Tag Archives: geographic disparities

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.

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Decisionmaking From on High

Tomorrow, Friday, February 18, is the deadline for members of Governor Cuomo’s Medicaid Redesign Team to submit their “scores” for 49 proposals given to them by the New York State Department of Health that are supposed to generate $2.85 billion–yes, billion–in cuts to the Medicaid program. These 49 were culled from the several thousands received via a severely flawed public hearing and online/written submission process that took place over the last several weeks in cities across the state. Not only were many proposals put forward by consumers and members of the public entirely excluded from the 49 that the Team will ultimately be deciding on, the few that did make it in were inaccurately captured in the bizarre spreadsheet format being used to capture major policy proposals to restructure the state and the country’s largest health insurance program for the poor. Oh, and did we mention that the proposals are going to be scored using Survey Monkey? That’s right, Survey Monkey.

In response, the Save Our Safety Net Campaign, of which we are a part, issued this open letter to the members of the Medicaid Redesign Team, instructing them how to vote on certain key proposals. This is not to say that we accept or buy into the ridiculous “process” that has been put in place by the MRT, but we also can’t remain silent on issues that will significantly impact the communities we care about. You can click here to download a copy of the letter.

Please let us know if you have any comments or concerns. There will still be other opportunities to weigh in on this process. On February 24th, the Medicaid Redesign Team will be meeting to discuss the scored proposals. The meeting will take place in Albany, and it’s important to have consumer voices out in full force. March 1 is when the final recommendations of the Team will be announced. We are planning activities in New York City around the announcement and will keep you posted about details. And, of course, state elected officials will have to weigh in on the recommendations too, and we are hoping that if you are  a New York resident that you will tell your representatives how you feel about the Medicaid program and why it is important to you and your community.

Critical decisions about the health care system in New York should not be made from on high, but from the ground up.

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Community Input When a Hospital Closes

As we have written about before, the community of Southeast Queens has long experienced some of the worst health outcomes in New York City across a variety of measures.  No doubt, the shuttering last year of both Mary Immaculate Hospital in Jamaica and St. John’s Queens Hospital in Elmhurst has only placed additional strains on the already insufficient healthcare infrastructure in Queens, and on Southeast Queens in particular. These and other hospital closures occurred without any input from community members – the very people who utilized the services that these hospitals provided were left unable to make their voices heard on how the closure would affect them, and on what healthcare services they thought were critical for the community.

In order to ensure that communities affected by future hospital closures would have at least some voice in the process, Assembly Member Rory Lancman and State Senator Shirley Huntley introduced the Hospital Closure Planning Act. This original bill would have required the Commissioner of Health to hold a “public hearing” within 30 days of a proposed hospital closure in order to assess the impact a hospital closure would have on the area it serves.

Despite the overwhelming support in the legislature, as well as advocacy in support of the bill from Southeast Queens United in Support of Healthcare (SQUISH) among others, Governor Patterson vetoed that initial bill.  Now, after negotiating with DOH and the Governor–and, importantly, after the closure of St. Vincent’s in Manhattan, which, in contrast to the hospital closures in Queens garnered significant and vocal opposition from a notably wide range of politicians and stakeholders –the Governor signed a revised version of the bill.

As Assembly Member Lancman said last week, “The government has to, at least, make an effort to let communities affected by a hospital closure know how their healthcare needs will be addressed. We may not be able to stop a hospital from closing, but we ought to be able to measure the impact of that closing and come up with a plan for serving the residents who relied on that hospital for healthcare services.”

The revised bill requires the Commissioner to hold a “community forum” within 30 days after a hospital closure to hear from affected community members.  After the forum, the Commissioner must also release a written report on the anticipated impact of the closure to the community, as well as the Department of Health’s plans to mitigate the negative effects of the closure and to ensure continued access to healthcare.

To be sure, the Act is only a small first step in making sure that low-income communities of color most in need receive equal access to quality health care. Nevertheless, it is an important one in that it begins to recognize the community’s role in health planning.

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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.

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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.

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Keeping the Community in Health Planning

Last week, the Commission on the Public’s Health System (CPHS) and NYLPI collaborated to comment on proposed legislation that would streamline the certificate of need process—the administrative procedure healthcare providers generally must go through in order to increase or modify their infrastructure (e.g., equipment, buildings and parking lots), or services they provide.  While a more efficient health planning process is a laudable goal, our organizations believe that it should not come at the expense of further removing community stakeholders—the very people who use the services—from the healthcare planning process.

Instead of simply deregulating the process even more, CPHS and NYLPI have called for three recommendations to amend the proposed legislation to still achieve efficiencies, but give communities a continued role in the process.  Our recommendations were not only made with an eye toward ensuring that community stakeholders have a voice in healthcare decision-making, but also that the State Department of Health is well-situated to strategically allocate healthcare resources in the most equitable way possible, especially for medically under-served communities of color and immigrant communities.  Read our memo and stay tuned for further developments.

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Run On and See Where It Ends: Fighting to Make Health Equality a Reality

This post, by Health Justice Director Nisha Agarwal, has also appeared on Race-Talk, Huffington Post and AlterNet.

Saturday morning, April 17th, the auditorium of Junior High School 22 in the Bronx was crowded with community residents who had gathered for a town hall meeting. Health care reform had passed, but these folks knew that their problems were not over. Ensuring that most Americans have health insurance, while important, will not be enough to eliminate the racial and ethnic disparities that have been dyed deep into the U.S. healthcare system and that reveal themselves, vividly, in the Bronx.

To save black and brown lives and to improve the vibrancy of those lives requires looking beyond access and focusing on quality. It requires, among other things, an examination of the practices of major health care institutions, which deny low-income people of color the highest quality of care they have to offer even when those people have health insurance.

The specific issue that community members had gathered about is this: in New York City, prominent private hospitals–facilities like New York-Presbyterian, Montefiore Medical Center, Mount Sinai–operate two different systems of care for patients with the same kinds of health problems but with different types of insurance. There are, for example, cardiology “clinics” for patients with Medicaid, a public insurance program, and there are cardiology “faculty practices” for patients with private insurance. Sometimes the clinics are right next door to the faculty practices, but Medicaid patients won’t be allowed into the faculty practices, and privately insured patients are not sent to the clinics.

What is more, the hospitals allow valuable and finite resources to be allocated unequally between the two systems of care. For instance, clinics often do not have enough financial support from the hospital to perform basic care coordination tasks like sending notes back to the patient’s primary care physicians, while faculty practices often receive administrative and other forms of support so that such tasks are routinely able to be done.

More significantly, board certified faculty physicians, the top docs, spend only a fraction of their time in the clinics–a mere half a day a week for four months out of the year in one case–even though they are required by law to spend the bulk of their time supervising resident doctors and caring for patients in the clinic setting instead of in the faculty practice. Hospitals do nothing to shift the balance and, as a result, Medicaid patients do not have a single, board-certified physician who is ultimately responsible for their care, whereas privately insured patients do. Here is a chart summarizing some of the main inequalities:

The impact of these differences are felt on the bodies and backs of low-income patients. At the town hall meeting, Medicaid beneficiaries spoke of being bounced from one doctor-in-training to the next within a fragmented clinic system, where fingers and toes were almost amputated and cancer remained undiagnosed until dangerously late. And they spoke of how these outcomes were not race neutral. In New York, people of color are far more likely to have public insurance than whites, which means that when hospitals create two systems of care based on insurance they are also perpetuating a de facto segregation based on race. (For more background and helpful stats on this issue, please see this excellent monograph on medical apartheid in New York City by the Bronx Health REACH coalition, the group that first brought this problem to light.)

Representatives of health care institutions have argued publicly that community residents are missing the point. The source of the problem, they claim, is with the Medicaid program and not with the hospitals. Doctors’ offices are reimbursed at extremely low rates through Medicaid and therefore can’t afford to see publicly insured patients in their faculty practices. The clinics have been set up to provide an avenue for care that otherwise wouldn’t exist.

But it is the hospital representatives who are missing the point. The provision of care to Medicaid patients is not something hospitals are choosing to do out of the goodness of their hearts. Under federal law, hospitals are required to open their doors to Medicaid beneficiaries, and provide them care without discrimination, in exchange for accepting millions of dollars of government funding to modernize and upgrade their facilities.

Moreover, while Medicaid reimbursement rates for doctors’ offices are very low, they are much higher for clinic-based services. In order to integrate care, hospitals could simply shift their resources to the clinic and ensure that all patients, public and private alike, are seen in that setting, instead of siphoning off the privately insured patients to the faculty practices. The increased resources and mixed patient population would help ensure that the quality of clinic care would improve dramatically and that this high-quality care would be accessible to all on equal terms.

Of course, hospitals are choosing not to do this and, given the dubiousness of the financial arguments, one is left to presume that their motives are more suspect: one cannot attract wealthy, white patients from the Upper East Side and Westchester if those individuals will have to sit in the same waiting room as people of a different class or race. The fight to integrate our health care system and to reduce racial and ethnic health disparities is therefore going to be just as messy as the historic battles to integrate our educational system or our housing. But fight is what Bronx residents will do, even in the face of uncertainty and resistance. As one faith leader said at the town hall meeting, quoting a song from the civil rights movement of deep South, we must “run on and see where it ends.”

To learn more about Bronx residents’ efforts to eliminated segregation in New York City’s healthcare system, please click here or visit the website of Bronx Health REACH.

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