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.
Tag Archives: health care providers
by Shena Elrington, Staff Attorney
Undocumented immigrants lack access to viable long-term care options. This is hardly surprising, given the surge in anti-immigrant sentiment, the serious budget crises facing federal, state and local governments and the piecemeal way in which we approach health care delivery. Although not surprising, the lack of long-term care options has very real consequences for both the lives of these immigrants and the overall well-being of the healthcare system.
A flurry of recent newspaper articles has brought the plight facing undocumented immigrants in need of long-term care into sharp focus. In the typical scenario, an undocumented immigrant suffers a catastrophic injury or illness, such as stroke, and is rushed to the emergency room, where she receives care, as required by federal law. The initial injury or illness may have been so severe that the patient becomes incapacitated, unable to feed or care for herself. The hospital then looks for appropriate long-term care facilities, such as nursing homes, to care for the patient. Finding such a facility, however, is nearly impossible because the patient cannot pay out of pocket and is ineligible for Medicaid because of her immigration status. The hospital, unable to find an appropriate facility to discharge the patient, chooses whether to continue to treat the patient, at a cost of several thousand dollars per day, for an indefinite period of time.
Some undocumented immigrants who find themselves in this precarious situation fare better than others. They all, however, live in a constant state of uncertainty, unsure of when the hospital will stop caring for them. And when the hospital terminates treatment, as it inevitably will, undocumented immigrants are faced with a truly terrifying range of “choices”, leading them closer and closer to death.
In September, a hospital in Atlanta refused to provide dialysis to nearly two dozen undocumented immigrants who had been receiving treatment for years. As deadly toxins built up in their systems, some immigrants sought care at various emergency departments, but were refused treatment because their conditions had not deteriorated significantly enough to trigger the hospital’s duty to provide emergency care under federal law. These immigrants were forced to wait until they were literally at death’s door to receive treatment. After much wrangling and public outrage, the hospital agreed to continue to provide dialysis for three more years.
But, what happens when that three-year period comes to an end?
Some hospitals, acting outside the federal immigration process, actually contract with private transport agencies to have these patients, with or without their consent, flown back to their home countries, without ensuring that there are any healthcare facilities in those countries able to support their needs. In essence, these immigrants are sent home to die. Based on our work with community partners and advocates, we know these “medical deportations” are not isolated events.
The perils undocumented immigrants in need of long-term care face are the direct result of failures in our immigration and health policies. Our current system mandates that hospitals provide care to undocumented immigrants when they are so ill that they require emergency treatment, at the most expensive point of access in the health care system – the emergency room – yet provides no real avenue for them to receive cheaper preventative care or be moved from more expensive acute care facilities to more appropriate, and less expensive, long term care facilities like nursing homes when necessary.
While health reform expanded the number of Americans eligible for Medicaid, it fell short of including undocumented immigrants – prohibiting them from even purchasing insurance within the exchanges. While the majority of undocumented immigrants are young and healthy, it is inevitable that tragedy will strike at one point or another and some immigrants will need long-term care. Our current policies make no provisions for this eventuality. Worst yet, there is virtually no oversight over hospitals that repatriate patients to their home countries, discharging them to family members or facilities abroad that often lack the means to properly care for them. And, there is little to no discussion of the legal and ethical breaches healthcare providers and hospitals may be committing by failing to discharge undocumented immigrants to appropriate healthcare facilities.
We need to discuss these issues, even if talking about them is difficult in a political climate where anti-immigrant sentiment runs rampant and budget cuts seem to always land on the backs of the poor, because some of our most fundamental values are at stake. Just a few weeks ago, we glimpsed the erosion of these values during a Republican presidential nominee debate, when the audience proudly affirmed their willingness to let a hypothetical 30 year old man who needed intensive care die because he opted out of health insurance. There is little doubt that this crowd would feel the same way about an undocumented immigrant in need of care, who had no access to insurance to begin with. Is this really the kind of world we want to live in?
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.
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.
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.
This post is by Alyssa Aguilera, NYLPI’s Health Justice Community Organizer.
Late last month I attended my first Mount Sinai Community Roundtable – a monthly convening of various community stakeholders interested in the happenings of the Harlem-based academic-medical center. These meetings, according to Mount Sinai’s own Community Service Plan, are held to “keep its pulse on the needs of the East Harlem and Central Harlem communities”. A worthy effort indeed, I was interested to see how the hospital would approach the invariably difficult town-gown relationship between a highly-touted medical center and its surrounding neighborhood, which despite proximity still remains a medically underserved community.
Last month’s meeting was to focus on the new Tisch Cancer Institute – “a state-of-the-art, patient-oriented, comprehensive cancer and research facility” slated to open in early 2011. On hand to explain the Institute was its director Dr. Steven Burakoff who led the group through a presentation highlighting the research, education, and care that would be provided at the Institute.
Funded in part by a $40 million gift from James and Meryl Tisch, the construction of the Institute is part of a larger expansion plan currently in motion at Mount Sinai. This initiative, led by Mr. Tisch, is being called The Campaign for Mount Sinai and is an aggressive and ambitious capital campaign aiming to raise $1 billion in private donations to improve the entire medical center.
What I found quite interesting in both the presentation and when perusing the Mount Sinai website, was the emphasis on “translational medicine” and the creation of “institutes” where this practice will be honed. Translational medicine, although multi-faceted, basically promotes the idea that “new treatments and research knowledge [should] actually reach the patients or populations for whom they are intended and [be] implemented correctly.” So for example, the Tisch Cancer Institute will house both the research and treatment of cancer allowing for mutual access between researchers, practitioners, and patients that will hopefully produce accelerated positive results for all those involved.
Mount Sinai is planning to create institutes for 14 different medical areas – The Black Family Stem Cell Institute, Friedman Brain Institute, Experimental Therapeutics Institute, etc. – and all are part of this ten-year expansion project.
In addition to the presentation on the Tisch Cancer Institute, the community roundtable also featured Professor Lina Jandorf, Director of Cancer Community Outreach in the Department of Oncological Sciences. She spoke about her work to reduce ethnic and racial disparities by improving education, screening and treatment protocols for communities of color in Harlem. Her own research emphasizes the need for this type of work. She writes:
Cancer mortality and incidence rates among minorities in [East Harlem] are 30% higher than elsewhere in New York City (NYC). For example, prostate and colorectal cancer incidence among adults aged 45-64 years living in this community is significantly higher than the average for NYC. Women in [East Harlem] are diagnosed with breast cancer at later stages of disease than are women from other NYC neighborhoods. Malignant neoplasms are the second leading cause of death in [East Harlem] after heart disease, with an age-adjusted rate of 147 per 100,000 when compared with 91 per 100,000 for the rest of NYC.
The lack of access to cancer prevention and treatment in low-income communities of color is unfortunately no surprise and I am happy to see that Ms. Jandorf and her colleagues at Mount Sinai are engaging in programming to help understand and ameliorate this somber public health reality. However, the lingering question I had throughout the presentation, and asked of Dr. Burakoff and Ms. Jandorf themselves, was this: It is great that the Tisch Cancer Institute is being constructed in a community so desperately in need of the care it provides, but what is Mount Sinai doing to grant access to the Institute for their neighbors many of whom are on Medicaid, are under-insured, or uninsured?
Their answer was not as straight-forward as I would have liked. They mostly just pointed to the community programs that are already available to the public. Dr. Burakoff said something interesting though, he said that as a hospital once they screen patients and detect cancer they have a responsibility to treat them. A vague answer, but I can assume that if the Institute had any plans to actually screen and treat low-income patients, they would have mentioned it at that time. Though just to be sure, I called a few days after the presentation to inquire about breast cancer treatment for a Medicaid beneficiary and was told they could be seen in the clinic setting, not the Institute itself.
So it seems more than likely that Mount Sinai will continue to deny access for low-income patients to the highest quality of care their facilities provide. They will regulate low-income patients to the clinic system, where they will get a lower quality of care (more on our work to end the two-tiered system of care in NYC academic-medical centers here), and the staggering health disparities in communities of color like East and Central Harlem will persist. Undoubtedly though, these new initiatives by Mount Sinai will allow them to rise in the ranks as one of the “best” hospitals in the country – well, for those who are lucky enough to have good private insurance.
Funny enough, Mount Sinai’s expansion project and institute model is all about breaking down walls: between the hard sciences and clinical medicine, between clinical medicine and patient outcomes, and between specialty areas in an attempt to tackle comorbidities often present in patients with chronic illness.
But despite millions of dollars, the recruitment of top faculty, and state-of-the art facilities, one big wall will still remain for low-income New Yorkers seeking cancer treatment at the Tisch Cancer Institute – the ability to afford it. And sadly, this treatment is one thing many New Yorkers cannot afford to live without.
 Woolf, Steven H., MD, MPH. “The Meaning of Translational Research and Why It Matters.” Journal of the American Medical Association 299(2) (2008): 211-3.
 Landorf, L and Fatone, A. and Borker, P.V. (2006) Creating alliances to improve cancer prevention and detection among urban medically underserved minority groups: The East Harlem Partnership for Cancer Awareness. Cancer. 107 (8). pp. 2043-2051.
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.