“The end result is a lot of people are going to suffer,” he said.

D.C.’s council recently gave preliminary approval to a plan that would close United Medical Center, known as UMC, in January 2023, while reducing the city’s financial contributions to the capital’s only public hospital in the intervening years. Hospital officials say they need some $40 million to keep operating in this fiscal year alone, but the city’s payments going forward would be capped at $15 million annually.

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The move — which will be up for a final vote on Tuesday — has activists and workers at the hospital concerned, for a whole host of reasons. It also fits into a wider recent trend of hospitals closing up shop in the neighborhoods that can least afford it.

UMC is currently the only hospital in Washington that is not in the city’s northwest quadrant — which is both its whitest and richest. The city is grappling with the effects of widespread gentrification and rapidly changing demographics. By one measure, it is the fastest gentrifying city in the country, and in the top four for most black residents displaced. The population UMC serves is majority black, the poorest in the city, and disproportionately composed of Medicaid and Medicare patients.

If the budget cap is implemented, UMC will have to cut back services before ultimately closing. Already, UMC has reduced services due to budget constraints and financial woes, including closing its cancer clinic; a notice that the hospital will lay off employees within the next 60 days was circulated recently. Meanwhile, a proposal to open a new private hospital in that part of the city is far from a done deal, meaning the current hospital has an explicit end date, but the plan for replacing it is only half-baked.

“There is a closing date in the legislation that is not tied to the opening of any other hospital and right now, the city is still only in negotiations with the new Ward 8 hospital provider, which seems to have many roadblocks. So we don’t know what a realistic timeline is to have a new hospital in that part of the city,” said Elizabeth Falcon, executive director of D.C. Jobs With Justice, which is fighting the budget cuts.

Cutting back at UMC will mean longer wait times for its patients, and according to Jean-Pierre, higher mortality rates for those who suffer from strokes, heart attacks, and gunshots, as they are the most vulnerable when delays occur.

“There’s a lot of delays now, but to even cut more is going to create a catastrophic event,” he said. “They’re paying taxes just like the folks in Georgetown, [the richest part of D.C.]. Why should they have the delay in health care when they face a stroke?” For some residents in the area, the next nearest hospital after UMC is a nearly nine-mile drive away, which can take more than an hour in rush hour traffic. And the hospitals closest to UMC already say they have more patients than they can handle.

“Too many of our debates in DC are win-lose or lose-lose. UMC is another example. The debate shouldn’t be: New hospital in Ward 8 or responsible patient care at old hospital in Ward 8. It needs to be both. Vulnerable lives are at risk,” tweeted D.C. council member Elissa Silverman.

But the closing of UMC is about more than just one hospital in one part of one city. It is also emblematic of larger trends in which hospitals are closing, consolidating, and moving out of low-income urban neighborhoods in favor of neighborhoods with richer residents.

In 2014, a Pittsburgh Post-Gazette/Milwaukee Journal Sentinel analysis found that the number of hospitals in major U.S. cities fell by nearly half between 1970 and 2010, and most of those that closed were public hospitals or hospitals located in low-income neighborhoods. Meanwhile, two-thirds of hospital openings during the same time period were in more affluent neighborhoods.

That tracks with D.C.’s experience. The city lost Providence Hospital, in its northeast quadrant, earlier this year, and now UMC has been put on life support, while its four other major hospitals are in wealthier or rapidly gentrifying parts of the northwest.

Not surprisingly, hospital closures lead to worse health outcomes, particularly for those who suffer from heart attacks or injuries that require immediate medical attention. Areas that lose hospitals also tend to lose other medical services as well, as doctors and other practitioners move away or decide to open new practices elsewhere. This turns low-income areas into health care deserts.

Plus, those same areas tend to be the least served by public transit, and have the most residents who don’t own their own modes of transportation, putting ever-higher barriers between patients and the care they need.

“Localities are getting out of the business of running hospitals. That doesn’t mean people are out of the business of getting sick in every neighborhood,” said Falcon. “We are at a moment in history where governments don’t like paying for government services.” Available data on hospital closures is not great, but between 1996 and 2002, per one study, at least 13 public hospitals closed; another study found that public hospitals that closed between 1990 and 2010 were in neighborhoods with significantly higher percentages of black residents than public hospitals that remained open.

On the private side, meanwhile, powerful, multi-facility health systems are responsible for much of the hospital consolidation cities have experienced. Between 2005 and 2017, there were 1,000 hospital merger and acquisition deals announced. 40 percent of hospital stays now occur in markets in which there is only one hospital owner. Such consolidation, in addition to making hospitals fewer and farther between, drives up prices and drives down management quality.

UMC has had its struggles, of course. A slew of errors led regulators to shut down its obstetrics ward in 2017. The only reason the city has been running the hospital at all is that its financial misadventures necessitated a 2010 rescue from bankruptcy. But few think that the city would let it collapse completely. Organizers are moderately confident that, if a new hospital is not completed in the neighborhood by January 2023, the council would at least continue to keep UMC’s emergency room open.

But none of that stops the slow bleeding already occurring there, or makes up for the preventable illnesses, injuries, and deaths that will happen in the intervening years due to the cap on funding; it says nothing good about the city that its poorest residents are saddled with its least-functional hospital. None of UMC’s problems change the fundamental fact that the bulk of D.C.’s available health care services are in the parts of the city where the residents are the wealthiest.

“We are trained to do no harm,” said Jean-Pierre, the UMC nurse. “But the D.C. council does not live by the same code of ethics. Based on the cutting, they’re doing a lot of harm.”

The rule proposed by the United States Citizenship and Immigration Services would require most immigrants seeking green cards to show that they have a middle-class income: specifically, more than 250 percent of the federal poverty line (about $62,750 for a family of four). Immigrants could also fail the test if they have received government benefits, including Medicaid and Medicare Part D, in the past or if officials feel they are likely to receive them at any point in the future. The test would also penalize use of the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) and housing assistance programs.

Researchers at the consulting firm Manatt found the proposed changes could drive disenrollment from Medicaid, even for people who are lawfully in the United States, eligible for coverage, and wouldn’t be subject to the public charge rule, because they fear running afoul of the new requirements. Similar fears are already pushing eligible immigrant families off SNAP, especially those in “mixed status” households that include lawful residents, citizens, and/or undocumented people.

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Overall, the researchers estimate public charge could affect 13.2 million immigrants on Medicaid, including 7.6 million children, who consume nearly $70 billion in Medicaid and Children’s Health Insurance Program services annually.

When people begin to unenroll from Medicaid, the rise in uninsured people who still need health care will lead to fewer Medicaid reimbursements and a corresponding increase in uncompensated care costs. That will be particularly hard on rural hospitals, in part because rural communities rely more heavily on Medicaid coverage than their urban counterparts due to the lower number of other insurance options and high poverty rates.

While the majority of immigrants in the United States live in urban areas, they are making up an increasing share of rural communities. When rural hospitals experience even a relatively small drop in income from losing these patients, Manatt researcher April Grady notes that it “can have an outsized impact.”

Texas, California, and Nevada could see particularly acute chilling effects for their immigrant residents in both urban and rural areas if the public charge rule is approved, thanks to their large immigrant communities. Texas is already struggling with hospital closures, where changes to Medicaid policy, along with the state’s refusal to expand the program, have hit rural facilities hard.

Sharita Thomas, a research associate with the North Carolina Rural Health Research Program (NCRHRP), observed that there have been 90 rural hospital closures since 2010, many in the South, with more on the horizon. 68 percent of rural hospitals vulnerable to full closure are Critical Access Hospitals, which are facilities that are at least 35 miles away from other hospitals, maintain 24/7 emergency care, and meet several other criteria to receive unique benefits designed to make them more financially stable, including cost-based Medicare and in some cases Medicaid reimbursement.

When the sole hospital in a rural community closes, it forces patients to search further afield for care, a particular concern with obstetrical and emergency treatment. It also has a wider negative economic impact. “In rural communities,” said George Pink, Deputy Director of the NCRHRP, “the hospital is the largest or second-largest employer in the region. When that source of employment goes away, there are often ripple effects.” This can extend to companies considering relocation but reluctant to do business in an area that lacks a hospital or doesn’t provide sufficient hospital services, depriving rural regions of economic opportunities.

Even if hospitals facing budget constraints don’t close, they could start cutting programs, with labor and delivery a frequent early target. When cuts fail to achieve the desired goal and get more drastic, a floundering hospital may ponder a merger with another health care entity. Hospital mergers in urban and rural areas alike are rapidly accelerating, with 102 in 2016 alone and a comparable number in 2017. Many of the hospital chains gobbling up smaller competitors are Christian, with the Catholic hospital system in particular expanding rapidly and cutting off access to reproductive health services in the process.

Public charge could have another unintended consequence on rural hospitals, where physicians from immigrant backgrounds make up an important component of health care access. Many rural communities are counting on immigrants to meet health care provider shortages, offering incentives to those willing to work in underserved communities. Physicians have already warned that the executive order restricting entry from majority-Muslim countries is detrimental to health care access in the U.S. and this rule could be another deterrent.

Determining the impact of public charge on rural hospitals “really is a bit of a numbers game,” said Grady, but it’s a game that the federal government has been unwilling to play. She added that while the proposed rule hints at issues like people being afraid to seek emergency care and mixed-status households withdrawing from benefits, it declined to provide estimated fiscal and social impacts.

“There’s administration hurdles that are not fully explored in the proposed rule,” she said.