Andrew Cuomo, once America’s most beloved governor, is fighting for his political life. At least six women have accused him of sexual harassment, and the FBI is probing how his administration tallied nursing home deaths during the Covid-19 pandemic.

But the popular pandemic narrative of Cuomo—as a successful responder to a crisis that has been lately led astray—is not fully accurate. New York state has America’s second-highest coronavirus death toll—nearly 50,000 people have died—and death rate. And choices made a year ago by Cuomo and his administration fueled the carnage in the state.

There was Cuomo’s delayed shutdown order and early downplaying of the virus. And recently another decision has drawn greater scrutiny: Cuomo’s directive ordering nursing homes to accept Covid-19 patients, the sweeping legal immunity granted to those facilities, the hiding of the death toll there, and a long-running quest to shutter poorer hospitals across the state.

Many of these decisions were driven by one of the most powerful and overlooked interest groups in the state, Greater New York Hospital Association. Representing more than 200 hospitals across New York, including the wealthiest private hospital networks, it enjoys an unusually close relationship with Cuomo, designing laws, staffing state government, and deciding how billions in health care funding gets spent.

As the Cuomo scandals grow, it’s worth remembering the interest groups and lobbies that would prefer that the governor stay in power. GNYHA’s influence on the Cuomo administration, in the words of Bill Hammond, a New York health care policy expert with the right-leaning Empire Center, is “hard to overstate.”

“They have more access than most people in the entire government,” added state Senator Alessandra Biaggi, a Bronx Democrat who has clashed with Cuomo. “They have essentially been given carte blanche for our legislative process.”

GNYHA’s clout begins with money. There are years when it has funneled more than $1 million to Cuomo’s campaign coffers alone. An in-house lobbyist, David Rich, donated more than $900,000 in a five-year period to various politicians, one of whom was Cuomo.

To fight for its agenda in Albany, the association employs Bolton–St. Johns, one of the top lobbying firms in the state. The father, brother, and sister of Melissa DeRosa, Cuomo’s highest-ranking aide who is at the center of the nursing home scandal, all work at Bolton–St. Johns.

Though many smaller hospitals belong to GNYHA, it’s the largest and wealthiest private networks that determine the direction of the organization and thus wield the power to determine the state government’s health care agenda writ large.

State health care decisions and GNYHA’s policy priorities are inextricably linked. As frustrated officials were leaving Cuomo’s Department of Health over the past year, Dennis Whalen, a lobbyist for GNYHA member Northwell Health, worked inside the department to shape the state’s pandemic response, including the vaccine rollout, according to New York Times reporting.

Though New York has increased its vaccination pace in recent weeks, it still lags behind many states, including Connecticut, Massachusetts, Vermont, and West Virginia. New York was particularly sluggish in December and January. Overly strict guidelines, in part, were to blame, including Cuomo threatening million-dollar fines on health care providers that vaccinated people not on the state’s priority lists. Another factor in the delay was a process designed by Northwell Health to empower hospitals to handle vaccinations at the expense of local health departments, which had been preparing for months for mass vaccination campaigns at the county level. West Virginia, in utilizing its independent pharmacy chains, has found success in this local approach.

Brian Conway, a GNYHA spokesman, said hospitals were the logical choice for rolling out vaccines because the state prioritized vaccinating hospital workers first. “In addition, hospitals were one of the few places that had the immediate ability to accommodate the refrigeration/cold storage requirements for the Pfizer and Moderna vaccines (especially Pfizer),” he said.

But a hospital-centric vaccination campaign could win networks like Northwell glowing headlines. It was no surprise that the first person vaccinated in New York was a nurse at Northwell. Northwell also received the first doses of the new Johnson & Johnson vaccine.

A special adviser to Cuomo, Rich Azzopardi, denied that GNYHA determined health care policy in the state. “We make policy decisions based on fact in consultation with the legislature. Suggestions otherwise are false.”

Greater New York Health Association’s influence, however, has been felt clearly throughout the pandemic. Last March, many state legislators were shocked to find sweeping immunity protections for nursing homes and hospitals in the state budget. Some had been notified about the last-minute additions hours before voting; others had no idea the language was there until after the budget passed.

And so, for almost a year, these facilities have enjoyed protections from any lawsuits related to coronavirus treatment. GNYHA lobbyists, according to many lawmakers aware of the process, crafted the language for the provision. GNYHA also lobbied for a controversial March 2020 directive that ordered nursing homes to readmit residents who had tested positive for Covid-19, helping to fuel the spread of the virus in elder-care facilities.

The directive, Cuomo argued, was necessary to free up hospital beds and was driven by Centers for Disease Control guidance, though the CDC merely suggested this could be done—but did not make a recommendation as to whether it should be done. Last May, the nursing home directive was repealed.

In the first two months of the pandemic, as nursing homes were overwhelmed and struggling from a lack of personal protective equipment—GNYHA’s influence helped ensure hospitals got priority over other health care facilities—public hospitals in working-class neighborhoods were besieged with patients, their morgues overflowing. At the height of the carnage, the hospitals of Brooklyn and Queens could not handle the surge of bodies, leading to tens of thousands of deaths. Had there been more hospital beds and ICU units in these neighborhoods, the facilities would not have been so overwhelmed. Queens County, the original coronavirus epicenter, had lost at least four hospitals in the last 15 years.

Greater New York Health Association’s influence within the Cuomo administration far predates the pandemic. Cuomo, like his predecessors, had long embraced a philosophy of closing and consolidating money-losing hospitals. Twice during his tenure, Cuomo has created so-called Medicaid Redesign Teams to recommend deep cuts to Medicaid funding in the state, which remains generous by national standards.

New York’s health care system is bifurcated between private, cash-flush hospitals and poorer safety net hospitals perpetually on the brink of economic ruin. Medicaid patients always show up at the latter. For progressives, GNYHA has been a particular roadblock because the association has opposed two ambitious policy aims: the creation of a single-payer health care system in the state and a law mandating higher staffing ratios for nurses at hospitals.

GNYHA has fought to ensure the “safe staffing” bill and the single-payer legislation, known as the New York Health Act, never makes it through the legislature. Ultimately, opposition to both boils down to money. More staff will be costly.

Single-payer, meanwhile, would ban private health insurance in the state, eating at a primary revenue source for hospitals, especially the most prestigious private plans that generously cover specialty care. Payments to various hospitals, rich and poor, would also be more equalized. “The legislation would place extreme downward pressure on already-inadequate hospital payments, endangering the survival of hospitals,” GNYHA said in a memo opposing single-payer.

The cochair of the second Medicaid Redesign Team, which attempted significant Medicaid cuts to public hospitals in the worst months of the pandemic, was Michael Dowling, a Northwell executive. Though GNYHA has publicly opposed hospital closures and funding cuts—“GNYHA has a longstanding record of fiercely advocating at the State and Federal level for adequate funding for private and public safety net hospitals,” said Conway—they have largely, and tacitly, supported the Cuomo approach to closing hospitals.

In 2012, Cuomo shut down Peninsula Hospital, one of two hospitals on the Rockaway peninsula. A few years later, over equally loud protests, Cuomo approved the shuttering of Long Island College Hospital in Brooklyn.

Early this year, Cuomo’s Health Department moved to drastically downsize the last hospital in the Rockaways, one of the areas that’s been most ravaged by the coronavirus. And a state-sponsored “transformation” of Kingsbrook Jewish Medical Center in Brooklyn will amount to its effective closure, argue advocates and nurses who work there.

Three years ago, Cuomo announced a proposal to merge three Brooklyn hospitals, including Kingsbrook, in an attempt to boost preventive and primary care services and rehab the three facilities while streamlining their electronic records system. More than 200 beds at Kingbrook were targeted for elimination.

The group tasked with designing the consolidation plan for the Brooklyn hospitals? Cuomo’s old friend and the prime mover and shaker of GNYHA, Northwell Health. Specifically, its consulting arm, Northwell Ventures. The result was a new network, One Brooklyn Health, created to oversee the hospitals. The chairman of the board of directors is Alexander Rovt, a billionaire Donald Trump supporter who has funneled hundreds of thousands of dollars to Cuomo’s campaigns.

With Cuomo’s political standing weakened, Julie Keefe, a Kingsbrook nurse and organizer, sees a chance to build pressure to oppose the closure plan. Such pushback against the governor felt unthinkable just a short time ago. “Local politicians and unions have been afraid to go against Cuomo on this plan and afraid of retaliation,” she said. “They once saw it as a political death sentence.”