Dr. Ramanthan Raju, Chief Operating Officer of the New York City Health and Hospitals Corporation, rejoined the agency in 2014, leaving his role as president of Chicago's public hospital system. City & State spoke to him about returning to New York City and the challenges facing HHC.  


The following is an edited transcript. 



City & State: You’re returning to HHC after a two-year stint at the helm of the Chicago public hospital system. Did your experience there change any perceptions you may have had about HHC? 

Ramanathan Raju: I was in New York for about 30 years before I went to Chicago. This analogy kind of [stays] with me: When you are in your home, you look at your home. You live there for many years, you look at the wall, you look at the ceiling—it’s a little cracked, it’s got paint peeling off. You look outside, it doesn’t look as good. Then you always say, “My house is getting old; it’s not right.” Then you start looking at the house from the outside, and you say, “You know, my home is generally better than my neighbor’s home. My portico looks better, my grass looks greener.” So sometimes to appreciate a system, you need to go outside a system; then you see how great the system is. That is the revelation I got when I was coming back. 

I was amazed at the New York City Health and Hospitals Corp for two major reasons. One was the sheer size of it: There are not many systems in the country that have this big of a clientele and the systems to take care of [it]; [they’re] not as well integrated as New York City is. Second, the cultural competency and diversity is very striking. This is probably one of the only systems in which you speak more than 180 different languages and you have people coming from all over the world to be in there. If anybody walks into our system from any part of the world, I’m pretty sure somebody in my system would be from that part of the world and probably speaking their language. I always used to say this: Our patients look like us, and we look like our patients. So I came back with a great appreciation for the system, more than what I had when I was here. 

C&S: In your previous HHC stint, you oversaw a cost-cutting program to deal with the rising deficits plaguing the system. How would you characterize the system’s current financial state? 

RR: There’s no public hospital system in the country that is always in the red; no system is in the black, ever. It has to do with the clientele that public hospital systems really deal with. After being a doctor I also got my MBA: If you want to succeed in a market, you control the market. In a public system, your market is the market nobody else wants. If you are really going to take care of more uninsured and undocumented and underinsured people in the system, the system will always be in the red, which is inevitable. But normally what happens is the governments usually come to the rescue to take care of people, and help the public systems. That method of compensation, what we call the disproportionate share of money which is given to the public systems to take care of people, is sort of going away. It’s getting smaller and smaller, and by 2020 it’s going to reach a state where it is very difficult. It is based on the premise that the Affordable Care Act gives a lot of people insurance, so once people have insurance, you don’t really need to support the public hospitals because there will not be anybody uninsured. But there are three groups of people who will be uninsured in spite of the ACA. One is undocumented immigrants, because they can’t be part of the Affordable Care Act—even if they wanted to be, they can’t buy products on the insurance market. The second part of it is people who can’t afford to buy the premium, because the premiums are very high, and the penalties are very low—if I am living paycheck to paycheck I would rather pay the penalty than pay the premium, because the premium is about five times more than the penalty. Then there is a group of people who we call “young invincibles.” These are the people who are younger. They don’t believe they will need healthcare, and they will not choose to buy healthcare unless the healthcare is given to them as a part of the employer’s plan. When these three groups of people get sick, they will probably be uninsured. So in a public system which basically takes care of everybody, doesn’t turn anybody away, government needs to support the system to take care of these groups of people. But under the Affordable Care Act, unfortunately a [disproportionate share of] dollars are going to go down, and that is going to present a huge problem for us. Naturally, the Health and Hospitals Corporation is looking at a large deficit because we continue to provide the mission of not turning anyone away, but at the same time the money we need to support this is going to slowly disappear. But we are looking at other avenues by which we are able to compensate and carry out our mission, to keep the system financially sustainable. 

C&S: Can the community health centers fill in the gaps in serving the undocumented immigrant population, or are there other means within the system that can help alleviate that burden? 

RR: Every quality health center in New York City serves undocumented immigrants in our society. But the New York City Health and Hospitals Corporation has got a large portion of them that seek care and get care. It has to do with the fact that that’s our mission, that we will serve everybody irrespective of their economic status, irrespective of their race, color, ethnicity and immigration status. That is a fundamental mission of the Health and Hospitals system. That mission is not for sale; we are not going to move away from it. 

The undocumented, uninsured problem will be a bigger problem, because as we are able to get insurance status to people because of ACA, we need to take care of this group of people who are absolutely essential to take care of. We have to really work together to make sure they stay healthy, because in an urban society like ours, our health depends on each other’s health. If you are in a subway or a restaurant, the person who is next to you or the person who cooks your food, if that person is sick, you are going home sick. They are part and parcel of our society, and economically they work hard and contribute to society, so it is our responsibility to keep them healthy. 

C&S: Four years from now, when Mayor de Blasio is up for re-election, what is the legacy you want to leave for him to point to, to say, ‘This is where we made real improvements to the health and hospitals system’? 

RR: My vision is in four years, every New Yorker will have geographically convenient access to healthcare all around the city. There will not be any healthcare deserts where people do not get healthcare or cannot get access to healthcare. That will be the legacy.