OPINION: Address community needs before closing hospitals

Check out the opinion piece written for the Brooklyn Daily Eagle by HJ team members Shena and Jenn about hopsital closures in low-income communities of color in Brooklyn and what they mean for access to care. You can read the piece here.

 

New Report on Health Needs, Gaps and Barriers to Care in North and Central Brooklyn Released in Conjunction with Proposed Redesign of Brooklyn’s Health Care System

See below—and congratulations to Shena, Jenn, and Alyssa for their hard work!

Brooklyn, NY (April 10, 2013)—In conjunction with the proposed redesign of Brooklyn’s Health Care System the Community Health Planning Workgroup (CPHW), a consortium of community stakeholders, healthcare providers and community health planners, today released The Need for Caring in North and Central Brooklyn, A Community Health Needs Assessment, sponsored by The Brooklyn Hospital Center, the I M Foundation, and the New York State Department of Health. The Community Health Needs Assessment, conducted by the Brooklyn Perinatal Network, the Commission on the Public’s Health System, and New York Lawyers for the Public Interest, sheds additional light on North and Central Brooklyn residents’ perception of the needs, gaps and barriers to care in their communities.

The report covers 15 zip codes, including Bedford Stuyvesant, Bushwick, Brownsville, Crown Heights, Cypresss Hills, East Flatbush, East New York, Flatbush, Fort Greene, Prospect Heights, Williamsburg, Downtown Brooklyn, Gowanus and Greenpoint, and addresses key findings, focus group results, and recommendations.

Field surveys and focus groups were used to capture the voices of the community. Community residents completed over 600 surveys, and 79 residents participated in nine focus groups targeting groups underrepresented in the survey sample, including teens; individuals with disabilities; Spanish speakers receiving mental health services; immigrants; men aged 18-35 and 45-55; senior citizens; pregnant women; and LGBTQ individuals.

Following the completion of the Community Health Needs Assessment, listening sessions were held to solicit community input and feedback concerning the findings.

Among the key findings:

• The report found the most common illnesses/health conditions among residents surveyed were high blood pressure/hypertension (24.8%), followed by asthma (19.9%); diabetes (15.7%); and hearing or vision problems (15.2%).
• 85% of respondents said that it would be most convenient to receive care in their neighborhood; almost 20% of the sample (18.7%) received none of their care in their community.
• 50% of residents surveyed said they or members of their household had visited an emergency room in the past two years.
• When asked which healthcare services households had difficulty accessing in their neighborhood, 100% of respondents said a dentist.
• Half of respondents had a limited ability to secure health care services. When asked why, 48% said barriers to health care included quality of care, culture and language differences, hours of service and attitudes of providers; 19.8% said insurance issues or lack of insurance; 23.1% said long waits for or at appointments; and 9.1% said cost of care.

“We are really pleased to have had the opportunity to ensure that the community’s voice is a driving factor in how healthcare is delivered and look forward to the healthcare planning developments that come from the CHNA process. We are hopeful that our process will serve as a model way to meet the needs of communities being served,” said Shena Elrington of New York Lawyers for the Public Interest who served as co-lead partner in the development of the report.

The report concluded with approximately 15 critical recommendations to improve healthcare in Brooklyn. These included addressing accessibility; improving screening, outreach, cultural and linguistic competency, patient-centered care, and customer service training; providing extended hours for primary care; increasing awareness and access to low-cost health services/insurance; providing financial support of efforts by grassroots community-based organizations (CBOs) to promote community resources; coordinating a network of health care and social service providers; engaging community residents; targeting services to focus on particular illnesses and communities; increasing access to specific health care services; working with Access-A-Ride to address transportation issues; increasing the number of providers who accept public health insurance; and increasing availability and access to mental health services.

To read the full report, click here. To read a summary of the report, click here.

Suffolk County Language Access Executive Order Signed!

by Lindsey Hennawi, Program Assistant

Great news! On November 14^th, 2012, Suffolk County Executive Steve Ballone signed an executive order requiring county government agencies to translate vital public documents into the top six languages spoken by limited English proficient (LEP) residents of Suffolk County and to provide interpretation services for all LEP residents as well.

Twenty percent of Suffolk County’s 1.5 million residents are LEP. Now, residents whose primary languages are Italian, Mandarin, Spanish, Polish, French Creole, and Portuguese will be able to access local government offices and communicate with officials. This means victims of domestic violence and hate crimes can access police protection. Residents affected by Superstorm Sandy can receive much needed information about recovery efforts. Support services such as unemployment insurance and public benefits are now also accessible to LEP residents. Thanks to this executive order, an individual’s language will no longer be a barrier to participation in government services or access to important resources.

The order is descended from similar legislation, including President Clinton’s 2000 executive order that mandated all agencies receiving federal funding develop language access plans in order to comply with the 1964 Civil Rights Act’s prohibition of discrimination based on national origin; Mayor Bloomberg’s Executive Order 120, signed in 2008, that bans city agencies from discriminating against residents based on their primary language or national origin; and Governor Cuomo’s 2011 Executive Order 26 that does the same for executive state agencies.

One of the first of its kind in a suburban county in the United States, Mr. Ballone’s executive order comes on the heels of the previous Suffolk County executive, Steve Levy, who in his tenure utilized county police as immigration agents, criminalized Latino day laborers, and marginalized Latino-majority neighborhoods, earning the county a reputation for anti-immigrant resentment and violence.

Suffolk County’s executive order is a result of the advocacy of the organizations with which NYLPI partnered on this campaign, including the Long Island Civic Engagement Table, the Long Island Language Advocates Coalition, Make the Road New York, the Center for Popular Democracy, and other groups that have tirelessly promoted immigrants’ rights in Suffolk County for years. Since 2009, NYLPI has advocated for language access orders on the city, state, and county level, and is currently working to develop materials to help other advocates replicate these efforts.

We are thrilled Suffolk County has taken this critical step toward advancing the civil rights of LEP individuals and making New York a more inclusive home for all its diverse residents. Congratulations to all of the advocates involved and thank you, Steve Ballone, for your work toward equality and justice on behalf of LEP residents! May yours be one of many county orders to come.

A Community Mobilizes to End Medical Apartheid

Hello readers, we are pleased to announce that the peer-reviewed journal, Progress in Community Health Partnerships, has published a piece about our campaign with Bronx Health REACH to end segregation in the delivery of health care services by teaching hospitals in New York. You can download a copy of the piece here. Feedback welcome! We are using every avenue at our disposal to get the word out about this urgent issue, including the very types of publications that health care providers and policy decision-makers are likely to peruse.

Acknowledging Difference, not Defeat: A Racial Justice Perspective on the Medicaid Debate

This post, by Health Justice Director Nisha Agarwal and Staff Attorney Shena Elrington, also appears on the Race-Talk blog, Huffington Post, and Alternet.

The federal Medicaid program has become something of a policy piñata in the national discourse. Over the course of the past year conservatives have been asking, “is Medicaid real health insurance?” The public insurance program for low-income individuals has been criticized for not providing sufficient access to physicians, long wait times to see a physician when one can be accessed, and poorer quality of care once patients get in the door – all of which conservatives argue are reasons to dismantle the program altogether. If being on Medicaid isn’t much better than being uninsured, why bother spending tax dollars on it?

Meanwhile, a recent editorial in the New York Times offered unequivocal praise for the Medicaid program, pointing to a study conducted in Oregon that allowed researchers to compare the experiences of people who received Medicaid coverage to those who did not. According to the study, Medicaid recipients reported better health than the uninsured recipients  and were less likely to have medical bills sent to  collection agencies or forgo other obligations in order to pay for their medical care. Supporters of the public health insurance plan were therefore able to hit back against conservative naysayers and argue that Medicaid truly is a program worth preserving and expanding.

While the national debate lurches back and forth, we find a more complicated reality on the ground, in the low-income communities of color where we work to eliminate race- and class-based biases in the health care system. The uncomfortable truth is that Medicaid beneficiaries do often receive poorer quality of health care, particularly when it comes to accessing specialists. But to see this you have to look at how Medicaid beneficiaries fare vis-à-vis privately insured individuals, not the uninsured, which has been the focus of current debates.

For example, in  our work with Bronx Health REACH, a faith-based community coalition in the Bronx, we have seen how Medicaid patients seeking specialty services at major New York City hospitals are seen in separate—effectively segregated—facilities from their privately-insured peers, with longer wait times, less experienced doctors, and much less continuity and coordination of care. (You can read more about these problems in this monograph published by the Bronx Health REACH coalition and in this complaint we filed with the New York State Attorney General.)

Working with low-income parents, we have also seen how children with Medicaid have to wait for grotesquely long periods of time before they can get mental health treatment and special education evaluations, if they are able to access these services at all, and how elite institutions providing such services refuse to serve publicly insured populations despite the significant shortage of pediatric mental health providers in New York City.

Our experience thus seems to support conservative arguments to some extent: Medicaid beneficiaries do not have sufficient access to physicians, experience long wait times to see a physician when one can be accessed, and suffer from poor quality of care once they get in the doctor’s door, at least when compared with those patients who are privately insured.

Undoubtedly the current climate surrounding Medicaid makes it difficult for advocates to point out the lower quality of care Medicaid beneficiaries receive, for fear that any criticism of the program will serve as powerful ammunition for the other side to use. But acknowledging certain aspects of the conservative argument need not mean that advocates have to accept the entirety of their conclusions. Something else we’ve learned through our work is that Medicaid isn’t “bad” insurance per se. Rather, healthcare providers and institutions choose to treat Medicaid beneficiaries badly by discriminating against them with respect to the quality of care provided. Consider the Bronx example. Hospitals in New York City (and elsewhere) are not only reimbursed by Medicaid for providing patient care, they also receive over $1 billion through the Medicaid program for non-patient purposes such as resident doctor training – a funding stream so substantial that the New York hospital industry is fighting tooth and nail to keep it safe from federal budget cuts. Medicaid seems to pay hospitals very well, and yet these same hospitals choose to provide segregated and unequal care to Medicaid beneficiaries. Why?

As with many things, these bizarre dynamics cannot be understood without accounting for race, and for the fact that the vast majority of publicly insured individuals in New York City are black and brown. We have heard how top-flight specialists want to be able to choose the patients that they treat, which is invariably code for avoiding people of color who are perceived to be more “complicated” and “non-compliant.” Elite NYC hospitals eager to attract these specialists happily comply to doctors’ demands by giving them fancy facilities to see their preferred patients, while the Medicaid patients are separated out into “clinics”, where they are treated by a rotating band of doctors-in-training.

In addition to wanting to attract renowned specialists, the hospitals want to attract the “right” kind of patients – that is, wealthy, white, suburban patients. Behind closed doors administrators will openly argue that their “‘paying’ patients will not want to sit in the same waiting room as people on Medicaid,” so it is simply better for the hospital to segregate the two groups.

Worse still, these biases become a part of the culture of how medicine is taught, with students and residents working with Medicaid patients in the clinics learning very early on that some patients—the kinds of patients they get to practice on, the poor patients of color—are less worthy than others. Indeed, research has suggested that by the end of their medical education, student doctors actually become more biased than they were when they began medical school. These biases, whether conscious or not, permeate the medical system at both an individual and systemic level, affecting the quality of care that Medicaid beneficiaries receive.

From our perspective, the debate about Medicaid is less about left-and-right and more about black and white. The conservatives’ sleight of hand is to point to quality of care problems for Medicaid beneficiaries and to jump from there to the conclusion that the Medicaid program is to blame, which obscures the mediating role that institutional racism plays in ensuring poor outcomes for Medicaid patients. Meanwhile, supporters of Medicaid effectively erase race from the debate as well by closing their eyes to the many challenges Medicaid beneficiaries face in accessing high-quality health care, despite the fact that they are walking in the door with an insurance that research shows is pretty good. A more nuanced position would acknowledge differences in care without accepting defeat. It is not the Medicaid program that must be dismantled, but the biased attitudes and policies that lead Medicaid patients to get inferior quality of care.

New York Needs Safety Net Hospitals

Here is our op-ed on the Medicaid Redesign Team that ran in today’s Albany Times Union. Comments most welcome!

By Nisha Agarwal and Shena Elrington

Gov. Andrew Cuomo‘s Medicaid Redesign Team was handpicked by him and elected by no one. Though touted as a collection of health care “experts,” the majority of the team’s members have strong ties to special interests in the health care industry.

Not surprisingly, its proposals for cuts reflect the vested interests of its members.

Proposal 67 calls for the closing or downsizing of safety net hospitals that provide health care services in medically under-served areas. We need more health services in these communities, not less, particularly since these communities have been ravaged by hospital closures in recent years.

Central Brooklyn, with its extremely low-income and 90 percent black and Latino population, has lost two hospitals, OB-GYN and prenatal services at two other local hospitals, 13 outpatient clinics, a federally funded health center and at least two women, infants and children program centers that provide nutrition education and assistance in recent years, despite having some of the worst health outcomes in the city.

The infant mortality rate in the Brownsville section of central Brooklyn is nearly five times that of Manhattan’s Upper East Side.

Do we really need more hospitals in areas like central Brooklyn to close?

When safety net hospitals close, people are forced to travel farther to see care at the few institutions that remain open — usually elite private academic teaching centers. These are the very same institutions to which many of the Medicaid team’s members have strong connections, raising questions about the appropriateness of using the regulatory process to funnel business to special-interest groups.

What is more, proposals that would actually support safety net institutions and use public dollars in an accountable and transparent way never made it into the final Medicaid reform package.

Proposal 66, for example, would have recalibrated charity care and Medicaid dollars so that the distribution of that funding would be based on the actual Medicaid and uninsured losses. Hospitals in New York now receive “indigent care” funding regardless of the volume of care they actually provide to Medicaid and uninsured patients. So, hospitals that provide very little care to low-income New Yorkers often get more money from the indigent care pool than they deserve, while safety net institutions, which provide a lot of care to Medicaid and uninsured patients, do not get their fair share.

Recalibrating the way this funding is distributed would not only make sense and bolster the financial stability of critical safety net institutions. It also is required under federal health reform and was very favorably ranked through the Medicaid Redesign Team’s own scoring process. Yet, the proposal never made it into the team’s final recommendations.

New York is in the midst of an epic budget crisis. Medicaid is seen as the linchpin to solving that crisis. But its redesign should not be done in such a way as to threaten the very institutions that serve as a safety net for our state’s most vulnerable residents. The erosion of our health care safety net threatens the stability of the system for all of us.

Save Our Safety Net – Video from Medicaid Redesign Hearings

On February 4, 2011 – Governor Cuomo’s Mediciad Redesign Team (MRT) held a public hearing in NYC. The MRT has been charged with finding $2.85 billion of cuts to New York’s Medicaid budget by March 1st. The MRT – which has a disappointing lack of consumer voices  – gave New Yorkers 2 minutes during the hearings to give their suggestions for Medicaid redesign.

This video captures the repeatedly expressed sentiment that cuts to already struggling safety net providers will have catastrophic impacts on low-income, immigrant and disabled communities.

Knowledge is Power

This post is by Julina Guo, a Columbia University student and intern for the Health Justice program.

Disparities in health care impact thousands of lives every day.  One of the biggest challenges in the fight for equal health care is lack of awareness. We can help ourselves to become more knowledgeable and informed so that our own voices are heard in the healthcare debate. Below is a list of notable works that have highlighted pressing issues in health care equality as it relates to race, immigration, gender, and socioeconomic status. Although numerous reports and research studies have been published on the topic of health disparities, we focus in this bibliography on more journalistic works that tell a story of how health disparities impact real human lives.  We hope you find it useful!  And if, in the course of your travels through this literature, you discover other wonderful texts you’d like to share, please email us  (healthjustice@nylpi.org) and we’ll add them to this bibliography.  Thanks!

Abraham, Laurie K. 1993. Mama Might Be Better Off Dead: The Failure of Health Care in Urban America.  Chicago: University of Chicago Press.

Abraham examines the real impact of unequal health care on the Banes, a low-income African American family, in Chicago. Through stories of inadequate medical attention, visits to the emergency room, struggles to qualify for Medicaid, and other misfortunes that befell this family, Abraham depicts the need for health care reform through the eyes of the poor.

Byrd, W. Michael and Linda A. Clayton. 2001. An American Health Dilemma: Race, Medicine, and Health Care in the United States, 1900-2000. New York: Routledge.

An extensive chronicle of the African American experience within the larger context of health care in the United States and global racism in the last 2,000 years. Byrd and Clayton posit that that the denial of quality health care to African Americans originated in colonial era, a tradition that quickly transformed into a social norm to deprive African Americans of their rights.

Fadiman, Anne. 1997. The Spirit Catches You and You Fall Down:  A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus, and Giroux.

This book describes the emotional and medical tragedy of the Lee family, a refugee Hmong family from Laos, in the 1980s. When their child Lia Lee was diagnosed with severe epilepsy at an early age, the Lees tried to negotiate with doctors in a culturally mismatched setting only to find tragedy.

Hilfiker, David. 1994. Not All of Us Are Saints: A Doctor’s Journey with the Poor. New York: Ballantine Books.

Hilfiker documents his experiences as a physician in a Washington, D.C. ghetto. In 1983, Hilfiker moved his family into the Christ House, a medical recovery shelter for homeless men, and later founded an AIDS shelter in 1990. This moving narrative depicts vivid personal encounters with a ravaged health care system divided by race and poverty.

Jones, James. 1993. Bad Blood: The Tuskegee Syphilis Experiment. Free Press.

An analysis of experimentation by the United States Public Health Service from 1932 to 1972 on poor African American men infected with syphilis. Jones argues that by purposing deceiving and depriving the men of medical treatment, doctors perpetuated an ugly symbol of racism that has survived to this day.

Smith, David B. 1999. Health Care Divided: Race and Healing a Nation. University of Michigan Press.

Telling first-hand accounts and statistical evidence of inequality in health care outcomes move this narrative as it details changes from the 1920s to the present. Smith examines efforts by the federal government and courts over the years, giving special attention to the 1964 Civil Rights Act in the health care arena.

Vigen, Aana Marie. 2006. Women, Ethics, and Inequality in the U.S. Healthcare: “The Count among the Living.” Palgrave Macmillan.

A perspective of the disparities of healthcare as seen through African American and Latina women with breast cancer. Vigen crafts their stories in the context of current healthcare research, giving a voice to those marginalized in the healthcare debate.

Washington, Harriet A. 2006. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York: Harlem Moon.

Washington examines the history of unethical medical experimentation of African Americans. She details practices in the colonial era, following the introduction of Darwinism, social eugenics, and the Tuskegee Experiment

Proton Beams or Primary Care

Crain’s Health Pulse, the New York health industry rag, has been abuzz for the last couple of weeks with news about health services in Queens.  Specifically, there’s been a lot of talk about a proposed “proton beam cancer center” to be located on the former site of Mary Immaculate Hospital (“MIH”), and to be funded by “500 rich foreigners” (for real).  Readers of this blog will recall that we have been collaborating with a community-based coalition, Southeast Queens United in Support of Healthcare (SQUISH), for several years, first working with coalition members to keep MIH from shutting down and now partnering with them to advocate for health services to fill the void created by the hospital’s closure.  The question is: does a proton beam cancer center fill that void, even in part?

And the truth is we’re not really sure.  On the one hand, cancer is one of the leading causes of death in Jamaica, Queens, resulting in 3,636 potential years of life lost in the area according to the NYC Department of Health.  Proton beam therapy is basically a way to offer cancer radiation treatment that is more targeted and less likely to impact healthy tissue surrounding the cancerous cells.  Considering these facts, a proton beam cancer center would seem to be a good thing because it offers cutting-edge treatment for a disease that kills a lot of people in Southeast Queens.

On the other hand, no one knows if the proposed cancer center would actually be affordable or accessible to most of the residents of Southeast Queens.  Will it accept public health insurance plans like Medicare and Medicaid?  Will it have sliding fee scales for the uninsured and under-insured?  If not, then the proton beam cancer center will hardly fill the enormous gaps in health access that plague the neighborhoods of Southeast Queens, and will serve instead as a lily pad for rich foreigners who can hop in and out of Queens for their high-end treatment from nearby JFK airport.  Viewed from this perspective, the proton beam cancer center isn’t worth celebrating; what is needed is more primary care and hospital beds.  Indeed, just recently, Crain’s also reported that the intensive care units of hospitals in Queens are themselves in a state of acute stress — over-capacity by over 200% in some cases.

There is no doubt that the Southeast Queens community needs more health services.  As we’ve written before, in New York City and in other major metropolitan areas across the country there is a close relationship race, place and access to healthcare services, and Southeast Queens is a prime example of the mis-match between healthcare need and resources.  In the wake of MIH’s closure, it is unclear whether wave-of-the-future technology like proton beam cancer therapy is really what the doctor ordered, or if it would simply be better to have some old school primary and preventative care services that would help people avoid getting gravely ill in the first place.  In an effort to better understand the implications of the center on their community, members of SQUISH are considering reaching out to the State Department of Health to find out more about the proposal and make their concerns known.  We will keep you apprised of any developments, but, in the meantime, don’t be shy!  Let us know through your comments here if you live in Southeast Queens and have any opinions on the matter.  We look forward to hearing from you.

Policy Is About Priority: Where Do Moms Fit In?

This post is by Rylee Sommers-Flanagan, a summer intern with the Health Justice Program and a student at Emory University in Atlanta, GA.

Recently, news sources and blog sites released a flurry of commentary and news articles on the results of a study by the New York State Health Department that indicate unusually high mortality rates for pregnant women in New York, particularly New York City. While the report declined to make a causal link, the article published in the New York Times mentioned not only that “death rates were highest in the Bronx and Brooklyn,” but that black women were “seven times as likely to die in pregnancy as white women.”

Unfortunately, these numbers don’t surprise us. Due to entrenched racial inequalities, health disparities between whites and people of color are visible in both treatment and outcomes. Care is often segregated and sometimes it is simply nonexistent.

Take, for example, Central Brooklyn, where 92% of the population is of color. Since 2003, three major medical providers – Caledonia Hospital, St. Mary’s Hospital and the Lyndon B. Johnson Health Center – have all closed. Also in the last seven years, Central Brooklyn has lost OB/GYN and NICU services at the Interfaith Medical Center, prenatal services at the Kingsbrook Jewish Medical Center, as well as two WIC centers and four primary clinics, all now closed.

Losing these services won’t improve the disparate health fates of residents in Central Brooklyn. Predictably, the most dramatically medically underserved are also victims of the highest rates of maternal mortality and similarly elevated infant mortality rates – in Central Brooklyn, 8.75 infants die per 1000 live births compared to 2.1 deaths per 1000 in the Upper East Side.

Maternal and infant mortality are enough cause for concern, but decreased medical services have many more consequences. Another telling example is the remarkable gap in both rates and results of diabetes in Central Brooklyn as compared with the same in New York City as a whole. In 2008, 68% more people died from diabetes in Central Brooklyn than did in the rest of New York City. The story repeats itself to the tune of a variety of medical conditions. Hope seems foolhardy in this climate of hospital bankruptcies, pared budgets, and continuously diminished access to care.

But improvement is not impossible. One approach, embodied in the Infant Mortality Reduction Initiative (IMRI) has been successful in reducing infant mortality and increasing the number of women who receive pre- and post-natal care. By networking with existing programs and creating community partnerships, IMRI is generating progress. Yet, even as the report on maternal mortality illuminated the distance stretching ahead, the city has moved to severely reduce funding for IMRI and consequently participating organization like the Brooklyn Perinatal Network. There are few groups currently filling the gaping fissure left by multiple hospital closures and decreased services in the medically underserved regions of New York City. We need them all to be secure.

New York City is not the only player to blame in this game. According to The Lancet, 23 countries are on course for reducing maternal mortality as outlined in Millennium Development Goal 5, that’s 75% by 2015. The United States is not among them. A surprising set of countries – China, Egypt, Ecuador and Bolivia – are ahead of schedule.

Ultimately, policy is about priority; why aren’t mothers, infants and health a priority? Well, that’s our question for the City of New York, as well as the rest of these United States.