In 1961, Ray Trussell, an associate dean at Columbia University, took on a huge challenge: transforming New York City’s struggling hospitals. These “safety-net” hospitals provide care to anyone in need, even if they can’t pay. However, they often face staffing shortages and lack necessary funding.
After visiting Harlem Hospital, Trussell noted shocking conditions. Patients waited hours for care, many were left without proper beds, and service was severely delayed. To tackle these issues, Trussell remembered his time on the Heyman Commission, where the main goal was to avoid a full-scale socialized medicine system, like that in England. Instead, Trussell decided on a collaboration between public and private hospitals, known as “affiliation.”
This approach aimed to allow nonprofit hospitals to manage city-run facilities more efficiently. While the idea had been around, Trussell’s aggressive implementation was unprecedented. Over the years, these affiliation programs became commonplace, leading to a complex system where private organizations run parts of public hospitals.
As of fiscal year 2025, affiliations are costing New Yorkers around $1.9 billion annually, with over 6,000 staff employed under these agreements. While this arrangement offers benefits—like giving medical students diverse experiences—it has also raised concerns about accountability and quality of care. Audits have shown misuse of public funds and billing for services not provided.
Physicians employed through affiliations often feel undervalued. In 2023, resident doctors at Elmhurst Hospital went on strike, pushing back against pay disparities compared to their counterparts at private hospitals. This growing frustration points to a broader issue: understaffing, which ultimately puts patient safety at risk.
Trussell’s push for affiliation was not without opposition. He faced backlash for his plans, particularly at Elmhurst. Critics argued the program treated low-income patients like test subjects, creating a “two-tiered” system of care. Despite the protests, Trussell pressed on, transforming the staffing structure at hospitals like Elmhurst and Harlem.
Supporters saw Trussell as a reformer, while critics accused him of prioritizing corporate interests. During the 1990s, Mayor Rudy Giuliani even suggested selling off public hospitals, further stoking fears about the future of safety-net care. Lawsuits were filed to protect these facilities, highlighting the essential role they play for vulnerable populations.
Despite the ongoing challenges, some hospitals are attempting reform. In September 2024, South Brooklyn Health announced plans to manage neurosurgery services internally, rejecting the affiliation model for improved financial control and patient care.
However, the challenges persist. Affiliated hospitals, like Woodhull, have faced serious complaints about patient outcomes. Tragic incidents have raised alarms about the real consequences of understaffing and corporate-driven care. This echoes Trussell’s early observations of Harlem Hospital, where lack of resources led to dangerous delays in care.
Today, as healthcare moves further away from direct public responsibility, the debate continues. Hospital systems need to address both patient safety and workforce conditions. The need to balance financial pressures with the ethical responsibility to care for all patients remains critical. As healthcare professionals emphasize, how we manage these systems has a profound impact on the lives of our most vulnerable neighbors.
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