In Poor Health

In 1961, a little-known associate dean at Columbia University was appointed as New York City’s hospital commissioner. He would fundamentally transform how the city’s hospitals are run.

Ray Trussell was put in charge of fixing the city’s ailing “safety-net” hospitals, facilities where people cannot be denied care, even if they can’t pay. In the United States, aside from the Veterans Affairs health system, a safety-net hospital is as close to universal health care as you can get. But these understaffed and underfunded hospitals were—and still are—considered by many New Yorkers to be second tier. After a visit to Harlem Hospital, Trussell told one news outlet that “injured and sick patients were sitting on benches because there were no more stretchers. People were lying on stretchers because there were no more beds. Patients were waiting eight hours for x-rays of fractures.”

Several years earlier, Trussell had been part of the Heyman Commission, a group of men tasked by Mayor Robert Wagner with proposing reforms for the city’s deteriorating hospitals. When the commission first met, its namesake David Heyman declared that his goal was to save the United States from “the way of England—socialized medicine.” The solution, which Trussell later enacted during his time as commissioner, was a partnership of “free enterprise” and government, referred to as “affiliation.” The hope was that nonprofit private hospitals, then called “voluntary hospitals,” could manage the city-run hospitals more effectively. Affiliation was not a new concept but the speed and intensity with which Trussell implemented it was.

“Affiliation amounted to the city waving a white flag,” wrote Merlin Chowkwanyun in his 2022 book All Health Politics Is Local, “and declaring that it couldn’t run its own hospitals by itself.” In other words, it was privatization by stealth. More than sixty years after Trussell’s tenure, affiliate programs—through which private nonprofit health groups, often with academic ties, are subcontracted to provide staff to municipal health systems—have been adopted in most city-run hospitals, at an annual cost of $1.9 billion in the fiscal year 2025. That same year some six thousand full-time employees worked at NYC Health and Hospitals (H&H) through affiliate agreements. More than half were physicians, with nurse practitioners, physician assistants, techs and clerical staff making up the rest. Elmhurst Hospital in Queens employs hundreds of physicians via Mount Sinai; Manhattan’s Bellevue and Brooklyn’s Woodhull hospitals are partially staffed by NYU Langone; and Lincoln hospital in the Bronx draws many of its workers from Physician Affiliate Group of New York (PAGNY), a nonprofit organization formed in 2010 with the specific intent of wrangling such lucrative city contracts. 

On paper, affiliation was meant to be mutually beneficial: medical school students were given a variety of patients to practice with—or, more critically, on—and the city was able to have sought-after doctors treat vulnerable populations at a lower cost. In practice, though, the relationship was ripe for corruption. Affiliate contracts were automatically renewed every few years, resulting in the private nonprofit hospitals viewing NYC H&H as a fount of money: multiple audits in the 1990s revealed that these companies were billing for services not performed and sending their staff on unauthorized trips to breezy destinations like Bermuda, all on the taxpayers’ dime.

Today, doctors claim they don’t receive the same benefits as health care workers employed directly by H&H; they also claim to be paid substantially less than their peers directly employed by the affiliates who work at their flagship hospitals. In 2023 physician residents at Elmhurst went on strike for three days demanding the substantial pay gap between them and their effective colleagues at Mount Sinai in Manhattan be closed. All of this leads to understaffing across the city’s public hospitals, posing a real risk to patients—which affiliation was designed to prevent in the first place.

The beginning of affiliation was marred by controversy. As the hospital commissioner, Trussell turned his sights on Elmhurst Hospital, hoping to bring in affiliate staff from Mount Sinai on the Upper East Side.  Locals, doctors, and leaders at Elmhurst, as well as the Kings County Physician Guild, were outraged. The proposal was seen as a betrayal of the patient-centered mission at the very core of public health.

The Committee to Save City Hospital at Elmhurst said that affiliation would create a laboratory environment, where researchers and students would practice on poor patients, viewing them as “guinea pigs.” Lester Tuchman, Elmhurst’s director of medicine claimed that it would create a “two-doctor system, an elite within the hospitals, and an inferior order outside.” Trussell subsequently fired Tuchman, along with the forty-two-member Elmhurst board; that same year, he also fired members of Harlem Hospital’s board when they opposed the level of control that their affiliate, his former employer Columbia, was starting to wield. In 1964, the arrangement between Mount Sinai and Elmhurst was officially recognized, and one third of Elmhurst’s doctors—those who had refused to bow down to affiliation—were replaced by Mount Sinai staff. As one reporter noted in the New York Times, Trussell was “a man as forceful as he was inventive.”

Mayor Wagner’s successor, John Lindsay, wasn’t a fan of affiliation and during his 1965 campaign claimed that “nothing has changed.” State Senator Seymour R. Thaler claimed that equipment purchased by the city for public hospitals had been transferred to the affiliate hospitals instead—and that the city had lost $100 million through payroll padding. By the early 1970s, it seemed unlikely affiliation would succeed, given all the high-profile reports and uproar from organized labor. But by 1975, the city’s finances were in dire straits and community health activism was diminishing—so affiliation dropped from the public’s concern.  

Affiliation came back into the spotlight in the 1990s, when Mayor Rudy Giuliani floated the idea of selling off three of the city’s eleven public hospitals. He set his eyes on Queens, hoping to give Elmhurst the honor of being among the first hospitals auctioned off, under the logic that a private company could run a health system more efficiently. Residents were concerned about the implications for their low-income and vulnerable neighbors, especially as AIDS ravaged the city. The Center for Constitutional Rights filed a lawsuit—and won. When Judge Herbert A. Posner ruled against Giuliani, he noted that H&H “was born out of the City’s need to salvage a hospital system nearly drowning in red ink” and that the response “cannot be simply to jump ship.” 

Switching tactics, Giuliani decided to overhaul the contracts held by many affiliates, which had recently been subject to unflattering audits. It turned out that critics in earlier decades had been justified. Patients who couldn’t afford treatment at private hospitals were systematically “dumped” at the public hospitals that they were affiliated with. In a 1996 Village Voice article on an audit of Mount Sinai’s $57 million contract with Elmhurst, it was noted that “Mount Sinai could not guarantee that X Rays were read by attending physicians within 24 hours or that residents did not work more hours than allowed by state law.”

Under Giuliani, H&H made more than half of its affiliates sign contracts explicitly holding them accountable for the care they delivered. The new contracts linked compensation to performance and set penalties for failure to comply with health targets. Additionally, medical directors chosen by affiliates had to be approved by H&H. “For too many years this has been a one-sided arrangement,” a board member for H&H told the Voice. “The affiliates had all the power. This has started to fix the balance.” While this helped to tamp down the more egregious corruption, structural problems persisted.

Trussell’s role as the Robert Moses of the city’s hospitals—an unelected official tasked with redesigning a core public service—has been largely relegated to old newspaper clippings. Today, the affiliation system appears to many as just the way things are: inevitable, permanent. Chowkwanyun attributes this to wider attitudes toward health care. “It’s an essential field that affects people’s lives but it’s not usually on their radar the same way highways, roads, parks and buildings are,” he told me in a phone interview. “You generally interact with the health system when something goes wrong.” Yet, he thinks that Trussell’s motivation was an altruistic desire to save the city’s hospital system. “I reject the idea that he did it because he was a henchman for private hospitals and simply wanted to leach and exploit public hospitals. I genuinely think he is somebody who thought that remaking the hospital system in this image is the right thing to do.”

Roona Ray, an emergency care physician who had been employed part-time by Elmhurst since 2019, witnessed the negative outcomes of the affiliate program when Elmhurst shut down its emergency outpatient clinic, ExpressCare, in 2021. The clinic was repurposed as a vaccination hub to help fight the Covid-19 pandemic, and then ultimately closed in favor of virtual-only appointments. When Ray got the news that the clinic would be virtual-only, she was assured her job was secure. However, she said, each virtual outpatient clinic had to technically be registered with a physical hospital for licensing checks—so the entire ExpressCare clinic was registered as being at Lincoln Hospital in the Bronx. This at first seemed like a minor issue, but the other staff in the clinic were employed by PAGNY, on behalf of Lincoln, while Ray was told she would remain employed by Elmhurst—by which they meant she would continue to be employed by Mount Sinai on behalf of Elmhurst. A bit confusing, to say the least.

When one of her bosses started hosting monthly hour-long meetings outside of work, Ray eventually realized her colleagues at Lincoln had been clocking in for these. She was upset to learn she had been missing out on paid time but had a solution: just ask for the administrative time she used to get when working in-person. This time is used by physicians to do paperwork and take meetings. She was stalled for six months until her request was finally approved. A few weeks later—when Ray was thirty-seven weeks pregnant—she was fired. To Ray, it felt retaliatory. After all, she had already been employed in this arrangement for two years. H&H passed the blame to Mount Sinai, and Mount Sinai passed the blame back to H&H. “It was one hospital system when it was convenient to them,” she told me, “and then when they decided I was difficult, they took this opportunity to lay me off and pretend that they are totally different employers that have no relationship to each other.” Mount Sinai was approached for comment but did not respond by the time this story was published.

In Chowkwanyun’s view, the affiliate system “allows a hot potato thing. If you’re the employer, or maybe-employer, you can say someone else is responsible for the labor issue, and on an organizing front, it chops up the population under the potential pool of people who are trying to organize.” One physician, who used to work at a H&H hospital and asked to remain anonymous, agrees. “You create a situation where you have fragmented workforce composition and nobody feels committed, and nobody feels interested in fighting and improving the situation.” For him the entire system is counterintuitive to helping some of the city’s most vulnerable patients. “From the elevators not working, to the HR services run by PAGNY or a private university, to the nurses being overworked and replaced with subcontractors or travel nurse services. The whole operation is a patchwork.” Subcontracting might look good on paper, Ray says, but it comes at a cost. “The public no longer has a direct view of what is happening . . . the public hospital system can kind of wash their hands off responsibility when they want to.”

Reforming the system is not impossible—and it’s already being done at some hospitals. In September, executives at South Brooklyn Health in Coney Island requested that the current affiliate contract for neurosurgical services be canceled and instead run by the hospital itself. The new contract, which would retain the same medical staff and is estimated to be worth close to $24 million over three years, would help retain billing revenue, expand services and eliminate PAGNY’s administrative fee. “These are dollars that are already being spent,” the executives noted. “Now they will be transition[ed] back to NYC Health + Hospitals to cover the cost directly.”

But for the most part, the status quo endures. Earlier this year, NYU Langone renewed its staffing contract with H&H. The new contract stipulates that NYU Langone will provide around 1,800 staff to facilities like Bellevue and Woodhull, the notorious Brooklyn hospital on the border of Bedford Stuyvesant and Bushwick. The contract is for a total cost of $4.4 billion over five years, more than double the previous contract, and is meant to add 252 new staff. (The city spent $680 million on all affiliate arrangements in 1980 and $963 million in 1990 adjusted for inflation.)

Despite the extraordinary cost of these contracts, extraordinary quality isn’t always a given. In September 2024, for instance, H&H primary care doctors were directed to halve their appointments from forty to twenty minutes to help manage the number of patients they had. And physicians who leave for more lucrative pay and benefits at private hospitals are often leaving behind a marginalized community who then face lapses in care or are forced to travel further to receive it. In an emailed statement a spokesperson for H&H said: “NYC Health+Hospitals has affiliations with leading health care institutions that join us to serve every New Yorker without exception. These affiliations allow us flexibility to respond to staffing needs, and establish specialty care that might not otherwise be available. These arrangements serve New Yorkers and help us care for hundreds of thousands of patients each year.”

At a New York City Council meeting of the Committee on Hospitals in January, Nicole Denuccio, a midwife at Woodhull, testified that the failure of H&H and their subcontractors to offer fair contracts to physicians was not just a labor issue but also an issue of systemic racism and patient safety. In July 2020, Sha-Asia Semple Washington, aged twenty-six, died in childbirth at Woodhull after a botched epidural. In 2023, a baby died during childbirth after hospital staff failed to alert the attending physician about worrying symptoms for twelve hours. Just two weeks later, thirty-year-old Christine Fields died after giving birth via a C-section after staff were not informed about an injury that occurred during her operation.

And then last year, Bevorlin Garcia Barrios died after delivering her baby via C-section, with medical staff reporting that she had been turned away from the hospital three nights earlier when complaining of severe abdominal pain and vomiting. “The number of people that have suffered preventable morbidity due to this crisis at Woodhull Hospital are far more numerous and warrant further investigation,” Denuccio said, noting that understaffing meant colleagues with multiple warnings were kept on. This testimony isn’t all too different from what Trussell observed at Harlem Hospital back in 1961—long wait times and substandard care, risking injury or death.

While contracts and subcontracting can sound like the dull machinations of city bureaucracy, the management of staffing at safety-net hospitals has an important role to play in how we care for people. As Denuccio testified, prioritizing the bottom line puts the lives of black and brown people at risk. “The case study of Woodhull’s OBGYN service is a warning to you in this moment.”