Court Opinion

ID: 8911923
Source: CourtListenerOpinion
Date Created: 2022-11-27 03:20:58.228775+00
Date Added: 2024-06-11T17:08:36.160703
License: Public Domain

KEARSE, Circuit Judge
(concurring in part and dissenting in part):
While I concur in the affirmance of the judgment in Boyd v. Harris, No. 80-6085, for the reasons stated in the majority opinion, I dissent from the affirmance of the denial of a preliminary injunction in Bryan v. Koch, No. 80-7401. I would decide the question left open by the majority, and hold that Title VI of the Civil Rights Act of 1964, 42 U.S.C. § 2000d et seq. (1976), condemns conduct which has a disproportionate racial impact or effect, and not merely conduct motivated by a racially discriminatory purpose. Under an effects test I conclude, like the majority, that plaintiffs made a prima facie showing of a Title VI violation, shifting the burden to the defendants (hereinafter referred to collectively as the “City”) to show justification for the decision. I do not agree, however, that the City successfully carried that burden. No one would contest the fact that the City must assign priorities among competing economic demands and evaluate political and economic alternatives. But in my view, when a recipient of federal moneys makes a decision to use those moneys in a way which has disparate racial impact Title VI requires the recipient to show, at the very least, that its decision was the product of a rational decision-making process. The City has made no such showing here as to its decision to close Sydenham.
I
My views on the proper test to be applied under Title VI may be stated briefly as follows. Title VI was enacted as part of a sweeping package of remedial measures known collectively as the Civil Rights Act of 1964. Section 601, the basic substantive provision of Title VI, 'broadly provides, without qualification, that:
No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.
42 U.S.C. § 2000d (1976). It might be argued that this provision, standing alone, is on its face ambiguous with regard to the question of intent vs. effects. But § .601 does not stand alone. Section 602 of the Act imposes on all federal agencies “empowered to extend Federal financial assistance to any program or activity,” a duty
. to effectuate the provisions of section 2000d of this title with respect to such program or activity by issuing rules, regulations, or orders of general applicability which shall be consistent with achievement of the objectives of the statute authorizing the financial assistance in connection with which the action is taken.
42 U.S.C. § 2000d-l (1976). Shortly after Title VI was enacted, no fewer than seven federal agencies carried out this mandate “to effectuate the provisions of § 601” by promulgating regulations that applied a broad “disparate impact,” or “effects,” test.1 These regulations — which include the regulations at issue in the instant case, 45 C.F.R. Part 80 — reflected the agencies' recognition of Congress’s intent that Title VI “would, in short, assure the existing right to equal treatment in the enjoyment of federal funds.” 110 Cong.Rec. 1519 (1964) (remarks of Rep. Celler, floor manager of the bill in the House of Representatives; emphasis added). To the same effect, see *622also id. at 6544 (remarks of Sen. Humphrey); id. at 6561 (remarks of Sen. Kuchel); id. at 7058 (remarks of Sen. Pastore). And see id. at 6543 (remarks of Sen. Humphrey, quoting Presidential message to Congress proposing the legislation):
Simple justice requires that public funds, to which all taxpayers of all races contribute, not be spent in any fashion which encourages, entrenches, subsidizes, or results in racial discrimination.
(Emphasis added.)
In Lau v. Nichols, 414 U.S. 563, 94 S.Ct. 786, 39 L.Ed.2d 1 (1974), the Supreme Court expressly upheld HEW’s2 Title VI regulations, establishing that the standard of liability is impact or effects, not intent:
Discrimination is barred which has that effect even though no purposeful design is present: a recipient “may not . utilize criteria or methods of administration which have the effect of subjecting individuals to discrimination” or have “the effect of defeating or substantially impairing accomplishment of the objectives of the program as respect individuals of a particular race, color, or national origin.” [45 C.F.R.] § 80.3(b)(2).
414 U.S. at 568, 94 S.Ct. at 789 (emphasis in original).3 Thus these remarks by the legislators, the implementing regulations of the responsible federal agencies, and the one Supreme Court decision on point all reflect the principle — as an element of “simple justice” — that a recipient of federal funds should not use those funds in a manner which has the effect of excluding persons on the basis of race, color or national origin.
The controlling precedent in this Circuit is to the same effect:
Title VI findings of discrimination may be predicated on disparate impact without proof of unlawful intent.
Board of Education v. Califano, 584 F.2d 576, 589 (2d Cir. 1978), aff’d on other grounds sub nom. Board of Education v. Harris, 444 U.S. 130, 100 S. Ct. 363, 62 L.Ed.2d 275 (1979). And other circuits have applied the same standard. E. g., Guadalupe Org., Inc. v. Tempe Elem. School Dist, 587 F.2d 1022, 1029 (9th Cir. 1978); Serna v. Portales Municipal Schools, 499 F.2d 1147, 1153-54 (10th Cir. 1974). In fact, with the exception of cases involving school desegregation, it appears that no court has imposéd the intent standard in a Title VI ease.4
The court below opined that dicta in the concurring opinion of four justices in Regents of the University of California v. Bakke, 438 U.S. 265, 324, 98 S.Ct. 2733, 2766, 57 L.Ed.2d 750 (1978), and the dissenting opinion of Justice Stewart in Board of Education v. Harris, 444 U.S. 130, 152, 100 S.Ct. 363, 375, 62 L.Ed.2d 275 (1979), had undermined the authority of Lau v. Nichols, supra. These dicta do not justify the district court’s burial of Lau. The majority in Board of Education v. Harris, for example, expressly declined to decide the issue of whether Title VI incorporated an intent test. 444 U.S. at 149,100 S.Ct. at 374. And most recently, a plurality opinion of the *623Court in Fullilove v. Klutznik, - U.S. -, 100 S.Ct. 2758, 65 L.Ed.2d 902 (1980), invoked Lau in support of the Court’s decision.5
Since the contemporaneous agency regulations and, in my view, the legislative history, clearly support application of an effects test, I believe we are correct to wait for an actual decision from the Supreme Court in a case fairly presenting the issue, before we assume that Lau v. Nichols has gone by the boards. Lau v. Nichols is precedent which clearly requires application of an effects test to the instant case, and I therefore would not be deflected by dicta in cases devoted to the resolution of other weighty issues.
II
The majority concludes, and I agree, that plaintiffs made a prima facie showing that the closure of Sydenham Hospital would have a disproportionate racial impact. Under the effects test, therefore, the issue on this appeal is whether the City has carried its burden of demonstrating a sufficient nondiscriminatory justification for the closure. See NAACP v. Wilmington Medical Center, 491 F.Supp. 290, 314 (D.Del.1980). Cf. McDonnell Douglas Corp. v. Green, 411 U.S. 792, 93 S.Ct. 1817, 36 L.Ed.2d 668 (1973) (Title VII); Robinson v. 12 Lofts Realty, Inc., 610 F.2d 1032 (2d Cir. 1979) (Title VIII). Accordingly, this Court must determine whether the decision to close Sydenham was, in some sense, a “proper,” or at least an “acceptable” one.
The threshold question, of course, is what may constitute justification for a decision that has prima facie been shown to have a discriminatory impact. Must the City show that it had no alternative to the course chosen? Must it show that it chose the best existing alternative? May it prevail by showing that it considered the existing alternatives and did what it thought best? May it prevail by showing that it considered the existing alternatives and then flipped a coin? I suggest that the most appropriate course is a two-phase evaluation of the purported justification, under which the court would first examine the process by which the decision was reached, and only then, if a rational course has been followed, inquire into the substantive merit of the decision.
Having made a decision which will have a discriminatory impact, a Title VI defendant should be required to show at the very least that it proceeded on a rational basis in its decision-making process. In my view a rational process must include consideration of appropriate alternatives in the light of a factual assessment of the effect of these alternatives. If the defendant fails to show such a rational basis for the decision we should proceed no further in the justification inquiry. Such a defendant cannot be permitted to justify its decision by simple reference to the substantive goals that it sought to advance, because if its process lacks rationality, the defendant will not know either the extent to which its goals are in fact advanced, or the price of their advancement. Ending' the inquiry at the point at which it is determined that the defendant has failed to show a rational basis for its decision has several advantages. It will spare the court the task, undertaken by the majority here, of attempting its own evaluation of suggested alternatives whose merits have been inadequately developed in the record. It will *624avoid the need to speculate as to what the defendant’s decision would have been had it actually known all the facts. And it will minimize the risk of judicial usurpation of executive prerogatives inherent in any review of the substance of the decision.
I see no need in the present case to reach the question of the substance of the City’s decision because in my view the City failed to show that its decision had a rational basis.
A. The Procedural Posture of the Case
Before turning to the facts, it is important to note the precise posture of this case as it comes to us. The propriety of the district court’s denial of preliminary relief turns on whether plaintiffs established, to some degree,6 their probable success on the merits of their claims. At the hearing below, plaintiffs made a prima facie showing that the closure of Sydenham would have a disproportionate racial impact, and the burden therefore shifted to defendants to justify the closure.
Unfortunately, while the district court purported to apply effects test analysis, it apparently did so only as an afterthought. This issue was treated in one summary paragraph at the end of a 50-page opinion, and the absence of any supporting analysis of the facts renders the lower court’s conclusion that justification had been established less than persuasive. The bulk of the opinion was devoted to whether effect or intent was the proper test and to the evidence of discriminatory intent. Virtually all of the district court’s factual analysis was directed at the latter question. It has therefore been left to this Court to wade through the record and to reconstruct the case along the lines of plaintiffs’ consistently asserted, and prima facie valid, Title VI claim. For these reasons, as well as for those stated by the majority, I agree that this is a proper case for relaxation of the standard of review of denials of preliminary relief.
B. The Inadequacy of the Attempted Justification
The underpinnings of the City’s defense of justification are the propositions that it needs to close Sydenham in order to save money, and that it has determined that this closing would not unduly affect Sydenham’s patients. The deficiencies I find in the City’s presentation are that it took an unreasonably narrow view as to the range of possible alternatives, and that it had insufficient information as to the actual effects of the closing on Sydenham patients to make meaningful an evaluation of the available alternatives.
In simplest terms, the question facing the City was whether closing Sydenham was an “appropriate” way to save money. No one questions the City’s need to save money. Appropriateness, in this context, therefore turns on what alternative methods of saving money are available. This Court is not in a position precisely to delineate all of the alternatives which the City should have considered, but it is possible and appropriate to settle upon a reasonable area of inquiry. The allocation of City expenditures as among education, sanitation, transportation, fire fighting, police protection, health services, and so forth, is clearly a political decision. I would not venture to *625say that the City should have considered decreasing expenses in these other areas in order to avoid closing Sydenham.7 I thus agree with the majority that the alternatives to be considered should be confined to those within the health services area, and am willing to assume that our inquiry should be limited to various measures that might have been taken within the Health and Hospitals Corporation (“HHC”). But I cannot subscribe to the majority’s assumption that closing one of the other 16 municipal hospitals was the real — much less the only — alternative to closing Sydenham. There are indications in the record, amounting to little more than statements of the common sense principle, that from the point of view of cost-efficiency the closing of a whole hospital will generally save more money than would a comparable reduction in beds effected by elimination of single beds, wards or wings within one or more hospitals. This is so because many overhead expenses that are difficult to reduce when the hospital merely shrinks, can be eliminated entirely when the hospital is closed. If cost-efficiency were the sole criterion, then the only alternatives to closure of Sydenham would probably have been closure of other hospitals. But it was not in fact the sole criterion: this was made clear, for example, by the Mayor’s Report, which purported to apply a much more complex analysis to the problem of eliminating excess capacity. One of the considerations applied in this analysis was patient access to comparable alternative facilities. The report recommended that some hospitals not be closed solely on the basis of this consideration.
The complexity of the problem is also suggested by the recommendations which the Mayor’s Report actually made. These included a wide range of cost-cutting measures, such as elimination of individual beds and of larger units within hospitals, as well as closure of two whole hospitals. It is therefore clear that the choices facing the City were in fact quite complex. There is no reason to assume a simple — but artificial — set of alternatives simply for purposes of evaluating plaintiffs’ Title VI claim. But this is what the majority does when it compares the closing of Sydenham only to the possibility of closure of some other hospital.
The plaintiffs have contended that there were perfectly sound money-saving alternatives to the closing of Sydenham, involving mergers of municipal hospitals plus the regionalization of services to promote other efficiencies. They presented testimony of a former HHC official to show the feasibility of such alternatives. The City sought to show that the possibility of savings resulting from mergers was speculative; but it remains true that the City’s position that this was not a feasible alternative was developed only during the course of this lawsuit. In the course of deciding to close Sydenham the City had not evaluated these possibilities, despite the fact .that a city official recommended the study of possible savings from hospital consolidations, and despite evidence at trial that a study of the alternatives suggested by plaintiffs could have been completed in just three weeks’ time. In my view, the failure of the City to consider significant possible alternatives is a serious defect in its decision-making process.
Even had the City considered all of the alternatives for health care savings, however, I would not conclude that it had justified its decision to close Sydenham. This is so because throughout the process, the City’s decisionmakers focused so closely on economic considerations that they ignored reality as to the impact that the various alternatives would likely have on Sydenham’s patient population.
In fiscal year 1979, Sydenham admitted 3711 inpatients and had an average occupancy of 93 inpatients. The hospital currently has 107 certified beds. It is there*626fore a relatively small part of HHC’s overall operations, and its occupancy rate has been somewhat lower than the 90% figure generally considered optimal. Sydenham Hospital has other problems as well, including an older physical plant and a low Medicaid reimbursement rate, which render its operation relatively cost-inefficient. In economic terms, therefore, the City was clearly justified in considering Sydenham as a candidate for shrinkage or closure.
Nevertheless, certain characteristics of Sydenham’s clientele tend to distinguish them from the patient populations of other municipal hospitals. Primary among these distinctions are the fact that 63% (in fiscal year 1979; the proportion has been steadily increasing) of Sydenham’s inpatients are admitted through the emergency room, and the fact that at least one third8 of the persons presenting themselves to Sydenham’s emergency room do not have medical insurance (i. e., Medicaid, Medicare, Blue Cross/Blue Shield or other coverage) at the time they come in. These two facts become critically important when we consider the City’s analysis of what will happen to Sydenham’s patients if that hospital closes. The City introduced the results of a hypothetical study that allocated Sydenham’s patients to surrounding hospitals which, according to the statistics relied upon, consistently have unoccupied beds. The study placed particular reliance on four hospitals: St. Luke’s, Presbyterian and Mt. Sinai, which are voluntary hospitals, and Harlem, which is municipal. Plaintiffs, however, presented persuasive evidence that the three voluntary hospitals have a practice of not admitting uninsured patients — i. e., patients who cannot produce proof of insuranee at the time of admission. The City never asked the voluntaries about their policy in this regard. Hence it is not in a position to rebut plaintiffs’ showing. The City’s study purported not to allocate uninsured patients to the voluntary hospitals, but since the study assumed a much lower proportion of uninsured patients than appears to exist in fact, the study necessarily (even if unintentionally) did make such allocations. The study therefore does not adequately account for Sydenham’s uninsured patients. Moreover, there is no basis in this record for determining the actual scope of the problem.
The City raises two arguments in this regard, neither of which is persuasive. First, it points to New York Pub. Health Law § 2805-b(l) (McKinney 1977), which provides that
Every general hospital shall admit any person who is in need of immediate hospitalization with all convenient speed and shall not before admission question the patient or any member of his or her family concerning insurance, credit or payment of charges .
The City argues that under this section, the voluntary hospitals would be required to admit some uninsured patients. It is far from clear, however, that this provision would aid most of the Sydenham patients, because only the true emergency patients are provided for by this section. While it is a fact that most of Sydenham’s patients are admitted from its emergency room, a relatively small percentage of these are true emergency patients.9 There is no reason to believe that the voluntary hospitals would admit the others.
*627The City also argues that even when provision for Sydenham’s uninsured patients is evaluated on the basis of plaintiffs’ statistics, there will be only an insignificant number of uninsured patients seeking admission as inpatients. The City argues in its reply brief that if there were 3767 admissions to Sydenham in calendar year 1979, and 63% (or 2373) were admitted through the emergency room, then we can conclude that only 33.6% of these (the proportion of emergency room visitors who are uninsured, equalling 797 patients, or 2.18 per day) will be uninsured patients seeking admission at the surrounding hospitals, after Sydenham closes. Thus, according to this brief, “The number of uninsured patients is so small (i. e., only about 2 inpatient admissions per day) that the record below amply demonstrates that they would be cared for at Harlem Hospital . . . .” (City Reply Brief at 2). One fundamental flaw in this argument is its apparent disregard of the fact that, once admitted, the average Sydenham patient remains hospitalized for about 10 days. Thus plaintiffs point out that on any given day Sydenham has in its beds 23-28 uninsured patients who would need to be cared for elsewhere if Sydenham closed. The City’s prediction that Harlem Hospital would care for two uninsured Sydenham patients per day is of little value to the vast majority.
There are other problems with the City’s analysis of the closure’s impact. For example, that analysis was based on hospital occupancy figures for past years. Plaintiffs introduced a variety of evidence — apparently uncontroverted — that more recently the occupancy rates in Harlem area hospitals had increased, so that frequently all of the beds at Harlem Hospital,10 Presbyterian and St. Luke’s are filled, and that apparently all of these hospitals are now constantly operating at close to maximum capacity. The district court apparently credited this evidence. See 490 F.Supp. 291 at n.14. There is no indication, however, that the City’s decisionmakers considered these new developments.
Another possible problem involves Sydenham’s Medicare and Medicaid inpatients. The voluntary hospitals in Sydenham’s area maintain a lower percentage of inpatients in these categories than does Sydenham or the other municipal hospitals. Since the Medicare and Medicaid payments do not cover the entire cost of treatment, the voluntary hospitals have a clear disincentive to take a greater number of patients in these *628categories.11 The City apparently did not consider this factor in assessing the impact of Sydenham’s closure.
The foregoing discussion, while hardly exhaustive, is sufficient to demonstrate that the City did not give adequate consideration to the actual impact of closing Sydenham. The City’s patient redistribution studies were nothing more than hypothetical constructs. This is well illustrated by the testimony of the City’s expert, referring to one aspect of the study:
It was a device and it doesn’t represent either a reality, which none of this construct does, nor does it represent any real percentage of Medicaid days which we either knew or believed would go to any one of these hospitals. It’s just a construct to show an order of magnitude figure on the bottom line.
(Transcript of Hearing at 1332.) Plaintiffs have convincingly demonstrated that the City’s constructs ignored major practical problems which Sydenham’s patients would encounter after a closure. The City did not try to find out what policies the voluntary hospitals actually follow, nor did it adequately analyze the actual availability of alternative hospital facilities. It simply made little or no effort to determine what would actually happen to Sydenham’s patients upon closure of that hospital.
I an unable to find justification on the basis of such untested hypotheses or on assumptions which are untried and quite possibly untrue. I believe plaintiffs were entitled to a preliminary injunction against the closure.

. The agencies were:
Department of Health, Education and Welfare
Department of the Interior
Department of Agriculture
Department of Labor
General Services Administration
Housing and Home Finance Agency
National Science Foundation.
See 29 Fed.Reg. 16274-305 (1964).

. The Department of Health, Education and Welfare (“HEW”) has been divided into the Department of Health and Human Services and the Department of Education. This change did not affect the regulations at issue here, since those regulations were of general applicability, covering all programs administered by HEW. 45 C.F.R. § 80.2.

. The Court also held that private parties may bring suit to compel compliance with the regulations. The City does not challenge plaintiffs’ right to do so in the present case.

. School desegregation cases, such as Parent Association of Andrew Jackson High School v. Ambach, 598 F.2d 705 (2d Cir. 1979), find an exception to the effects test required by Title VI, reasoning that Title VI must be read in light of the explicit limitations of Title IV of the same Act, 42 U.S.C. § 2000c-6 (1976), which limitations were specifically addressed to the remedies available in school desegregation suits. Lora v. Board of Education, 623 F.2d 248 (2d Cir. 1980), apparently followed this principle. It may be that in other contexts, other statutory provisions or other considerations will be called to our attention which will lead us to carve out other exceptions to the Title VI effects test; those cases are best decided when they are presented to us. I see no such considerations in the present case, and no reason to follow blanket dicta uttered in the specialized context of school desegregation cases, to the effect that a Title VI claim always requires a showing of discriminatory intent.

. The opinion stated as follows:
There are revelant [sic] similarities between the MBE program and the federal spending program reviewed in Lau v. Nichols, 414 U.S. 563, 94 S.Ct. 786, 39 L.Ed.2d 1 (1974). In Lau, a language barrier “effectively foreclosed” non-English-speaking Chinese pupils from access to the educational opportunities offered by the San Francisco public school system. Id, at 564-566, 94 S.Ct., at 787. It had not been shown that this had resulted from any discrimination, purposeful or otherwise, or from other unlawful acts. Nevertheless, we upheld the constitutionality of a federal regulation applicable to public school systems receiving federal funds that prohibited the utilization of “criteria or methods of administration which have the effect . . . of defeating or substantially impairing accomplishment of the objectives of the [educational] program as respect individuals of a particular race, color, or national origin.” Id at 568, 94 S.Ct. at 789 (emphasis added).
Id at 2775.

. The standard in the Second Circuit for injunctive relief clearly calls for a showing of (a) irreparable harm and (b) either (1) likelihood of success on the merits or (2) sufficiently serious questions going to the merits to make them a fair ground for litigation and a balance of hardships tipping decidedly toward the party requesting the preliminary relief.
Jackson Dairy, Inc. v. H. P. Hood & Sons, 596 F.2d 70, 72 (2d Cir. 1979) (footnote omitted). The district court found that
closing Sydenham will have adverse consequences in some cases, particularly those involving serious gunshot and knife wounds and advanced drug overdose victims.
492 F.Supp. at 226. The resulting harm would, in at least a substantial number of such cases, be irreparable. I would also think that this sort of harm tips the balance of hardships decidedly toward plaintiffs, so that the injunction should issue if plaintiffs demonstrate “sufficiently serious questions going to the merits to make them a fair ground for litigation.” But since I believe that plaintiffs have in fact demonstrated likelihood of success on the merits, the balance of hardships question need not be reached.

. The City introduced evidence that HHC had not been subjected to budget cuts comparable to those imposed on other City agencies in the wake of New York’s fiscal crisis. The City apparently considered that fact to be a sufficient policy reason for imposing some restrictions on HHC.

. Figures compiled in the Mayor’s Report indicate that the “Self-Pay” (i. e., uninsured and non-paying) category accounted for 36.7% of the emergency room visitors in 1977, and 33.6% in 1978. These figures must be considered in light of the “Other” category, which apparently includes uninsured patients who make a partial payment for their treatment. The “Other” category accounted for 6.3% of the 1977 visits, and for 10.3% of the 1978 visits.

. Indeed, in a medically impoverished area such as Harlem, it seems likely that a large number of people would go to hospital emergency rooms for treatment which, in other areas of the city, would more routinely be sought in a doctor’s office. Although Manhattan as a whole has one doctor for every 400 people, and the United States as a whole has slightly more than one doctor for every 500 people, Harlem has only one doctor for every 4000 people. And some sections of Harlem have just one doctor for every 15,000 people.

. The majority relies on evidence that Harlem Hospital had 434 medical/surgical beds, and that its occupancy rate was 84%. At the hearing below, plaintiffs showed that Harlem Hospital in fact has only 263 general medical/surgical beds (i. e., the category into which Sydenham’s 107 beds fall), with a significantly higher rate of occupancy.
The figure 434, which is found in the reports of the Hospital itself, includes beds of a type not provided at Sydenham, i. e., specialty medical and specialty surgical beds. Plaintiffs point out that the conversion of these specialty beds (which now offer complex technical services) to general beds involves a protracted approval process, is sometimes infeasible, and would limit Harlem Hospital’s ability to provide the special services it presently offers. Finally, the 484 bed figure to which the majority alludes comes from City hypotheses, not from the Hospital’s reports. Given the City’s persistent claim that it must reduce the number of beds in the municipal hospital system, it is speculative, at best, to believe that Harlem Hospital’s bed complement would now be increased.
As to the rate of occupancy of Harlem Hospital’s beds, the Hospital’s monthly reports show an occupancy rate of 87.5% in the 263 general medical/surgical beds, which would indicate that only six Sydenham patients a day could be absorbed. Moreover, plaintiffs presented evidence at trial that these beds were often 100% occupied. For example, Dr. Sixsmith, chief of emergency services at Harlem Hospital, testified that perhaps once a week it happens that there are no beds available for patients needing to be admitted from the emergency room, and that the patients must therefore be kept lying on stretchers in the emergency room, waiting for beds to become available (Tr. 299).
Finally, plaintiffs point out that even if the specialty beds are included, to get the total up to 434, the 84% occupancy rate argued by the City (a) is lower than that shown by the Hospital’s own reports, and indeed lower than one of the City’s own calculations, and (b) in any event is inadequate to absorb all of Sydenham’s uninsured and underinsured patients, who require a total average of 33 beds per day.

. The exception to this pattern was the voluntary Hospital for Joint Diseases, which had a Medicare/Medicaid rate comparable to that of the municipal hospitals. Apart from the fact that Joint Diseases faces severe financial problems and may not survive, it could not have absorbed all of Sydenham’s Medicare/Medicaid patients.