Christine C. Quinn, the City Council speaker, said during a debate last month that she would make sure "that the mayor isn't sitting on the sidelines as it relates to private hospitals."
William C. Thompson Jr., a former city comptroller, echoed her, saying, "The city can't sit on the sidelines."
And Bill de Blasio, the public advocate, who helped make the hospitals a main issue by getting arrested at a rally to save Long Island College Hospital in Brooklyn, said, "We have to end this epidemic of hospital closures."
Despite the discourse, it is the state that regulates hospitals and gives the grants and loans needed to keep them from failing. And Gov. Andrew M. Cuomo is not throwing the hospitals a lifeline.
That the candidates are even talking about hospitals is, if nothing else, a testament to their vital role in the city's ecosystem. More than just health care facilities, they are neighborhood institutions where local doctors take care of people they know from birth to death, where politicians can be heroes by providing taxpayer support and patronage, and where unions can count on employment for workers at various levels of schooling.
Hospitals in poor areas have been struggling for years; since 1990, 52 hospitals in New York State, half of them in the city, have closed or been converted into another type of medical center. In that time, the state has tried to keep remaining hospitals alive by authorizing hundreds of millions of dollars in bond sales or direct subsidies. But the Cuomo administration believes that New York State, especially in Brooklyn, still has more hospital beds than it needs and that some of the weakest facilities might have to shut down or be significantly reshaped.
"Years of state financial support and bailouts in the absence of real systemic reform has left Brooklyn residents with an unstable and unaffordable hospital system that falls short of delivering the real primary care that the community actually needs," Bill Schwarz, a spokesman for the State Health Department, said. "The administration is seeking to end this unsustainable cycle."
Over all, New York City has 3 hospital beds for every 1,000 residents, more than the national average of 2.6 beds, according to the American Hospital Association's 2010 survey. (New York's rate is still lower than that of some other cities, including Phoenix, with 4.7 beds per 1,000 residents, and Dallas with 4.4 beds.)
Brooklyn hospitals have a vacancy rate of almost 30 percent and, with more efficiency, could cut more than 1,200 beds — the equivalent of three or four community hospitals, according to a recent state report. A large portion of Brooklyn's more affluent population goes to the more prestigious academic medical centers in Manhattan for care, further weakening the system. About 25 percent of health care spending for Brooklyn residents is on Manhattan doctors and hospitals, according to the state.
Generally, the Brooklyn hospitals that are in financial straits disproportionately serve patients with Medicaid, which pays less than private insurers, and the uninsured.
Kenneth E. Raske, president of the Greater New York Hospital Association, called Brooklyn hospitals "the poster child for the problems affecting safety net hospitals throughout the entire country," and said the federal government should step in.
State health officials acknowledged that hospitals have become one-stop shopping centers for health care in poor neighborhoods, a pattern that is hard to break.
"If those hospitals simply disappear, you'll have health care deserts," Jason A. Helgerson, the governor's Medicaid chief, said. "Individuals will have to travel extremely long distances for even the most basic forms of health care services."
However, Mr. Helgerson added, the state does not favor the way those hospitals are operated today, each with a heavy emphasis on inpatient care that requires a costly staff and upkeep. In an effort to turn more money over to primary care — in part because the Affordable Care Act is expected to create a demand for it, as an estimated one million state residents gain coverage — health officials talk about turning some hospitals into what they call medical villages. Some of those villages, which might include some combination of emergency care, primary care and other services, but not the full array they now provide, would have to send patients to another hospital when they needed to be admitted.
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