Safety-net hospitals are vulnerable to government financing. After the Nixon administration encouraged states to conduct utilization review to identify medical cost savings, federal campaigns against hospital subsidies placed public hospital systems in perilous states and paralleled efforts in cities to eliminate “underutilized” facilities. New York City mayor John Lindsay sought a political balance between community participation and the technocratic search for underused beds. Subsequent mayors Abe Beame and Ed Koch proved less sympathetic. With community participation limited to symbolic input on hospital administrator hiring, south Brooklyn, the Bronx, and Harlem all suffered closures. This article contributes to literature on urban governance and health care administration by showing how macroeconomic fiscal decision-making overrode local demands and eventually became microeconomic motivators between and within hospitals. Municipal hospitals and Community Accountability Boards debated austerity budgeting’s negative effects on chronic and epidemic disease readiness, while the Health and Hospitals Corporation framed deprivation as patient choice.

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