This triple issue of the HealthPAC Bulletin focuses on the challenges faced by health systems agencies (HSAs) in controlling healthcare costs amidst a conservative political climate and budgetary constraints. It highlights the decline of the New York City Department of Health (NYCDOH) due to severe cuts in preventive and primary care services, exacerbated by the city's fiscal crisis and the shift towards a market-driven healthcare model. Notable articles discuss the implications of these changes on public health services and the ongoing struggle for community-based care alternatives, particularly in the context of mental health facilities in Washington, D.C.