Ailing from the recession, many U.S. hospitals have had to begin making painful cuts to patient services and laying off staff, as previous cost-cutting hasn’t been enough, an industry survey found.

In previous recessions the health care industry has held up well, but this time hospitals and other health care businesses are hurting. Besieged by financial pressures including more needy and uninsured people, hospitals now are making tough decisions that affect their patients and communities.

The American Hospital Association found 22 percent of hospitals that responded to its March survey have reduced services since the economic crisis began in September. Those services range from outpatient clinics and behavioral health programs to patient education and home health care after discharge.

Nine of 10 hospitals said they cut expenses in the first quarter, with eight in 10 cutting administrative spending. Other strategies include eliminating jobs, selling assets, reducing overtime, cutting staff hours, freezing salaries, cutting benefits and reducing supply costs. In addition, some hospitals are considering mergers to reduce costs.

Just under half the hospitals have cut staff, and the number resorting to mass layoffs — 50 or more employees at once — is up.