Healthcare in an Age of Austerity
Since its formation last year, the Florance Johnston Collective (a small organizing collective, many of whose members live in Brooklyn) has focused on struggles around what we call “social reproduction”—the work required for human bodies to keep on working, living, and loving. In N.Y.C., the materiality of these struggles is never far off. On a recent date, one of our members was talking about the Collective’s organizing work around Long Island College Hospital (LICH). “Oh, my friend was just there!” the date said. “He was scared to go there because he heard what a bad hospital it was. And later, when we went to visit him, the people working at the front desk said, ‘Oh, you must be here to visit Joey!’ There were so few beds that they knew exactly whom we were there to visit. It was really creepy.”
This is a common sort of story about LICH (and many other hospitals in New York). On the one hand, LICH continues to provide much-needed care to Brooklyn residents: it is where people go, no matter how reluctantly, when they are sick, and where ambulances take them when they are in need of urgent medical attention. On the other hand, many locals look on it with apprehension and unease, perhaps well deserved; like most hospitals, it is certainly not a place where people want to go. But just describing the conditions for patients and workers in the hospital wouldn’t be telling the full story. The drama of this hospital has played out on the terrain of broader issues: gentrification, race, social welfare, the limits of electoral politics, and what it means when we talk about struggling around things that matter for “our community.” To get to the heart of an issue so complexly layered, we have spent much of our time flyering, surveying, researching, meeting with contacts, and generally just listening. What we have found is a complicated reality that presents an urgent cause for struggle, and in particular, struggle outside the mechanisms established by the courts and the government.
The story of LICH is pretty grim on the surface. It is the story of an ailing hospital, of dwindling patient numbers, of wasted resources. But it is also much more than that. In many ways, LICH is representative of bigger changes in the healthcare system in New York City and across the country. Specifically, healthcare is decentralizing in an effort to push the cost of social reproduction onto the working class. Concretely, this means fewer sizable healthcare institutions like hospitals and more specialty clinics aimed at turning a profit, alongside increased dependence upon low-waged, homebound healthcare workers.
In early March of this year, the LICH story reached a partial conclusion: The struggle to keep the hospital at full capacity, which for many years meant 1,400 employees and 516 beds, ended. The decision was made that the hospital would remain open with only a few emergency rooms and a few workers, although the details were still under negotiation during the writing of this article.
In talking with people across this city, and learning about the day to day operations of its hospitals, one of the most striking things we have seen is how little workers, patients, and community members know about what is going on at the top at their local hospitals, through no fault of their own. Elected officials, union officials, and hospital bureaucrats make important changes behind closed doors, leaving everyone else—the people who will be directly affected by those decisions—in the dark. For this reason, it is important to lay out some of the basic facts about the controversy in which LICH has been steeped before looking at the outcome.
Opened in 1858, LICH was the first hospital in Brooklyn to offer emergency care services; it was also the first hospital in the United States to teach medical students bedside practices, a model that was quickly replicated across the country. Throughout the 20th century, the Cobble Hill hospital was one of several in Brooklyn that provided care to a significant percentage of Medicaid, Medicare, and uninsured patients, including hosting over 100 psychiatric beds. Following the introduction of national Medicaid reform in 2011, the Cuomo administration began significantly restructuring Medicaid disbursements to New York State hospitals, many of which, including LICH, were threatened with closure due to the determination that they “wasted” too much money. Thus it was during the 2011 restructuring that city and state officials, headed by Governor Cuomo’s office, first put LICH on the chopping block. The hospital was only “saved” when the State University of New York (SUNY) acquired it as a teaching hospital in 2011. That merger itself almost led to the hospital’s closure, with LICH’s former owners, Continuum Health (who had just acquired Beth Israel and St. Luke’s, Roosevelt Hospital Center and merged them with Mt. Sinai with some detrimental effects), initially refusing to release their grants from the State to the new merger.
Since then, SUNY has claimed that the hospital has become a drain on its resources, causing it to lose $13 million per month. Hospital services were quickly deflated; the number of beds fell from 250 to 23, entire departments were cut from the roster, and ambulances diverted to other hospitals. At a meeting in November of 2013 attended by a member of the Florence Johnston Collective, workers and union representatives described what it was like to come in to work every day with no patients. It was also at this time that many workers and patients found out about the proposed cuts: only emergency services, with no operating rooms, labor and delivery, and without other vital services that people who came to emergency would have to be transported elsewhere to receive. By that time, workers had been receiving layoff notices for nearly eight months, each one with a different pending termination date.
During the initial stages of its acquisition of LICH, SUNY representatives said they would need either to sell the hospital or to take drastic measures—like substantially raising student tuition—to keep the decrepit institution afloat. However, since early February there have been rumors that SUNY was accepting bids from local real estate developers to flip the hospital into profitable condominiums. In late February, local courts ruled in favor of SUNY’s ability to move forward with an “accelerated bidding” process that includes open community meetings. Meanwhile the Request for Proposals (R.F.P.)—the invitation for developers to bid on LICH—concedes that a full-service hospital is undesirable. While an early R.F.P. weighed the importance of healthcare services (which are called “technical” matters) in SUNY’s decision-making at only 40 percent, with “financial” details (how much income the system will yield) counting for much more, the current proposal assigns healthcare a weight of 70 percent. However, it is still unclear what quantity and quality of services bidders will provide. All the developers currently bidding on LICH would reduce health services to some extent, although the three major bids received as of March 19 have some provisions for a “full-service” hospital, as opposed to only the emergency services discussed in initial R.F.P.s. Meanwhile, SUNY officials make up 51 percent of the decision-makers for the “technical” aspects of choosing among R.F.P.s, while they make up all of the financial decision-making team. Practically, this means while R.F.P.s that are better than previous ones are coming in, the decision to accept any of them still rests by a strong majority on the same SUNY officials who have been attempting to close the hospital entirely. If SUNY does not receive an acceptable offer by May, LICH will close. At this point, those who support a full-service hospital in Cobble Hill may be forced into acquiescence in order to retain at least some services.
Last fall, amidst the drama of LICH’s deflation, then mayoral candidate Bill de Blasio got himself arrested at a demonstration, supposedly an attempt to save the hospital and provide necessary care for the community. In the post-election bliss, few asked follow-up questions, simply assuming that savior de Blasio would come through. De Blasio, as well as local unions, got workers and supporters to rally around the idea of “saving our community.” While it is quite difficult to disagree with such a position, it was unclear what it meant. While groups like Patients for LICH worked hard, using tactics such as going around Red Hook housing projects with petitions, in general the strategy never moved beyond working toward litigation. Ultimately, many have been guided by the incorrect equation “elect de Blasio = save the hospitals,” an equation that leaves the fate of the hospital to the courts and de Blasio, not those most affected by the cuts.
Those who have focused on court proceedings have hoped that a new ruling would deem closing the hospital illegal under federal and local law and keep it open. In the course of this struggle, two different “communities” have been selectively deployed in dramatically different ways to serve distinct ends. In the March 3, 2014 meeting between potential bidders on the hospital and local representatives, including non-profit groups, unions, and neighborhood associations, gentrification—something that has often been blamed for the hospital’s demise—was touted as its potential savior. These advocacy groups are drawing on ideas about who lives in the neighborhood to frame LICH not just as socially necessary infrastructure but also as a potentially lucrative investment. The area surrounding Cobble Hill is growing, and DUMBO techies and Brooklyn Heights entrepreneurs will all, the story goes, need to utilize LICH’s services. In fact, many workers describe their patients as largely coming from Red Hook and including many people from public and low-income housing, people who are bearing the brunt of gentrification not just in the loss of hospital services, but in rises in cost of living and evictions in the hospitals’ neighborhoods. Many of the new Brooklyn residents, in contrast, actively avoid going to LICH, making the long commute or expensive taxi ride to Manhattan for what is seen as better service. Now, however, those same residents are being invoked as the very reason why investors should keep LICH open as a full-service hospital.
Competing ideas of “community” reflect real conflict in southwest Brooklyn, as in the city as a whole. From the Bronx to Harlem to Crown Heights to Cobble Hill, workers and patients are dealing with the material impact of ongoing capitalist accumulation that leads to the dispossession of access to wages, housing, healthcare, and, for that matter, any sense of a “community.” As neighborhoods become more affluent, working-class and poor people are pushed out, and so are the institutions that have historically served them. But gentrification is a largely structural process, transcending the individual actions of both new affluent residents and the working-class people who are being displaced. Residents of all stripes have looked for an ethical reaction to their plight by claiming that LICH cannot close because people need it. People also need housing, work, and healthcare, but capitalism has successfully abolished all boundaries to its movement and growth, regardless of the impact. Posing the conflict as one between SUNY officials and the benevolence of the State hides the real conflict behind hospital closures: between the value of human life, especially the lives of working-class and poor people, and the maintenance of the ruling class in all its forms, including the state.
This means there is no simple solution for LICH to be expected from the State, the courts, the managers, or new wealthy residents of the neighborhood. In fact, the crisis that LICH is in is a product of the relationship between the “public” policies around healthcare, the interests of investors, developers, hospital management (whether from “public” or “private” institutions), and the tendency in a society based on capitalist accumulation to put the growth of profits over peoples’ lives. Furthermore the changes to the neighborhood itself mean that just saving the hospital will not keep people healthy, out of poverty, or in their homes. As New York City healthcare restructuring, fueled by the Affordable Care Act and Cuomo’s Medicaid Redesign Team efforts, continues to push care workers to handle more patients, encourage hospitals to force out patients as quickly as possible, and allow insurance providers to stratify the city according to quality of care (many of the finest hospitals do not accept Medicare or the more “affordable” private insurance packages), keeping a single hospital open would only be a victory in a preliminary skirmish over accessible healthcare for all New Yorkers.
The March 3 announcement that 600 employees will be without work at LICH by the end of April, and that the hospital will open with severely limited emergency services, seems to ensure that LICH will never go back to its full operating days. In a time when hospitals are deemed viable or not based on how much profit they make, it does not look like LICH will ever be able to transform itself from a loss-leader to an earner, especially with diminished services during its “transition” time. This suggests two possible scenarios as we move forward through the formal systems already established to deal with LICH.
First, if investors keep LICH open as only an emergency care facility, residents around the borough risk not having access to necessary medical care, and those seeking emergency care will find themselves packed shoulder to shoulder with care seekers from other neighborhoods blighted by cutbacks and closures. This is a likely outcome, demonstrating, as we have argued elsewhere, the growth of a formalized two-tier system for New York healthcare: specialty clinics for high-income patients and understaffed emergency centers for the working class. More and more hospitals are devolving to walk-in clinics, community-based nonprofits, home healthcare, or even passing off functions to local pharmacies like CVS. With its myriad of mandated insurance policies, according to income, the Affordable Care Act has helped stratify care seekers in a handy way for high-end care providers. In such situations, tragic stories like that of John Verrier, who died while waiting in a Bronx emergency room, are not altogether surprising: with resources cut and staff overworked, our existing medical institutions have even less ability to support patients.
The Cuomo administration, which has been criticized for not stepping in to save the hospital, resists the idea that LICH is becoming too small. In fact, State Health Commissioner Nirav Shaw said LICH has merely been “right-sized,” changing shape to fit Brooklyn’s needs. It is no surprise that this same phrase is commonly used by corporations attempting to gloss over the gritty realities of downsizing. In a similar move, Shaw’s description masks the fact that cutting hospital beds exemplifies an ongoing medical austerity program.
A second scenario: if SUNY does not find a successful bidder, the hospital will close. People throughout Brooklyn will have to travel even further to receive care, and there will be more deaths due to lack of care. Hospital workers will be let go, or will be unwillingly transferred to other hospitals.
This does not necessarily mean the fight for LICH is over. If anything, the inability of the court system and local politicians to keep the hospital open points to a need for a drastically different strategy, based on a different analysis. As R.F.P.s from developers roll in, we already know none of them will be in favor of the workers and patients at LICH, and we know by now that de Blasio and the courts are not capable of saving us—not due to any personal shortcomings, but because they are part of the same structure that has led to LICH’s closing and the problems in the surrounding neighborhood themselves. For those of us, both workers and patients, who rely on healthcare for work and survival, the case of LICH should prove that we need to find different ways to struggle. And the checkered past of many New York City hospitals also points to the need to go beyond just saving our existing hospitals to actually transforming them. A strategy for LICH has to abandon the courts and the politicians and focus on what people have been asking on the sidelines the whole time: what kind of care do people need, and in what conditions?
Throughout the long winter, when LICH had a low number of patients, and workers continued to go to work even when there was literally no one to work on, workers and community organizations took to congratulating themselves on a hospital “occupation.” This has become a very important part of the story of LICH for many workers and activists: the reason the hospital is open at all, people say, is that workers kept coming in, ignoring the layoff notices and the lack of work. In line with this approach, many people have said that if it comes time to really close the hospital down, people will not leave, with some workers speaking of chaining themselves to the fences, or holding onto car tires to blockade the entrances. While these ideas rarely make it into the public discourse about LICH, they are actually the most viable. But an occupation that would be able to capture the hearts, minds, and support of all of working-class New York would have to go beyond “saving” the hospital to address what is at the root of its threatened closure. It would have to link up not just with the “community” but with hospital and healthcare workers all over the city. And it would have to have more than just demands to stay open and be about more than “loyal workers,” but a vision of a different kind of healthcare, one that reflects the ideals that have been at the root of the ethical struggle with the courts. It would have to consider the needs of workers and patients and ask new questions: Is a hospital the best form to care for people? Why are fewer and fewer people coming to LICH? Workers and patients would need to engage in an active fight with the courts that would try to evict them, the state that would try to defund them, and the politicians who would tell them to “calm down.”
If the hospital does close, all eyes will be on LICH: will the workers and patients calmly leave, calling for more sympathy from de Blasio and the courts, or will the visions of chains, resistance, structural change, and unity become a reality? If this does happen, LICH will be no less a ground for struggle than over the previous year. But with new R.F.P.s on the table, it is unclear where the struggle for LICH will go, and it seems possible that if a full-service hospital proposal is approved, whatever the cuts to staff and working conditions, many will see the struggle as over. This doesn’t mean that nurses, doctors, patients, and other workers will stop struggling. As workers’ patient-loads increase, hospitals stays are shortened, and overall health declines, there is no doubt workers and patients will fight back. The question remains, how?
ContributorThe Florence Johnson Collective