A recent study by the University of Pennsylvania reveals that half of low-income communities in the United States have no ICU beds. These circumstances are especially disconcerting as the United States endures its sixth month of covid-19 devastation, approaching 195,000 deaths. The particular failings of how this country approaches medical care are causing globally unique levels of harm. This continued suffering, and the ways it falls disproportionately on Black Americans and other minorities, should cause outrage. It should not, however, cause surprise.
The lack of ICU beds in low-income communities is not only part of a larger unsettling pattern. It is the result of decades of federal and state policies, especially spending cuts, that date back to the post-World War II period and that have limited hospital care access in the United States. This history of cuts has led to the United States having just 2.9 hospital beds per 1,000 people, compared to 3.1 for Italy, 4.3 for China and 13 for Japan.
These cuts have most heavily affected poor people, and especially Black Americans. The chronic hospital resource constraints we are witnessing during the covid-19 pandemic must be placed in proper context when, in the state of Georgia alone, Black people have constituted over 80 percent of covid-19 hospitalizations. They are the direct result of government at every level and the court system failing to protect the most vulnerable Americans.
Following World War II, President Harry Truman signed the Hill-Burton Modernization and Construction Act in 1946. Hill-Burton funded the construction of an average of 4.5 hospital beds per 1,000 people across the United States. On one hand, by distributing funds on a per capita basis tied to income, the new legislation significantly expanded health-care coverage for poor, predominantly Black people in the rural South. On the other, by allowing for “separate but equal” facilities, Hill-Burton perpetuated hospital segregation while barring funds for Black hospitals that lacked modern medical technologies.
It was not until the 1963 decision by the U.S. Court of Appeals for the 4th Circuit in Simkins v. Moses H. Cone Memorial Hospital and the passage of the Civil Rights Act in 1964 that segregated hospitals were compelled to desegregate. In theory, these decisions mandated equal access to a relatively high number of integrated hospital resources across the country.
However, with declining infectious-disease morbidity and migration to suburbs, urban and rural bed occupancy rates declined by double digits between the 1940s and 1970s. In response, health planners began to cut hospital beds under the euphemistic guise of “hospital cost containment.” In 1969, New York City’s liberal Republican mayor John Lindsay (he would switch parties two years later) created the nation’s largest public hospital system: the Health and Hospitals Corp. (HHC), which centralized control of hospital budgets. Quasi-public status allowed the corporation to accept private funds. Using these newfound powers, Lindsay pushed for upward of 25 percent higher average bed occupancy rates by cutting inpatient beds and redirecting those resources to outpatient care. By mid-1973, Lindsay succeeded in decommissioning 900 hospital beds in New York City.
While these cuts allowed Lindsay to channel savings toward prevention in the form of mobile vaccination and diagnostic services, they reduced the city hospital’s surge capacity. The policy resulted from a zero-sum calculation that pitted increased outpatient care against decreased inpatient beds. These local trade-offs did not occur in a vacuum, however.
Reduced federal reimbursements for inpatient admissions played a consequential role. Nationally, the federal government began disinvesting from the Hill-Burton Act’s priorities with President Richard Nixon’s Economic Stabilization Program (ESP) in 1971. The ESP included freezing hospital charges, limiting wage increases and restricting aggregate revenue to stop inflation. Nixon’s attempts to cut overall federal subsidies failed, but they successfully reoriented both Republican and Democratic presidential and mayoral priorities away from funding inpatient care and toward bolstering outpatient care.
These attempts to control “cost-push inflation” by reducing federal reimbursement for hospital care had little effect on controlling prices. As inflation spiked from 1973 to 1975, the cost of medical care also skyrocketed. In New York, the economic crisis gave Lindsay political cover to eliminate more beds, primarily in the city’s poorest neighborhoods. Kings County Hospital Center in the predominantly Caribbean and working-class neighborhood of East Flatbush, Brooklyn, lost 343 acute care beds — nearly one-fifth of the 2,000 total cut going into the mid-1970s.
Lindsay’s hospital bed studies and cuts laid the groundwork for successive mayoral administrations to continue reductions throughout the decade after he left office in 1973. During the city’s 1975 fiscal crisis, Abe Beame’s administration closed all 50 neighborhood clinics in an attempt to stave off bankruptcy. After the Emergency Financial Control Board had assumed control and with falling federal reimbursement for inpatient care, the city’s share of the hospital budget shrank from 40 percent to 27 percent, the days of care provided dropped by 23 percent, and the number of HHC beds fell by 16 percent. The majority of these cuts took place in Harlem and in Brooklyn’s predominantly Black and working-class neighborhoods.
The national policy push to reduce inpatient beds intensified with a second wave of hyperinflation between 1977 and 1979. In response, President Jimmy Carter proposed mandatory and voluntary hospital cost containment efforts. The logic of cutting “unused” capacity extended from hospital beds to other items such as masks, gloves and critical medicines. By keeping equipment and staffing levels low, hospitals could increase profitability. Removing hospital beds from poor inner city neighborhoods accompanied a dispersal of remaining resources into suburban neighborhoods, which made accessing health care more distant and costly for the poor.
To redress these fiscal inequalities, in the late 1970s, inner-city residents attempted to bring civil rights lawsuits against cities, fearing that stripped-down hospitals failed to provide adequate emergency and routine care. In the August 1977 case NAACP v. Wilmington Medical Center Inc., plaintiffs sought an injunction against the movement of specialty and acute care beds away from Wilmington’s Delaware Hospital to a brand-new facility in the suburb of Stanton. They charged that this spatial segregation discriminated against inner-city Black, Brown and elderly residents. The Federal District Court in Delaware dismissed the charges in May 1980, with a claim that adding bus service would solve the problem of more remote care.
That same month in Bryan v. Koch, the District Court of the Southern District of New York reviewed Mayor Ed Koch’s 1977 plan to close Harlem’s second-to-last public hospital. Koch’s Health Task Force picked up where Lindsay’s left off, keeping on the chopping block for the 1970s the same hospitals originally identified for closure in the late 1960s. Judge Abraham Davis Sofaer ruled that Koch’s plan did not violate civil rights law, which, in any case, provided “no guaranty against adversity.” Because the spatial reorganization of medical care was defined by income, and not by race, civil rights legislation provided little protection for those left behind. These legal decisions combined with fiscal cuts produced disastrous outcomes. In New York City alone, bed capacity shrank from around 54,000 in 1970 to 35,000 in 1987.
The discriminatory impacts of under-resourced health care in the United States became clear as the AIDS epidemic exploded by decade’s end. Hospital workers across the country scrambled to create ICU capacity in the hallways of severely under-resourced inner-city hospitals. The crisis forced New York state’s commissioner of health, David Axelrod, to reverse the decades-long push to cut beds. He temporarily authorized a mere 500 additional gurneys plus cooperating agreements with voluntary hospitals to handle the surge in AIDS cases. Furthermore, the city pursued the construction of dedicated AIDS wards in Harlem rather than other neighborhoods, eliciting condemnation from local business leaders that the city sought to ghettoize the provision of care.
AIDS claimed 50,000 lives in the United States over five years. In five months, covid-19 has claimed more than three times as many. Policymakers — both elected and career officials — can hardly claim to be surprised by these unfortunate realities.
The history of spending cuts, which have specifically targeted hospitals in Black and Brown communities in the name of cost-savings and greater efficiency, paved the way for the United States’ dire response to covid-19. The five-alarm bell should continue to ring since hospital systems such as New York City’s HHC continue to face cuts to Medicaid even as the virus rages. In the opposite direction, Missouri voters’ approval of Medicaid expansion this summer signals that the pandemic may be connecting the impact of Black, Brown and poor people’s lack of health-care access to covid-19’s stubborn persistence in the states.
Everyone must reckon with how the politics of short-term economic policy has limited the availability of acute hospital care to the detriment of the United States’ epidemic preparedness. We must grapple with the history of why bipartisan administrations from the presidential to the local level have paradoxically impoverished the publicly facing hospital systems that carry the greatest burdens of disease.