save a New York Birth Center Tests State Law,” Wall Street Journal, September 27, 2023, wsj.com/health/healthcare/fight-to-save-a-new-york-birth-center-tests-state-law-9cd5be3b.

41. Save Burdett Coalition, “Community-Led Health Equity Impact.”

42. Save Burdett Coalition, “Community-Led Health Equity Impact,” 1.

43. Save Burdett Coalition, “Community-Led Health Equity Impact,” 9.

44. R. Silberstein, “Troy Birth Center Closure Delayed, Equity Study Released,” Times Union, October 23, 2023, timesunion.com/health/article/troy-birth-center-closure-delayed-equity-study-18442761.php; and Spectrum News Staff, “St. Peter’s Delaying Burdett Birth Center Closing,” Spectrum News 1, October 24, 2023, spectrumlocalnews.com/nys/capital-region/health/2023/10/24/burdett-birth-center-closure-delay.

45. R. Silberstein, “Troy Hospital Warned Not to Close Maternity Beds Without State Approval,” Times Union, January 3, 2024, timesunion.com/history/article/state-warns-troy-hospital-not-close-maternity-beds-18586203.php; and S. Eagle, “NYS DOH Sends Cease-and-Desist Letter to Samaritan Hospital Over Burdett Birth Center,” News10 ABC, January 4, 2024, news10.com/news/rensselaer-county/nys-doh-sends-cease-and-desist-letter-to-samaritan-hospital-over-burdett-birth-center.

46. R. Silberstein, “Dozens Plead with Attorney General to Stop Troy Birth Center Closure,” Times Union, September 18, 2023, timesunion.com/health/article/dozens-plead-attorney-general-stop-troy-birth-18373054.php; and D. Lucas, “At Daylong Hearing, New York State AG Takes Testimony on Proposed Closure of Burdett Birth Center,” WAMC Northeast Public Radio, September 19, 2023, www.wamc.org/news/2023-09-19/at-daylong-hearing-new-york-state-ag-takes-testimony-on-proposed-closure-of-burdett-birth-center.

47. Times Union Editorial Board, “Editorial: Burdett Closure Plan Falls Short,” Times Union, January 17, 2024, timesunion.com/opinion/article/editorial-burdett-closure-plan-falls-short-18610978.php; and Times Union Editorial Board, “Editorial: Burdett Decision Is Health Department’s to Make,” Times Union, March 6, 2024, timesunion.com/opinion/article/editorial-burdett-decision-health-department-s-18704755.php.

48. E. Scharfenberger, “Bishop Scharfenberger: News of the Proposed Closing of Burdett Birth Center in Troy Is of Great Concern,” Roman Catholic Diocese of Albany, July 12, 2023, rcda.org/news-events/media-center/news-releases/bishop-scharfenberger-news-proposed-closing-burdett-birth-center-troy-great-concern.

49. K. Crowe, “Public, Officials Bash St. Peter’s Plan to Close Troy’s Burdett Birth Center,” Times Union, February 29, 2024, timesunion.com/news/article/st-peter-s-health-system-told-keep-troy-s-18693647.php; and E. Bouska, “‘Lip Service’: Community Members Dissatisfied with Public Forum on Burdett Birthing Center Closure Plan,” The Record, March 1, 2024, troyrecord.com/2024/02/29/lip-service-community-members-dissatisfied-with-public-forum-on-burdett-birthing-center-closure-plan.

50. S. Hughes, “$5 Million in State Funds Will Help Keep Troy’s Burdett Birth Center Open,” Times Union, April 29, 2024, timesunion.com/news/article/st-peter-s-announce-plans-future-burdett-birth-19428538.php; and D. Lucas, “Burdett Birth Center in Troy, Slated for June Closure, Gets a Reprieve,” WAMC Northeast Public Radio, April 29, 2024, www.wamc.org/news/2024-04-29/burdett-birth-center-in-troy-slated-for-june-closure-gets-a-reprieve.

51. J. Sheehan, “Affirmation of Good Faith and in Support of the Attorney General’s Motion to Compel Investigatory Subpoenas for Testimony,” affidavit filed with the Albany County Court Clerk, July 29, 2024, iapps.courts.state.ny.us/nyscef/ViewDocument?docIndex=PZMMaGB6QnxjruEkYtlnFA==.

52. M. Ashley, “SUNY Downstate Gets $300M in New York 2025 Budget,” Becker’s Hospital Review, April 22, 2024, beckershospitalreview.com/finance/suny-downstate-gets-300m-in-new-york-2025-budget.html#:~:text=New%20York%20Gov.%20Kathy%20Hochul%27s%20final%202025%20budget,at%20Downstate%2C%20in%20New%20York%20City%27s%20Brooklyn%20borough.

53. Local Input in Community Healthcare, A01633B, 2023–24, New York State Assembly, assembly.state.ny.us/leg/?default_fld=&leg_video=&bn=A01633&term=&Summary=Y&Actions=Y&Floor%26nbspVotes=Y; and Senate Bill S8843A, 2023–24, New York State Senate, nysenate.gov/legislation/bills/2023/S8843/amendment/A.

54. A. D’Ambrosio, “Lawmakers Pass Bill to Increase Transparency of Hospital Closures,” Crain’s Health Pulse, June 6, 2024, crainsnewyork.com/health-pulse/lawmakers-pass-bill-increase-transparency-hospital-closures. Also, Office of New York State Senator Gustavo Rivera, “Senator Rivera’s Local Input in Community Healthcare Act Passes Both Houses,” press release, June 6, 2024, nysenate.gov/newsroom/press-releases/2024/gustavo-rivera/senator-riveras-local-input-community-healthcare-act.

55. Office of New York Assemblymember Harvey Epstein, “Lower Manhattan Health Activists Release Health Equity Impact Study: Beth Israel Closure Would Harm People with Disabilities and Low Incomes, Elderly,” press release, January 29, 2024, nyassembly.gov/mem/Harvey-Epstein/story/108934.

56. Community Coalition to Save Beth Israel and NYEEI, Lower Manhattan Lifeline, 1.

57. Village Sun, “Breaking: Mount Sinai Ordered to Halt Beth Israel Hospital Shutdown,” December 22, 2023, thevillagesun.com/breaking-mount-sinai-ordered-to-halt-beth-israel-hospital-shutdown.

58. M. Kaufman, “New York Officials Find Beth Israel Hospital Violated Cease-and-Desist Order amid Closure,” Politico, March 26, 2024, politico.com/news/2024/03/26/new-york-mount-sinai-beth-israel-hospital-00148987; and J. Goldstein, “A Hospital’s Slow Death: As Beth Israel Shrinks, Patient Care Suffers,” New York Times, May 16, 2024, nytimes.com/2024/05/16/nyregion/beth-israel-hospital-closing.html.

59. J. Ahern, “Battle Heats Up Over Beth Israel Closure, as Mt. Sinai & State Health Dept. Receive Temp. Restraining Order,” Our Town, February 16, 2024, ourtownny.com/news/battle-heats-up-over-beth-israel-closure-as-mt-sinai-state-health-dept-receive-temp-restraining-order-JF3153865.

60. M. Kaufman, “Mount Sinai Submits New Closure Plan for Beth Israel,” Politico, May 28, 2024, politico.com/newsletters/weekly-new-york-health-care/2024/05/28/mount-sinai-submits-new-closure-plan-for-beth-israel-00160064.

61. G. Heyward, “Beth Israel Hospital in Manhattan Gets ‘Conditional’ OK to Close—but Not Yet,” Gothamist, July 25, 2024, gothamist.com/news/beth-israel-hospital-in-manhattan-gets-conditional-ok-to-close-but-not-yet; and “Beth Israel still on life support as new judge extends order barring closure,” Village Sun, Aug. 17, 2024, accessed at: https://thevillagesun.com/beth-israel-still-on-life-support-as-new-judg…

62. M. Kaufman, “Major NYC Hospital Warns of Safety Risks from Delayed Closure,” Politico, July 18, 2024, politico.com/news/2024/07/17/mount-sinai-beth-israel-delayed-closure-00169116.

63. A. D’Ambrosio, “Mount Sinai Spent $72K on Lobbyists in Beth Israel Closing Push,” Crain’s New York Business, July 22, 2024, crainsnewyork.com/health-pulse/mount-sinai-paid-brown-weinraub-lobbying-close-beth-israel.

64. K. Golvala, “Sharon Hospital’s Plan to Shut Labor and Delivery Gets Initial Denial,” CT Mirror, August 30, 2023, ctmirror.org/2023/08/30/ct-sharon-hospital-labor-delivery-unit-closing-denial.

65. Minnesota Session Laws – 2023, Regular Session, Chapter 66—H.F.No. 402, www.revisor.mn.gov/laws/2023/0/Session+Law/Chapter/66.

66. Centers for Medicare and Medicaid Services, “Rural Emergency Hospitals,” cms.gov/medicare/health-safety-standards/guidance-for-laws-regulations/hospitals/rural-emergency-hospitals.

67. J. Rodriguez, “Operating in the Red: Half of Rural Hospitals Lose Money, as Many Cut Services,” KFF Health News, March 7, 2024, kffhealthnews.org/news/article/rural-hospitals-half-operate-in-red-many-cut-services.

68. T. Reed, “Good Vibes for Hospitals on Wall Street,” Axios Vitals, January 31, 2024, axios.com/2024/01/31/hospitals-earnings-hca-medicare.

[Illustrations by Stephanie Dalton Cowan; photos courtesy of Assemblymember John T. McDonald III, New York State Senate, and AFT]