The first time he entered the new spine center at Allen Hospital, Joe Dempsey could not believe his eyes. The main desk looked like it was made of marble. Pictures hung on freshly painted walls, and was that parquet flooring that he was walking on? It was the antithesis of the psychiatric ward, one floor above, where Dempsey was a clinical nurse.

“I was like, ‘Are you joking?’ They had really renovated that place, to the point where it looked state of the art,” said Dempsey, who retired at the end of April. His visit to the new spine center happened in 2016, around Christmas, when he dropped by to deliver one of his famous red-velvet cakes. He had baked them as holiday treats for each nursing unit in the hospital, which is part of NewYork-Presbyterian/Columbia University Irving Medical Center. “I told the nurses, ‘I’m not leaving this cake down here! You people are doing better than everybody else in the building.’”

“I gave them the cake anyway,” said Dempsey, chuckling at the memory. But the visit left an impression. “The Spine Hospital’s going to take over the Allen,” he said.

Nearly two years later, NewYork-Presbyterian is trying to close Allen’s psychiatric unit in order to further expand the spine center. The community is resisting—with some, perhaps temporary, successes so far. NewYork-Presbyterian originally planned to close the psychiatric unit at the end of June 2018; now, it’s delayed closure until at least next summer. Some advocates of the psychiatric ward have declared victory. Others remain worried. Given NYP’s behavior in the past—tactics that appeared to flout state regulations—many in the neighborhood do not believe the psychiatric unit is safe.

In many ways, this story is an emblem of mental-health care in America, as providers close down psychiatric units for lack of financial viability, further eroding critical services at a time when the destination for people with untreated mental illness is, all too often, jail or prison.

“This is a national crisis,” said Miriam Callahan, a medical student at Columbia University and one of the organizers of Save Allen Psych, a coalition of nurses and community members. The group, which is working with the Bronx/Upper Manhattan branch of the Democratic Socialists of America, hopes to use the psychiatric ward’s year reprieve to rally support and maintain pressure on the hospital and state regulators. “I definitely see what’s happen at the Allen as part of a national trend,” Callahan, a DSA member herself, said, “and I’m hoping we can be part of reversing that trend.”

When it was completed in 1988, the Allen Hospital was “dedicated to the medical needs of the Washington Heights–Inwood area.” It is perched on the bluffs of northern Manhattan, drawing patients from an area where nearly half of residents are immigrants. Median income in the area ranges from $25,000 to $34,999, at least 50 percent lower than the median incomes of NewYork-Presbyterian’s other catchment areas, which include neighborhoods in Lower Manhattan, the Upper East Side, and Westchester County. In Allen’s Upper Manhattan environs, more than half of residents are on Medicaid. Nearly a fifth have no health insurance at all.

In the psychiatric ward, mental illness is usually not the only problem afflicting patients. Substance abuse and homelessness are common, according to nurses and doctors, who said they often treated those known as dual-diagnosis patients, who have both mental illness and substance-use disorders.

Dempsey remembered one such patient who had been repeatedly admitted and discharged, only to return time and again. “One of his biggest issues was that he wasn’t close to his family,” Dempsey said. “I would allow him to cry in my arms, like, ‘It’s okay, it’ll be all right.’ He called me Dad.”

In 2015, NewYork-Presbyterian opened a swanky new unit at the Allen: the Spine Hospital. The new unit was part of a broader effort to expand its orthopedics program, and it recruited, in its own words, “world class” doctors to treat spinal injuries and deformities, as well as degenerative spinal diseases. Yet the levels of investment and promotion—tailored to attract patients from around the globe to these highly specialized services—seem incongruous with the idea of a community hospital.

“It’s a Spa, It’s a 5 Star Hotel: No, It’s The Spine Hospital!” cheered an article in the trade publication Orthopedics This Week in October 2015. It quoted Dr. Dan Riew, the Spine Hospital’s director of cervical-spine surgery, who spoke of a “concierge-level service often reserved for elite hotels” and of amenities like Spine Hospital robes. NewYork-Presbyterian itself has touted the Spine Hospital as having an operating room that “looks like the set of a Hollywood movie.”

In October 2017, the Spine Hospital acquired a lengthier moniker, the Daniel and Jane Och Spine Hospital, after Daniel Och, a hedge-fund manager and hospital trustee, and his wife, Jane, gave $25 million to NewYork-Presbyterian. Dr. William Levine, the chief orthopedic surgeon at NewYork-Presbyterian/Columbia University Irving Medical Center, said in a press release that the Ochs’ donation would allow NewYork-Presbyterian “to realize our dream of building the premier spine program in the world.”

Daniel Och’s donations, however, came on the heels of some decidedly less philanthropic expenditures. In 2016, his firm, Och-Ziff Capital Management Group, agreed to pay fines of $412 million after the Justice Department determined that the company had paid millions of dollars in bribes to officials in several African countries. Och-Ziff “positioned itself to profit” from corruption, then–US Attorney Robert Capers said.

For a health-care service to close in New York, the facility that operates it has to have a state-approved transition plan. “You can’t just go in, switch off the lights, and say, ‘We’re done now.’ There’s a highly developed protocol for how you close a unit,” said Greg Burke, a former hospital administrator at Montefiore Medical Center in the Bronx who is now director of innovation strategies at United Hospital Fund of New York. “If you’re taking a piece of supply out of the system, you have to be able to show that this will not harm the public.”

According to New York State guidelines, “Information on a potential closure may not be disclosed to the public, patients/residents or staff prior to notifying the DOH [Department of Health], submission of a closure plan to the DOH, and approval of such plan by the DOH.” The guidelines add that “no announcements or actions related to the proposed closure should be taken prior to receiving approval,” and that a hospital “must have written approval from the department of health prior to implementation of a closure plan.”

But the lack of official approval did not keep NewYork-Presbyterian from nudging staff to leave. Around last Thanksgiving, about a month after the Ochs’ donation, a meeting was held on 3 River East, the psychiatric unit of the Allen Hospital. Joe Dempsey wasn’t there—he said he was out with an illness—but about three dozen of the ward’s nurses, doctors and other staff were, and they were told that 3 River East would close in June of 2018.

“The timing was awful, just before the holidays,” said Raelynn Price, a registered nurse working on 3 River East. “People were trying to decide what to do.”

Soon, the hospital was telling nurses about other jobs, some of them elsewhere in the NewYork-Presbyterian system, that they could take.

“Right off the bat, management started offering positions and directly dealing with the nurses to find other positions,” said Anthony Ciampa, first vice president for the New York State Nurses Association (NYSNA), which represents nurses at the Allen. Although some of those positions were within NewYork-Presbyterian’s network, they were not in psychiatry, according to Ciampa.

On December 29, 2017, in the midst of the holiday season, NewYork-Presbyterian submitted to the New York State Department of Health a $70 million plan to close 3 River East. It proposed the “closure and decertification of the 30-bed psychiatry unit.” It also planned to relocate maternity services within the hospital and build three new operating rooms.

To date, the New York Department of Health hasn’t greenlighted the closure. A spokesperson said the agency is still evaluating NewYork-Presbyterian’s proposal.

In response to repeated queries from The Nation about staff departures and bed closures, NewYork-Presbyterian’s press office sent form statements that did not address those questions. Its most recent statement, in late October, said, “We are continuing our discussions with government officials and key community stakeholders regarding new proposals for Northern Manhattan.”

Far from being an isolated case, the shifts taking place at NewYork-Presbyterian are part of a trend playing out in cities and hospitals around the country. Many of these cases have striking parallels. In April, the University of Washington Medical Center announced that it would close all or part of its psychiatry unit because of financial losses and necessary but expensive upgrades. (UWMC has since said it will delay closure until 2019, promising new psychiatric beds at another hospital nearly six miles away.) At the end of June, Tri-City Medical Center in Oceanside, California, revealed it would eliminate indefinitely its 18 behavioral-health beds along with other mental-health services, citing, in part, a $5 million deficit.

Last year, The Press Democrat, a newspaper in Santa Rosa, California, conducted an in-depth review of local mental-health care in Sonoma County 10 years after two psychiatric hospitals closed there. It found that local emergency rooms were overwhelmed, that patients with severe mental illness had to leave the county to get treatment, and that the jail had become “the largest psychiatric treatment facility” in the county.

In January, Jeffrey Lieberman, the chief psychiatrist of NewYork-Presbyterian/Columbia University Irving Medical Center, sent out a “Dear Colleagues” e-mail, received by psychiatrists in the hospital system. “After many decades of outstanding service to the Washington Heights community, the Allen Hospital 3 River East Inpatient Psychiatric Unit will be closing on or before June 30, 2018,” his message began. Repurposing the space would allow for the addition of new operating rooms “to extend the Och Spine Center.”

3 River East’s five full-time psychiatrists had been relocated to “alternative position [sic] within the NYP and NYSPI [New York State Psychiatric Institute] systems,” Lieberman’s e-mail said, despite its being sent prior to any official state approval. “Changes are often difficult but inevitable, and in this case part of the evolution and regionalization of health care,” he wrote.

In February, Community Board 12, an advisory group that represents Washington Heights and Inwood, passed a resolution opposing the closure. It sent a letter to the CEO of NewYork-Presbyterian, Dr. Steven Corwin, asking the hospital to “rescind its plan” and “discontinue its efforts to transfer the nurses working in this unit.” In March, a doctor at Allen started a petition to Governor Andrew Cuomo that has so far gathered more than 1,500 signatures.

Save Allen Psych has mailed about 1,000 postcards—containing handwritten anecdotes and pleas from community members—to Ann Marie Sullivan, the commissioner for the New York State Office of Mental Health. “Everybody wants to do something,” said Callahan, the med student-cum-organizer. The group has also canvassed at subway stations in Inwood, close to Allen Hospital, to build community support. In the coming year, they hope to take their message directly to the leaders of NewYork-Presbyterian.

In an open letter in April, Dr. Steven Corwin, President and CEO of NewYork-Presbyterian Hospital, defended the hospital’s plan. To compensate for closing 3 River East, NYP would expand “intensive, individualized, community-based services,” he wrote. It would keep school-based behavioral health sites and develop an intensive outpatient psychiatric program for adults. Those needing inpatient treatment could go to other NewYork-Presbyterian hospitals, Corwin said.

But according to nurses and doctors at the Allen, the inpatient psychiatric wing is a neighborhood necessity, and its beds are always full. The same holds true in the areas surrounding the hospital. “Especially in northern Manhattan and the Bronx, we really have a shortage of beds,” said Bruce Schwartz, clinical director of psychiatry at Montefiore Medical Center in the Bronx and president-elect of the American Psychiatric Association. If 3 River East closes, psychiatric patients who could have been hospitalized at Allen would, at best, be assigned to a facility three miles to the south, or sent to Brooklyn Methodist Hospital, well over an hour’s drive away in Park Slope. Or they might have to wait for a psychiatric bed through the city’s public hospital system, where “beds are, generally, reasonably full,” Dr. Charles Barron, deputy chief medical officer of New York City Health & Hospitals, told The Nation.

“We routinely have anywhere from 10 to 15 patients a day waiting for a bed to open somewhere in the NYC or Westchester area,” said Schwartz.

Currently, a person must wait an average of four to six days—and possibly as many as 10 days—to get a psychiatric appointment at one of the city’s public facilities, Barron told the New York City Council Committee on Hospitals during a hearing in June. When asked whether the public system would be ready to accommodate the patients from Allen’s shuttered beds, Barron responded ambivalently. “We’re gonna have some challenges in absorbing additional capacity,” he said, but added, “Our mission is to serve, so we certainly won’t turn anybody away.”

Judith Cutcheon, a registered nurse in the public system, was more direct during her testimony. According to Cutcheon, 95,000 adults in New York, or nearly 40 percent of those with serious mental illnesses, were not treated in 2017. “The continual removal of hospital beds and the funding of mental health treatment will only exacerbate this issue,” she said.

In recent years, private hospitals in New York City have been retreating from inpatient psychiatric care, even though the need for such treatment has not declined. A report by the New York City Independent Budget Office in 2017 suggested that public hospitals in New York City were taking on a greater proportion of mental health patients than their private counterparts, which include NewYork-Presbyterian. From 2009 to 2014, the number of mental health hospitalizations at New York City Health & Hospitals, the city’s public system, rose 20 percent, roughly from 21,000 to 25,000. But at private hospitals, those numbers fell by nearly 5 percent.

The reason hospitals close psychiatric units is often financial. Doctors and hospitals are paid less for mental-health care than other types of medical care. For an office visit, for example, primary-care providers made at least 20 percent more than psychiatrists, and specialists made 17 to 19 percent more than psychiatrists (based on Medicare-allowed amounts), according to a national report by Milliman Inc., published last December. (The report was commissioned by a subsidiary of the Bowman Family Foundation, which actively funds psychiatric research and care. Its president, Matthias Bowman, founded a company that develops and sells designs for clinical trials.)

“Ultimately, the hospital is making a business decision,” Dr. Jorge Petit, a former associate commissioner in the New York City Department of Health and Mental Hygiene, said of NewYork-Presbyterian. “Community-based providers have very, very, very thin margins, if any at all, for behavioral-health care,” Petit said.

Spinal surgery, by contrast, is synonymous with lucrative. According to research published in 2012, the price tag for spinal fusions leapt from $24,671 per operation in 1998 to nearly $82,000 in 2008.

Petit, who directed psychiatric emergency services at New York’s Mount Sinai hospital in the 1990s, is now the CEO and president of Coordinated Behavioral Care, a network that advocates for community-based care in New York City. He has observed the health-care system in New York City, from multiple vantage points, for decades.

“I think the system has created these behemoths,” he said of groups like NewYork-Presbyterian. “I just don’t know how much power the state has to be able to really influence the decision [regarding 3 River East], but they can and should ensure that there is a commensurate development of community-based behavioral-health services offered to the local community instead.”

Throughout the spring, when NewYork-Presbyterian was promising to close 3 River East (despite its still not having state approval) staff started to trickle away. In April, an administrative assistant took a position at another NewYork-Presbyterian Hospital. At the end of that month, Dempsey left. At 63, he’d already been considering retiring, but, if he hadn’t expected 3 River East to close, he “might have stayed for another year,” he said.

On May 9, Allen’s unit chief left for a job at another NewYork-Presbyterian hospital. The following day, the hospital closed four beds, lowering the total to 26. “They did tell us they’re going to cut down the beds because there’s going to be a shortage of doctors,” Price, still a nurse at 3 River East, said.

“We feel like they were trying to bleed the unit out from within,” said NYSNA’s Ciampa. “And then they can turn around and say, ‘Hey, there’s no nurses, there’s no doctors, there’s no patients, the census is low.’ But it’s by their own hands.”

In June, it became clear that 3 River East would not close by the end of the month. Instead, NewYork-Presbyterian delayed the date by a year. What prompted its decision is unclear—the community outcry has been firm, but the Department of Health has also not approved NYP’s plans for Allen.

The four staff psychiatrists on 3 River East who were originally reassigned elsewhere were subsequently asked to stay, at least temporarily. One of those psychiatrists went on maternity leave for the summer, and then followed through with a transfer to NYP’s Westchester campus. Another honored her reassignment—set up after NYP announced its intent to close 3 River East—and moved to a different NYP psychiatric facility in September. As of publication, 3 River East is down to just two full-time psychiatrists (in addition to a part-time psychiatrist and two nurse practitioners added by NYP in recent months).

The hospital’s tactics have not, as yet, seriously decreased the ranks of other nurses at 3 River East. Besides Joe Dempsey, only one other nurse left the unit, according to Price, Dempsey, and others at the Allen. They also say that one social worker and one recreational therapist have departed. After a request from the union earlier this year, NYP administration stopped contacting nurses directly with possible transfer options, according to Ciampa. At this point, none of the staff really knows when, or if, the unit will close, and the hospital has done little to allay its employees’ apprehension and uncertainty.

“They’re scaring people,” said a physician at Allen, who requested anonymity out of fear of retribution. “They’re saying, ‘This job offer is only going to be open another couple of weeks, or, you can take your chances when the unit closes.’”