Primary Care and Opportunity in New York
Geographic Barriers to Hospital-Based Health
Care in New York City
In many communities hospitals function as a primary source of both emergency and preventive health
care. When a hospital is closed or services are shifted elsewhere, patients risk losing access to needed
health-care services. Historically, hospital closures have disproportionately affected communities of color
and low-income communities. Closures exacerbate problems that people in these communities face in
accessing health care, because of low rates of health insurance and other economic problems.
In New York City many residents lack access to quality health care in general. Health services are distributed inequitably, and low-income communities and communities of color face a serious shortage of
health-care providers. The potential closure of community hospitals and clinics throughout the area could
increase such geographic disparities, exacerbating the shortage of essential services, such as prenatal care,
in neighborhoods already lacking critical medical services. If the current imbalance in the availability of
prenatal-care services in New York City worsens—due to bankruptcies and the state’s pending recommendations for hospital downsizing and closures—it will contribute to higher health-care costs for all and
weaken public institutions upon which New Yorkers depend.
This fact sheet describes the risks associated with the lack of hospital-based services, and how we can
improve the health of all families by increasing access to such care. With accompanying maps, the fact
sheet highlights the inequitable distribution of maternity beds in New York City and outlines what must
be done to fix it.
Why Distance Matters
Fair geographic distribution of hospitals is important in ensuring that all people have access to
adequate health care. Many people rely on having hospitals and affiliated clinics available to
them in their communities. Furthermore, hospitals serve as anchors in communities for other
health-care clinics and providers. In poor neighborhoods private doctors’ offices are often located near hospitals. Hospitals draw physicians
to neighborhoods they might not otherwise
serve.1
When community hospitals close, people have to
travel farther to access care. The increased time
and distance to care is a significant burden, particularly for people in low-income communities
who rely on public transportation to access care.2
For pregnant women, in particular, distance can
determine the health of mothers and their children. A study of new mothers in New York City
examined factors that determine timing of prenatal care for poor women. Among the most commonly cited barriers were transportation prob-
lems and distance of providers from women’s
homes and workplaces.3 Additional studies have
concluded that pregnant women living in New
York City’s distressed neighborhoods are significantly more likely to begin care later than
women living elsewhere in the city.4
Hospital Location and Health
in New York City
In the case of reducing and eliminating maternity beds, communities can experience a decline
of providers that once provided care for those
hospital beds. Without incentives for physicians
to work in all communities, disadvantaged areas
will face further shortages of providers. The
health risks of a few communities are truly the
risks of everyone. Therefore, it is important that
community hospitals and clinics are accessible
to residents of every neighborhood in order to
attract health-care providers.
The accompanying maps display the locations of
New York City’s hospitals and their maternity
beds. Figure 1 shows the relationship between
hospital location and the percentage of women
who receive late or no prenatal care in each of
New York’s 42 neighborhoods. The map indicates that many neighborhoods with high rates
of women’s receiving late or no prenatal care
lack nearby hospitals with maternity beds. For
example, recent hospital closures and downsizing in Central Brooklyn have left women with
limited hospital-based services nearby. Despite
high rates of women who receive late or no prenatal care, two hospitals (Interfaith Medical and
St. Mary’s Brooklyn) in its neighborhoods have
completely eliminated their maternity beds in
the last five years.
Figure 2 also paints a disturbing picture of the
percentage of low birth weight (LBW) babies
across New York City. In both Southeast
Queens and neighboring Jamaica the lack of ma-
ternity beds is clear, as their residents have only
four hospitals located at the outer edges of the
neighborhoods. Residents of those neighborhoods must overcome immense geographic distances in order to receive care at a hospital. This
is despite the fact that these hospital-deprived
areas suffer from some of the highest percentages of LBW babies born: more than 10% of
babies born in those neighborhoods are LBW
babies.
Geographic Barriers to Care
Despite the well-known benefits of adequate
care, not all people are afforded the same opportunities to access that care. There are numerous
barriers to people’s receiving adequate and
comprehensive care, many of which disproportionately affect low-income and minority families.5 Barriers include:
• Geographic inaccessibility, such as:
o A shortage of medical facilities and
health-service providers in neighborhoods with large minority populations and concentrated poverty;
o Increased travel time to providers;
and
o Lack of private transportation and
slow or difficult public transportation systems.6
• Hospital closures. The closure of many
community hospitals and their affiliated
outpatient departments limits access to care
for people who rely on hospital-based physicians, emergency-care departments, and
providers at affiliated clinics.7
Insufficient transportation. In a survey of innercity mothers 26% of the women listed transportation as a barrier to care, and nearly 20% of
them indicated that the closest clinic was too far
away. Thus, some women may conclude that the
discomfort and inconvenience associated with
keeping a clinic appointment outweigh its respective benefits.8
Figure 2
NEW YORK CITY, NY
MATERNITY BEDS AND LOW BIRTH WEIGHT BABIES
This map displays the location of hospitals and number of
maternity beds each offers, as of June 2006, in relation to the
percentage of Low Birth Weight (LBW) babies in New York
City between 2001-2003, by United Health Fund (UHF)
neighborhoods.
LABEL
A
B
C
D
E
F
G
H
J
K
L
M
N
P
Q
R
S
T
U
V
W
X
Y
Z
AA
AB
AC
AD
AE
AF
AG
AH
AJ
AK
AL
AM
AN
AP
AQ
AR
AS
AT
NEIGHBORHOOD
Bayside - Little Neck
Bedford Stuyvesant - Crown Heights
Bensonhurst - Bay Ridge
Borough Park
Canarsie - Flatlands
Central Harlem - Morningside Heights
Chelsea - Clinton
Coney Island - Sheepshead Bay
Crotona - Tremont
Downtown - Heights - Slope
East Flatbush - Flatbush
East Harlem
East New York
Flushing - Clearview
Fordham - Bronx Park
Fresh Meadows
Gramercy Park - Murray Hill
Greenpoint
Greenwich Village - Soho
High Bridge - Morrisania
Hunts Point - Mott Haven
Jamaica
Kingsbridge - Riverdale
Long Island City - Astoria
Lower Manhattan
Northeast Bronx
Pelhem - Throgs Neck
Port Richmond
Ridgewood - Forest Hill
Rockaway
South Beach - Tottenville
Southeast Queens
Southwest Queens
Stapleton - St. George
Sunset park
Union Square - Lower East Side
Upper East Side
Upper West Side
Washington Heights - Inwood
West Queens
Williamsburg - Bushwick
Willowbrook
AD
26
!
?
F
!
?AC
!
?
13 35
W
!
?M
74 23 M
AP
AC
26
16 Bronx 50
36 J
!
?
V
72
AB
Q
20
AQ
52
NEW JERSEY
30
Y
W
P
Manhattan
10 33
!
?
!
?
AN
?
?!
!
?!
?!
68
S AN
36
G
AR
24
Z
2442!
?
!
?
25
U
AM
20 Queens
!
?
AE
20
16
AS
42
K
40
!
?
X
AJ
AH
N
L
!
?
30 34
AL
28
40
Brooklyn
60
34
NEW YORK
!
?B!
?
35
AF
!
?
24
AK
?
!
?!
D
E
C
!
?
AF
H
AT
Staten Island
26
15
AA
38
41
R
42
T
AA
AA
A
30
44
20
41
!
?
25
Queens
AG
!
?
Parks
Hospitals
NY Boroughs
# of Maternity beds
Water Feature
0
10
15
Miles
Source of Data: Census.gov; NY SPARCS database; GeographyNetwork.com
NYS AHEC System - Data Resource Center
Projection: State Plane 83 New York East | Date: September 25, 2006
Neighborhood data
26 - 39
% LBW
Better
I
5
40 - 90
State boundary
6.3% or less
B e t t e r
Prepared by:
1 - 25
6.3 - 7.5%
7.5 - 8.5%
8.5 - 10.1%
Above 10.1%
!
?
0 (No Mat. Beds)
All data ranges contain almost
equal number of observations
% LBW: Percentage of Low Birth Weight babies
Figure 1
NEW YORK CITY, NY
MATERNITY BEDS AND PRENATAL CARE
This map displays the location of hospitals and number of
maternity beds each offers, as of June 2006, in relation to the
percentage of women receiving late or no prenatal care in New
York City between 2001-2003, by United Health Fund (UHF)
neighborhoods.
LABEL
A
B
C
D
E
F
G
H
J
K
L
M
N
P
Q
R
S
T
U
V
W
X
Y
Z
AA
AB
AC
AD
AE
AF
AG
AH
AJ
AK
AL
AM
AN
AP
AQ
AR
AS
AT
NEIGHBORHOOD
Bayside - Little Neck
Bedford Stuyvesant - Crown Heights
Bensonhurst - Bay Ridge
Borough Park
Canarsie - Flatlands
Central Harlem - Morningside Heights
Chelsea - Clinton
Coney Island - Sheepshead Bay
Crotona - Tremont
Downtown - Heights - Slope
East Flatbush - Flatbush
East Harlem
East New York
Flushing - Clearview
Fordham - Bronx Park
Fresh Meadows
Gramercy Park - Murray Hill
Greenpoint
Greenwich Village - Soho
High Bridge - Morrisania
Hunts Point - Mott Haven
Jamaica
Kingsbridge - Riverdale
Long Island City - Astoria
Lower Manhattan
Northeast Bronx
Pelhem - Throgs Neck
Port Richmond
Ridgewood - Forest Hill
Rockaway
South Beach - Tottenville
Southeast Queens
Southwest Queens
Stapleton - St. George
Sunset park
Union Square - Lower East Side
Upper East Side
Upper West Side
Washington Heights - Inwood
West Queens
Williamsburg - Bushwick
Willowbrook
AD
26
!
?
F
!
?AC
!
?
13 35
W
!
?M
74 23 M
AP
AC
26
16 Bronx 50
36 J
!
?
V
72
AB
Q
20
AQ
52
NEW JERSEY
30
Y
W
P
Manhattan
10 33
!
?
!
?
AN
?
?!
!
?!
?!
68
S AN
36
G
AR
24
Z
2442!
?
!
?
25
U
AM
20 Queens
!
?
AE
20
16
AS
42
K
40
!
?
X
AJ
AH
N
L
!
30 34 ?
AL
28
40
Brooklyn
60
34
NEW YORK
!
?B!
?
35
AF
!
?
24
AK
?
!
?!
D
E
C
!
?
AF
H
AT
Staten Island
26
15
AA
38
41
R
42
T
AA
AA
A
30
44
20
41
!
?
25
Queens
AG
!
?
Parks
Hospitals
NY Boroughs
# of Maternity beds
Water Feature
0
I
5
10
15
Miles
Source of Data: Census.gov; NY SPARCS database; GeographyNetwork.com
NYS AHEC System - Data Resource Center
Projection: State Plane 83 New York East | Date: September 25, 2006
26 - 39
% Late Prenatal
20% or less
B e t t e r
Prepared by:
1 - 25
20 - 27.5%
27.5 - 32.5%
32.5 - 35%
Above 35%
Better
40 - 90
State boundary
Neighborhood data
!
?
0 (No Mat. beds)
All data ranges contain almost
equal number of observations
% Late Prenatal: Percentage of women who received late
or no prenatal care
Conclusions and Recommendations
Low-income and minority communities often have a greater need for health-care services. However, because the health-care system does not encourage providers to serve these communities, poor women and
women of color must often endure longer waiting times to see providers in their communities or travel
longer distances (at greater expense and inconvenience) to see providers at hospitals and affiliated clinics
in other neighborhoods. The failure to address the health-care needs of a community, including child care
for working parents and language accommodations for limited-English speakers, bars substantial numbers
of people from obtaining services vital to their well-being and security.
Several policy steps are necessary to expand and ensure equitable access to health care. State, federal, and
local governments should:
• Provide universal health care. The most direct and efficient way to improve access to primary
care is through universal health-insurance coverage.9 Universal health-insurance programs also
reduce financial disincentives that limit health-care providers’ willingness to practice in lowincome communities.
• Address geographic barriers and spatial inequalities in the distribution of health-care resources.
Efforts to expand the primary-care infrastructure must follow from a thorough assessment of
community needs, including cultural, linguistic, and health-care service needs.
• Increase government investment in community health centers and other community-based programs.
• Eliminate other barriers to health care by providing sufficient transportation, shortening waiting
times for appointments, providing medical translators, and ensuring equal treatment in the healthcare system regardless of race and ethnicity.10
• Promote collaborations among local health departments, hospitals, and academic medical centers,
which can create a foundation for improved services for underserved populations.11
• Ensure that all women have access to adequate health care before conception in order to ensure
healthy pregnancies and birth outcomes.12
• Halt further erosion in health-care capacity, especially health services for populations at risk for
not receiving adequate primary care. These actions can be accomplished through private investment incentives for improvements in quality of care.13
1
J. Currie and P. Regan, “Distance to Hospital and Children’s Use of Preventive Care: Is Being Closer Better, and for Whom?”
Economic Inquiry 41, no. 3 (July 2003): 378–91.
2
L. Bonstock, “Pathways of Disadvantage: Walking As a Mode of Transport among Low-Income Mothers,” Health and Social
Care in the Community 9, no. 1 (September 2000): 11–18.
3
D. Kalmus and K. Fennely, “Barriers to Prenatal Care among Low-Income Women in New York City,” Family Planning Perspectives 22, no. 5 (September/October 1990), 215–18, 231.
4
K. Jaffee and J. Perloff, “Late Entry into Prenatal Care: The Neighborhood Context,” Social Work 44, no. 2 (March 1999): 116–
28.
5
S. Rosenbaum, P. Shin, and R. Perez Trevino Whittington, Laying the Foundation: Health System Reform in New York State
and the Primary Care Imperative (New York: 2006), 30; L. Shi and B. Starfield, “The Effect of Primary Care Physician Supply
and Income Inequality on Mortality among Blacks and Whites in U.S. Metropolitan Areas,” American Journal of Public Health
91, no. 8 (August 2001): 1249; J. Farley, “Spatial Mismatch and Access to Physicians among African Americans,” The Edwardsville Journal of Sociology 4 (2004): 2–9.
6
Farley, “Spatial Mismatch and Access to Physicians,” 2–9; Council on Graduate Medical Education, Tenth Report: Physician
Distribution and Health Care Challenges in Rural and Inner-City Areas (Washington, D.C.: U.S. Department of Health and Human Services, February 1998), 29–30, http://www.cogme.gov/rpt10.htm (accessed June 30, 2006).
7
Council on Graduate Medical Education, Tenth Report, 35.
8
C. A. Loveland Cook et al., “Access Barriers and the Use of Prenatal Care by Low-Income, Inner-City Women,” Social Work
44, no. 2 (March 1999): 129–39.
9
Council on Graduate Medical Education, Tenth Report, xiii.
10
Ibid., xiii; Kalmus and Fennely, “Barriers to Prenatal Care,” 215–16; Loveland Cook et al., “Access Barriers and the Use of
Prenatal Care,” 130; C. Golden, M. Besculides, F. Laraque, Prenatal Care Appointment Survey 2001: Barriers to Accessing Prenatal Care in New York City (New York: Bureau of Maternal, Infant, and Reproductive Health,
http://www.nyc.gov/html/doh/downloads/pdf/ms/ms-pncsurvey2001.pdf (accessed June 16, 2006); R. Milligan et al., “Perceptions about Prenatal Care: Views of Urban Vulnerable Groups,” BMC Public Health, http://www.biomedcentral.com/14712458/2/25 (accessed June 16, 2006).
11
Ibid., xiv, xv.
12
A. Healy et al., “Early Access to Prenatal Care: Implications for Racial Disparity in Prenatal Mortality,” Obstetrics and Gynecology 107, no. 3 (March 2006): 625–31.
13
Rosenbaum, Shin, and Whittington, Laying the Foundation, 30.