Health care officials offer diagnoses for New York's funding challenges

Thanks to a flu season that’s one of the worst in recent memory, it has been a tough winter to stay healthy. Influenza hospitalizations are up and thousands have died. The flu vaccine has proven to be less effective than in years past, and public health experts say the disease may have yet to reach its peak. The spread of the virus is likely to continue for weeks.

It has also been a tough winter for New York policymakers and government officials who rely on Washington for funding. While congressional Republicans failed to repeal the Affordable Care Act, they’ve taken incremental steps to undermine the law, such as eliminating the individual mandate. The federal government has also reduced funding for safety net hospitals and for the ACA’s Basic Health Program, both of which play a major role in New York. Some Republicans in Washington still hope to scale back Medicaid and Medicare as well.

So we checked in with a few of New York’s top health care officials to hear their diagnosis of the situation – and how to remedy it.

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RICHARD GOTTFRIED

Chairman, Assembly Health Committee

C&S: What are your health legislative priorities this year?

RG: Our first order of business is, of course, dealing with health care cuts in the budget. This is not the worst year, not the worst budget we’ve seen, nor the best. But there are still serious cuts in health programs and restrictions in Medicaid that I and the Assembly will be trying to reverse. Beyond that, not necessarily in any particular order, passing the Reproductive Health Act in the Assembly again, and hopefully helping to advance it in the state Senate. A particular budget agenda item which we hope to deal with in the budget, and if not we will continue to try to deal with after the budget, is protecting safety net hospitals. The state’s various aid programs for hospitals are not very well targeted to get money to the hospitals that have the most serious financial need. Next, again in no particular order, is strengthening the medical marijuana program. I will be focusing on three issues there. One is to repeal the list of specific conditions for which medical marijuana can be used. There is no other drug that I know of that the law lists the conditions it can be used for. Secondly, today, only physicians, nurse practitioners and physician assistants can certify a patient for medical marijuana use. I think it makes sense that any practitioner who, under law today, can prescribe controlled substances ought to be able to certify a patient for medical use of marijuana as long as the treatment for the condition is within that practitioners scope of practice. The third piece deals with the current business model of producing, distributing and retailing, or dispensing, of medical marijuana. Today, all the licenses that have been issued require the registered organization to grow, process, distribute and dispense the product. There is almost no industry where we allow that degree of vertical integration, and certainly no industry where we require it. The next item is the New York Health Act, my single-payer bill. We will, I hope, pass that again in the Assembly as we have in the three years before. And our goal will be to continue to build support for that around that state. The last item is the Medical Aid in Dying bill that would allow an adult patient with decision-making capacity who is dying from a terminal illness to get a prescription for medication that would end their life. I think that legislation is very morally compelling for New York and I hope we can at least get it to the Assembly floor and pass it.

C&S: How would you assess the state of health care in New York based on what you’ve seen?

RG: It’s mixed. We have some of the finest health care providers, some of the finest physicians and hospitals in the country, but millions of New Yorkers still every year go without health care because they can’t afford or they suffer financially to get that care. Many of our nursing homes provide care that is well below national averages and well below standard. Our systems for inspecting nursing homes are really lacking. We need to invest a lot more of our resources into primary and preventive care, which is very difficult to do in a world where health care is controlled by insurance companies.

C&S: You mentioned your single-payer bill you would like to pass through the Assembly again. Why is that the best way forward for New York to go in in terms of health care?

RG: I believe that no New Yorker should go without health care or have to suffer financially to get it. To use the president’s term, that only gets complicated when the system is focused on the care and financing of insurance companies. And as long as our system is rooted in insurance companies, we will be spending tens of billions of dollars on, necessarily, on insurance company and health care provider administrative costs. You will have insurance companies taking thousands of dollars out of families’ pockets for premiums and deductibles and co-pays without any relation to ability to pay. And insurance companies telling us which doctors and hospitals we can go to, and which services they will pay for. To me, that’s no way to run a health care system. And I don’t know any alternative to a single-payer system that can work.

C&S: And you have seen support for that grow since you first introduced it?

RG: Oh, enormous growth and support, particularly in the last several years, because people have seen that while the Affordable Care Act made a lot of improvements, it still leaves us in the hands of the insurance companies with enormous problems. So people who thought maybe reforming the insurance system would do the job, now see that that really still leaves us falling way short. And it’s also clear that whatever health policy comes out of Washington is going to make things worse in New York, whether it’s for insurance or Medicaid or Medicare. So more than ever, people realize that, whether you call it improved Medicare for All, or single-payer, is really the only answer, and that we have really no alternative but to pursue that at the state level because it’s clearly not coming from Washington any time soon. And so we are constantly picking up more community organizations. There are activists all around the state having meetings with their state senators, there are more unions supporting the bill than ever before, so the issue really is moving forward more than I’ve ever seen.

C&S: Do you have any concerns for what is happening on the federal level, such as cuts in spending or other kinds of legislation that might affect health care in New York?

RG: Their efforts to dismantle the Affordable Care Act will undermine insurance in New York. They are already implementing cuts that are hurting the program called the Essential Plan, which is a subsidized health care program for people whose incomes are a little above Medicaid. And there will be more devastation coming to Medicaid any day now. And their next target will be Medicare. Republicans have had their eye on trashing Medicare since it was enacted in 1965. And that will be coming next. And all of that will be ripping money out of our health care system and putting more burden on out-of-pocket spending by New Yorkers who can’t afford it.

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MITCHELL KATZ

President and CEO, New York City Health + Hospitals

C&S: What are the problems you’re facing at Health + Hospitals and what are your plans to address them?

MK: I believe, like the nuns, that there’s no mission without a margin. And so while my career has been dedicated to taking care of people who don’t have insurance, I’ve always done that by billing insurance for people who do have insurance, and attracting insured patients to my systems. Currently in Health + Hospitals, in most of our centers, we are still sending away insured patients, not providing the services that are better remunerated. This doesn’t come from a bad place, it’s sort of the history of public hospitals, that public hospitals like ours generally started before Lyndon Johnson’s Medicaid and Medicare in the ’60s when nobody had insurance. And so nobody billed and that was fine. But gradually, public hospital systems have learned how to bill and how to attract and keep paying patients, so there’s a margin to provide the care to the people who don’t have insurance. Health + Hospitals has a long way to go in that area, but this is work I’ve done in two other municipalities, and it’s well-known how to do it. And it’s a lot easier than saving people’s lives in trauma, which I’m proud my system does every day. So if we can revive a pulseless person who’s lost most of the blood volume in their body, surely we can learn how to bill insurance the way other systems do, and we are.

C&S: Could the affordable health care program that you spearheaded in California, Healthy San Francisco, work in New York City?

MK: I think that the model could work. Like a lot of other questions, it comes to participatory democracy. One of the features of Healthy San Francisco was that employers who did not provide insurance for their workers were required to pay into a fund or provide benefits or pay insurance bills. So that’s a political question as to whether or not the city would want to do that. It would have been a lot harder, maybe not impossible, but certainly a lot harder to have had the success we had in San Francisco without the employer spending requirement.

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CARLINA RIVERA

Chairwoman, New York City Council Hospitals Committee

C&S: What has been your experience so far heading this new Committee on Hospitals?

CR: Well, it's been educational. It's definitely been informative as to how nuanced the issues can be. We have two other committees that are tackling issues in the health field, but we're focused on hospitals. So what I've been doing is trying to meet with as many stakeholders, groups, individuals, people who are advocates, people who are retired advocates who worked in hospitals and with patients, and really try to get a broad perspective of what's going on, how the budget, the deficit is affecting patient care, and how best we can use this committee for oversight, for investigations. But also to push forward legislation that's going to take care of all New Yorkers. My focus is to really dive deep into Health + Hospitals, but also bring in our private partners. This is a very big network, I say it's the most important public system in the city, and I want to make sure we're talking about the underinsured, the insured, the undocumented and all of the people who are so dependent on the system. So again, it's going to be a focus on the public system, but bring in our private partners as well. And it's been eye-opening. There are a lot of people working on different campaigns, local, citywide and of course statewide, so I'm trying to, again, meet with as many different people as possible, other elected officials who are chairs of their own committees in their own legislative bodies, and then of course labor and community leaders that do the work.

C&S: Based on some of these meetings that you've been having, what is the most pressing issue when it comes to Health + Hospitals?

CR: I would say that would be DSH funds, Disproportionate Share Hospital programs, and that's the funding to hospitals that treat the poorest New Yorkers. And also the risks from Washington, the threats of cuts to this very important care, these programs, the charity dollars and the way they're distributed amongst the public and private systems. But when I talked to people, undoubtedly, one of the first things that comes up is DSH. I think it's also about how are we going to address a billion-dollar deficit and keep 11 major hospitals open? We have the mayor's commitment that he will keep these facilities open, but how are we going to look at underutilization in terms the spaces in these brick-and-mortar facilities? And how are we going to generate revenue? I had a really great conversation with (President and CEO of Health + Hospitals) Dr. (Mitchell) Katz, along with some of the committee staff here at the Council, just to get a little preview of some of the issues that we're going to be going over next week. And he has some basic, I think, fundamental outlook on how to make sure we're getting the reimbursements that we're not getting, and to implement a more efficient system, and getting paid for the services we're providing.

C&S: Dr. Katz is also new to Health + Hospitals, and you're the new head of a new committee. What is that like, to have everyone who's now trying to tackle this problem be  fairly new? Is that detriment or is it good to have a lot of fresh ideas coming in?

CR: I think that's it, you took the words right out of my mouth. I think it's great to have fresh ideas. I think it's good to have someone with a different perspective. He's coming from tackling a similar issue in another major city. I come from more of the community-based care perspective. My work in Healthy Aging has been working with seniors, with very low-income families in accessing health care and navigating the Affordable Care Act. Though my experience is limited and his is incredibly comprehensive, I'm really excited because it just allows for a clear break from past issues and mismanagement, and I think that's going to be something that's going to be important to looking at the health care system in a different lens.

C&S: Was this a chairmanship that you had wanted? And how did you feel when you received it?

CR: Yes, of course. I think I've said this before, that I think that making this its own standalone, full committee, it shows the needed urgency for such an important issue. I did mention my interest to the speaker. We're very aligned when it comes to our beliefs and values and the things we want to achieve in terms of our agenda for the City Council. So we talked a lot about health. We talked about some of the work that he had done, how I wanted to continue that work in terms of the legislation and the policy he put forward, and then bringing my own ideas based on my experience. So this was something I was interested in, and when I was assigned to it, I was very, very excited. I know that I have him for support, I have a great committee staff here and lots of advocates throughout the cities.