Gotham Gazette

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Citizens Union

Mayoral Issue Grid: Health

Mayoral Issue Grid


-Top Priority?
-Smoking Ban?

New York City has enormous public health challenges. Roughly 2 million residents are not insured. New York is the only state in the country that requires local governments to pay a substantial share of Medicaid costs. Medicaid will cost the city almost $4.9 billion this year.

In 2002, the mayor and the City Council agreed to a new smoking ban. The measure requires that public places including bars, nightclubs and restaurants and all places of employment in New York City smoke-free. Officials agreed to some exemptions: cigar bars, owner-operated bars, fraternal organizations and portions of outdoor cafes will still allow smoking.

Fernando Ferrer

Ferrer promises to enroll 290,000 children without health care insurance and another 200,000 adults in health care programs. Ferrer says he will invest in community-based enrollment centers and provide information technology to ease the process of enrollment. He also promises to curb Medicaid fraud which costs $1 billion a year. (Read Ferrer's health care plan.)

When he served in the New York City Council, Fernando Ferrer chaired the health committee and he points to his work to improve services at hospitals. As Bronx Borough President, he created Bronx Health Link, a consortium of four Bronx hospitals and numerous clinics.

He promises to increase enrollment in programs like Family Health Plus and Child Health Plus. He also promises to increase funding for the Health and Hospitals Corporation.

Ferrer supports the smoking ban and would not overturn it.

Michael Bloomberg

Michael Bloomberg says he has improved the health of every New Yorker by instituting a ban on smoking in public places. He claims that the law along with smoking cessation programs has reduced the number of smokers by 188,000.

On the topic of providing health insurance for children, Bloomberg released a plan to enroll all eligible children in public health insurance. His campaign estimates that 215,000 kids are eligible but unenrolled. The city will also subsidise low-income families' enrollment in private insurance.

Bloomberg has also called for a $25 million investment for digitizing medical records to improve health care delivery through efficiency and accuracy and save money on administrative costs. He will also ask the State to match the funds 3-1.


He has funded improvements to local hospitals and created programs for mammograms, HIV/AIDS, and prenatal care.

(Read Bloomberg’s health platform)


- Making Medicaid Cheaper
- AIDS In New York City
- Obesity
- New York City’s Elderly




Campaign 2005: Expanding Access to Health Care

As a private citizen, Michael Bloomberg showed a keen interest in health care. He sat on the boards of health care organizations, including a local foundation that provided services and sponsored research on the immunity disorder lupus; helped sponsor the Children’s Health Fund’s mobile medical units for the children of homeless families in New York; and donated so much money to Baltimore’s Johns Hopkins School of Public Health that the board eventually decided to name it after him.

Bloomberg’s enthusiasm for public health has continued since he became mayor four years ago. His administration has developed Take Care New York, an guide for healthy living that has been described as the most comprehensive public health plan that the city has ever had. Most people now see his aggressive anti-smoking policies, which provoked controversy when introduced, as a success – with the notable exception of Audrey Silk, who is running for mayor on a pro-smoking platform. The city has recently turned its focus towards trans fats. Many health care advocates appreciate the mayor’s energy and acknowledge his accomplishments.

Still, 1.8 million New Yorkers don't have health insurance, including almost a million who work full time. Medicaid is straining the city and state budgets, even though hundreds of thousands of people who are eligible receive nothing from the program. Many hospitals are struggling financially, and a new state commission has begun discussing which ones could be closed.

When the Community Service Society recently asked low income New Yorkers what they thought of the city's approach to health care, 70 percent said New York is on the wrong track. It's not hard to see why. While the average New Yorker lives longer than the average American, white city residents live an average of six years longer than those who are black. High rates of chronic diseases, from AIDS to diabetes to obesity, are clustered in low income and minority neighborhoods. Language barriers at local hospitals continue to cause problems (report in .pdf format). For those who can’t access basic health care, the city’s tips on healthy living provide little help. And while many hospitals are struggling, the only one where closure is imminent is St. Mary’s in Central Brooklyn, an area whose residents are hospitalized at 30 percent higher rate than the city as a whole, and where 30,000 people went without necessary health care as of 2003.

“The biggest issue we face as New Yorkers is access to affordable health care,” says Mayor Bloomberg. His rivals in the mayoral race agree. When they talk about health care, it is to stress the importance of providing New Yorkers with health insurance through public or private plans, and to break down other barriers to receiving health care.


Financial hardship, language barriers and other cultural problems combine to keep many New Yorkers from getting regular checkups or treatment for minor health problems. This is both bad for the health of the individual and expensive for the city. When someone puts off minor treatment they often miss signs of major problems that could have been averted. By the time someone arrives at the emergency room, it is often too late to avoid drastic, expensive measures.

Under Mayor Bloomberg, the city’s department of health has worked on several programs to make it easier to access preventive health care by letting people know what is available to them. It has opened district offices in underserved areas, which also serve as places for people to receive direct medical services. The administration boasts of increased number of breast cancer screenings and the widespread distribution of nicotine patches. But critics say that the health department neglected to use such district offices to identify and address local health problems, and has centralized its approach when it could have expanded relationships with community-based organizations.

Other parts of city government have focused on breaking down barriers that keep immigrants and minorities from accessing health care. The City Council passed a law requiring city agencies that handle Medicaid to have translation services for six languages – Arabic, Chinese, Haitain Creole, Korean, Russian, and Spanish. As Manhattan borough president, Virginia Fields spent time studying the disparities in health among communities of color (report in .pdf format). Her recommendations included programs to steer people from underserved populations towards health care professions, which she believes would increase cultural sensitivity.

Even before preventive care, though, comes improving environmental conditions that lead to health problems. Bloomberg described his proposed garbage plan largely in terms of taking the burden off neighborhoods where heavy truck traffic leads to high asthma rates. As speaker of the City Council, Gifford Miller forced a tough lead paint law through a mayoral veto, and passed bills that required the city to buy energy efficient appliances, improved the emissions standards of its trucks, and supported green buildings.

Of course, the major way to expand access to preventive health care is by enrolling as many of the nearly two million uninsured New Yorkers in some kind of health care plan.


New York has the most expensive Medicaid program in the country, and Albany is unique among state governments in passing along a significant portion of the cost to local governments. Last fiscal year, the city spent $4.9 billion on Medicaid, about 10 percent of its total budget. City officials and budget watchdogs (report in .pdf format) believe Albany should pay a greater share of Medicaid costs, but it looks unlikely that this will happen soon. Mayor Bloomberg now describes the program as one of the major budget items over which the city has no control.

Because the city does not control Medicaid, a major part of the mayor’s role is to put pressure on the state and federal governments. In addition, the city can actively seek to enroll more people in the program. Currently there are about 500,000 city residents who are eligible for Medicaid but not enrolled. Signing them up has the obvious benefit of giving them access to health care coverage. Moving uninsured New Yorkers onto Medicaid also makes financial sense; the city splits Medicaid costs with the state and federal governments, but foots the entire bill when an uninsured patient shows up in the emergency room of a public hospital.

Mayor Rudolph Giuliani did not make it easy to access Medicaid. The Bloomberg administration, by contrast, boasts that there are 900,000 more people enrolled in public health plans than there were three years ago. Democratic mayoral hopefuls hope to expand this: Anthony Weiner says that as mayor he would focus on improving the technology used to administer public health plans, simplifying the enrollment process; he believes that by doing so the city could sign up two-thirds of eligible uninsured New Yorkers for Medicaid. Fernando Ferrer says he would enroll every child in some type of public health insurance program (all children are eligible for public insurance regardless of immigration status) while also adding 200,000 adults in public health care programs.


Many of the 1.8 million city residents without insurance are not eligible for public health insurance. Since most Americans get their health insurance through their employers, the best thing the city can do is explore ways to expand the number of employers who give their workers health coverage.

This summer, the City Council passed a bill that would require grocery stores and other food retailers to contribute $2.50 towards health care for each hour an employee works, or $5,000 a year for a full-time employee. Mayor Bloomberg said that the city doesn't have the authority to pass such a law, and that this specific bill unfairly singles out one industry. He has promised a veto, but as of the end of August the council seemed to have the votes to override it. The law’s supporters – including Fernando Ferrer – have said that the law is only a pilot program, and hope to extend it to other industries.

Another approach the city can take is to make it cheaper for employers to provide health coverage by encouraging them to band together to bargain with insurers. Anthony Weiner recently pointed to Brooklyn Healthworks, such a program run by the Brooklyn Chamber of Commerce, as a model for the city. By developing a similar plan citywide, Weiner hopes to provide coverage to about a third of the 969,000 uninsured New Yorkers who work full time.


Because they do accept patients regardless of whether they have insurance, New York City’s public hospitals, run by the Health and Hospital Corporation, suffer financially from serving the city’s uninsured population. In 2004, the Corporation ran a deficit of $200 million.

The Bloomberg administration has invested in new equipment and other upgrades for the system, which advocates say contrasts sharply to the approach of his predecessor. Still, both Virginia Fields and Fernando Ferrer say public hospitals need more attention: Fields says she will put more money into the system, and Ferrer calls for “full funding” of the Health and Hospital Corporation.

But it is not just the city’s public hospitals that are facing tough financial times. Due to a myriad of factors – overcapacity, rising health care costs, the strain of serving uninsured populations, diminishing federal aid for teaching hospitals, tough state regulations – some private hospitals are doing badly as well. These are mostly smaller hospitals serving poorer areas, where fewer people have insurance. Seven hospitals in New York City have closed since 2003, one is planning to close soon, and several more are reportedly at risk.

This will likely be an issue that the next mayor will have to deal with, but the city’s role in all this is unclear. Local governments have no representation on the state’s hospital closing committee. If that committee decides that some hospitals in the city should close, there is little the mayor can do.


Mayoral Issue Grid: Health

Mayoral Issue Grid


-Top Priority?
-Smoking Ban?

New York City has enormous public health challenges. Roughly 2 million residents are not insured. New York is the only state in the country that requires local governments to pay a substantial share of Medicaid costs. Medicaid will cost the city almost $4.9 billion this year.

In 2002, the mayor and the City Council agreed to a new smoking ban. The measure requires that public places including bars, nightclubs and restaurants and all places of employment in New York City smoke-free. Officials agreed to some exemptions: cigar bars, owner-operated bars, fraternal organizations and portions of outdoor cafes will still allow smoking.

Fernando Ferrer

Ferrer promises to enroll 290,000 children without health care insurance and another 200,000 adults in health care programs. Ferrer says he will invest in community-based enrollment centers and provide information technology to ease the process of enrollment. He also promises to curb Medicaid fraud which costs $1 billion a year. (Read Ferrer's health care plan.)

When he served in the New York City Council, Fernando Ferrer chaired the health committee and he points to his work to improve services at hospitals. As Bronx Borough President, he created Bronx Health Link, a consortium of four Bronx hospitals and numerous clinics.

He promises to increase enrollment in programs like Family Health Plus and Child Health Plus. He also promises to increase funding for the Health and Hospitals Corporation.

Ferrer supports the smoking ban and would not overturn it.

C. Virginia Fields

Virginia Fields has outlined a plan to help elderly New Yorker’s health needs.

She promises to increase funding for senior centers and expand mental health services in them. She says she would increase the availability of services for people with Alzheimer’s. She would fund and promote programs that help senior citizens stay in their homes and maintain their independence.

Fields supports the smoking ban and would not overturn it.

A. Gifford Miller

As Speaker of the City Council, Gifford Miller passed new lead paint legislation that puts new demands on landlords and business owners to rid their properties of lead paint, which can be harmful to children. He created an Asthma Task Force to submit recommendations to state and federal officials.

He promises to enforce environmental regulations to make the city’s environment safer.

Miller voted in favor of the smoking ban in the City Council.

Anthony Weiner

Anthony Weiner promises to modernize the current system of enrolling New Yorkers in Medicaid, the health program for low-income individuals. He has set a goal of enrolling two-thirds of the 800,000 people who qualify, but have not joined the program. He says the current system could be updated with new technology that would streamline the process. He promises to improve service from primary care physicians, and expand programs that provide comprehensive home health care services for elderly.

Weiner also says he demonstrates his commitment to the health of the city by driving a hybrid car. He pledges to address environmental concerns by improving mass transit and encouraging the use of hybrid vehicles. (Read Weiner’s health plan)

Weiner supports the smoking ban and would not overturn it.

Michael Bloomberg

Michael Bloomberg says he has improved the health of every New Yorker by instituting a ban on smoking in public places. He claims that the law along with smoking cessation programs has reduced the number of smokers by 188,000.

He has funded improvements to local hospitals and created programs for mammograms, HIV/AIDS, and prenatal care.

(Read Bloomberg’s health platform)


- Making Medicaid Cheaper
- AIDS In New York City
- Obesity
- New York City’s Elderly


Cemeteries: The End is Near

New York City Marble Cemetery

Following his death on July 4, 1831, and a glorious funeral procession through the streets of New York watched by as many as a hundred thousand people, United States President James Monroe became one of the first people to be buried in the brand new New York City Marble Cemetery on the Lower East Side, then a leafy, bucolic suburb on the northern fringe of New York City.

Thirty years later, Virginians reclaimed their native son, deeming the cemetery an insufficiently dignified place. By that time, the area was becoming the city's most crowded slum, and those from the fairer classes, living or dead, were fleeing.

The New York City Marble Cemetery still stands, on East 2nd Street, across from the Anthology Film Archives, near Urge bar and Anyway Cafe.

It might seem to have changed far less than the neighborhood around it, but in truth there are many parallels between the city's residences for the living and those for the dead. In Manhattan, burial space is even harder to find than an apartment. There is only one truly active graveyard in Manhattan - Trinity Church's cemetery in Washington Heights – and even there the only available space is in above ground "community mausoleums", large marble blocks that are, essentially, condos for corpses. Unhindered by rent regulations, the prices for graves have continued to rise. This has driven some who have spent a lifetime resisting the pull of the suburbs to wind up there posthumously.

Close to 325 graveyards have existed at some point during the city's history, according to Graveyard Shift: The Family Historian's Guide to New York City Cemeteries. Of these, the New York State Division of Cemeteries estimates that 75 are still accepting newcomers, mostly in Brooklyn or Queens. There is no reliable estimate for how many people get buried here each year, but given that the two largest cemeteries in the city -- Brooklyn's Green-Wood and Woodlawn in the Bronx -- bury only 3,000 people combined, there is little doubt that many of the 60,000 or so city residents that die annually end up beyond the city limits.

Green-Wood Cemetery

Still, city cemeteries are concerned that they will soon run out of space. When a graveyard fills up, it loses its primary means of income. Many fall into disrepair; some are abandoned completely. Many New Yorkers see cemeteries as not only places to bury the dead, but also as important green spaces and historical relics, and there are increasing efforts to preserve cemeteries or restore those in need.

For their part, all cemeteries are setting money aside to prepare for the day when they run out of space. Some are also looking for other ways to raise the money they need to mow their lawns and maintain their tombstones in perpetuity.

"When your entire annual budget is spent on a few hours gardening and general maintenance, you want to think creatively," said Colleen Iverson of the New York City Marble Cemetery. The cemetery, like others, solicits donations by promoting itself as a historical site through events like Open House New York (this year, four cemeteries are participating: New York City Marble Cemetery, nearby New York Marble Cemetery, Green-Wood and Woodlawn). Cemeteries are also encouraging engagement by throwing concerts (there is a concert this Thursday at the New York City Marble Cemetery), leading regular tours, holding cocktail parties, and even offering themselves out for weddings.

Forty years ago, New York reacted to the loss of old Pennsylvania Station by passing a law to protect city landmarks. This series, in partnership with Open House New York, looks at the physical city since the birth of the preservation movement.

New York City Marble Cemetery has also decided to give burying people another try. The cemetery has held two funerals in the last five years, and is now trying to let people know that there is some room left yet. But if the recent funerals have presented potential for the cemetery, they have also reminded it of its vulnerability. In November 2000, over 150 years after Monroe was buried there, the cemetery held another military funeral. Twenty-five people gathered and listened as two soldiers played taps. At the moment that the trumpets hit their last note, a large section of the cemetery's wall collapsed.


Nationwide, there is no danger of cemeteries running out of room, according to Bob Fells of the International Cemetery and Funeral Association. More people are choosing to get cremated - about 28 percent of Americans who died in 2002 were cremated, as opposed to 7.6 percent 25 years earlier. Cemeteries have developed more efficient ways to bury everyone else, like "stacking" more than one coffin in a single gravesite, and more people are being buried in above ground community mausoleums. Some cemeteries are even selling or leasing land that they don't need. Places like Long Island's Pinelawn Cemetery, home to many former New Yorkers, has so much extra space that it has built a 27-hole golf course on land it originally intended to use for burials.

But for many New York cemeteries it's a different story. The problem is most dire at Catholic and Jewish graveyards, said Richard Moylan, head of the Metropolitan Cemetery Association and president of Green-Wood. But even 478-acre Green-Wood, the city's largest cemetery, is feeling squeezed. Green-Wood buries about 1,500 people a year, and only has enough room to do so for about five more years. It has long been closing roads and rethinking its layout to make more room for gravesites.

As space in cemeteries gets scarcer, its price rises. In 1882, legendary Wall Street speculator Jay Gould bought a 30,000 square foot plot of land at Woodlawn for his family mausoleum at $2 a square foot, an exorbitant price at the time. The same plot today, instead of costing $60,000, would cost $6 million. A typical (far smaller) gravesite at Woodlawn costs $4,400, even as the cemetery insists it still has plenty of room. At Green-wood, plots start at $7,000.

Layering the dead at Trinity Cemetery in Washington Heights

The problem of scarcity is unlikely to be solved by cemeteries acquiring land. Acquiring real estate in New York City is difficult for anyone, and there are strict regulations for cemeteries buying land to bury people in. Because this land comes off the tax rolls, there is little incentive for governments to approve such conversions even if cemeteries could afford to try.

"It's pretty well status quo," said Rich Fishman, head of the state's Division of Cemeteries.

What the state has done recently is make it easier for cemeteries to use their own land more efficiently. Some cemeteries have a significant amount of unused land that was purchased by people who the cemeteries have since lost contact with. Lawmakers in Albany recently passed a measure that would allow cemeteries to reclaim such land after 75 years have passed without word from the owners.

Many of the empty graves were bought some 80 years ago, when rumors of limited grave space led people to hoard plots for future burials or resale, making them eligible for reclamation. The state and the Metropolitan Cemetery Association see this as a way to provide some immediate relief to some cemeteries where space is a concern.

Not having the money for continued maintenance is a serious concern for aging cemeteries. In the past some have disappeared below new development, a fate that theoretically won't happen now because the restrictions for new development on cemetery land are even tougher than those keeping cemeteries from developing new land. But the threat of falling into disrepair or abandonment is real, say some who manage historic cemeteries in the city. To avoid this, they are looking beyond burials to other fundraising possibilities.


Richard Moylan began cutting the grass at Green-Wood in 1972 as a summer job the year he finished high school. At the time being bereaved was the price of entry for those who didn't work there. Anyone approaching the cemetery's gates intending to take a stroll through its grounds or get a glimpse of its stunning view of Manhattan's skyline was turned away.

"We did not encourage the public to enter," said Moylan. "It was basically lot owners and families."

The cemetery closed its gates because it was frightened of vandalism and a bit ashamed of its unkempt state. With its own problems to consider, the cemetery didn't think much about its interaction with the public. Its financial struggles turned into young Moylan's own; he was laid off when he came back to work in the summer of 1973.

But eventually Green-Wood decided it couldn't pretend it was just a graveyard. It was an enormous park in the center of Brooklyn, and a historical resource as well. There were former mayors, deceased gangsters and Boss Tweed, a member of both categories. Charles Ebbets of Ebbets Field was buried there, as was Horace Greeley, the editor of the New York Tribune. The city had even declared that the gates that kept people out were a landmark. In the early 1990s the cemetery opened those gates, and it now plays host to about 300,000 visitors a year.

Green-Wood isn't the only cemetery whose appeal stretches beyond those whose loved ones are buried there. The city has designated so many cemeteries as landmarks that a spokesperson for the Landmarks Preservation Commission declined to even guess at the total number. It is a distinction that, while it does not involve any direct funding, can make it easier for cemeteries looking for grant money or private donations.

New York Marble Cemetery

And increasingly they are looking. They are organizing tours and other events aimed at seducing history buffs into helping out. A music teacher from Brooklyn gave Green-Wood $5,000 to restore a monument to William Wheatley, who has been credited with creating the American musical; Woodlawn is currently hoping a generous musician will do the same for Augustus D. Juilliard's grave.

The potential historic significance of some cemeteries is made clear by a drive through Woodlawn with Susan Olsen, the cemetery's cheery historian with an "I brake for historic graveyards" bumper sticker on the back of her car. She points out the tombs of Robert Moses (in the corner of the cemetery directly adjacent to the entrance to the Major Deegan Expressway); Fiorello LaGuardia and four other mayors (none of whose tombstones have the word "mayor" on them); "Moby Dick" author Herman Melville ("every failed writer comes to pay tribute to poor old Melville"); and the adjacent resting places of Duke Ellington and Miles Davis, the cemetery's most popular spot.

A new addition is salsa queen Celia Cruz, and the cemetery recently learned that Colin Powell made annual visits to pay respects to members of his family - when the Bronx native mentioned the trips at a dedication ceremony at the World War II memorial in Washington DC. Contrary to popular belief, however, Bronx rapper Big Pun is not buried here - his remains were returned to his family after his cremation in the Woodlawn crematorium.

Such a rich history is a valuable resource, says Olsen, and the cemetery is often playing host to a historic researcher or two digging through the archives. But Woodlawn does try to keep this function separate from its primary purpose. Olsen's office is located about as far away from the main office as one can get without ending up on Jerome Avenue.

"What we try to do is keep our happy history stuff separate from our regular business," said Olsen. "People who are doing genealogy are all excited about researching Miles Davis; you don't want them to be in a situation where they're working next to someone burying a loved one."

There is definitely a line that can be crossed - Green-Wood's movie series, which included a run of horror movies, inspired complaints by some who were visiting to mourn. The cemetery decided to cancel the movies. But being close to capacity, Green-Wood is trying to cultivate its role as a public space more aggressively than Woodlawn. "Our end isn't imminent, but it's coming," said Moylan. "And to start thinking about it when you're out of space is too late."


Trinity Cemetery

Cate Ludlam was introduced to Prospect Cemetery in 1989, when she got a telephone call from a woman who had entered what she thought was a dump to save some puppies. The woman had found hundreds of tombstones, some with the name "Ludlam" on them, and looked Cate up in the phone book.

The woman had stumbled onto the oldest cemetery in Queens, established in 1668. It had been effectively abandoned for years; there were records as far back as 1910 describing the cemetery as so overgrown that it was impassible, about 50 years after one of Ludlam's ancestors commissioned a chapel to be built there. Ludlum was shocked to find that the tombstones and chapel had been badly damaged.

"When I saw the chapel, when I saw the destruction, I wept," she said. "You couldn't do anything but weep. I've never seen something so lovely vandalized that badly."

New York State tries to ensure that cemeteries do not allow themselves to fall into such a state of disrepair. State law calls for a portion of burial costs to be set aside in a trust which, in theory, is supposed to sustain cemeteries in perpetuity.

This had not worked for Prospect Cemetery. It had some funding and was being run by a board of trustees when Ludlam discovered it. But the board's management style was minimal to say the least: its director, the wife of a man who was buried there, was herself in her late eighties. She lived out of state.

Ludlam formed a new board with several other descendants who had also been contacted by the puppy saver. They had access to about $1,500 a year - and an enormous task ahead of them.

Immediately, Ludlam enlisted the help of the Greater Jamaica Development Corporation. As most of the other board members drifted off she also recruited the New York Landmarks Conservancy. With their help repaired the fence to prevent vandalism, and has arranged for volunteer workers come several times a year to help landscape. The cemetery is still closed to the public, but Ludlam is eager to lead tours for those who request it.

Through continued use of endowments and a slow stream of donations, the cemetery is nearing the point where it will have enough money to fix up the chapel that made Ludlam cry 15 years ago. A congregation has inquired about renting it one day a week, and she hopes that it will also serve as a small museum and a place to hold events that will bring in other funds as well.

"What looks like a snail's pace is really progress," said Ludlam of the restoration. "We may be able to do the chapel this year. This is really a miracle - for me at least."


Making Medicaid Cheaper

A staff member sees a patient at the Betances Health Center where 70 percent of clients are on Medicaid.

About 25 years ago, the Betances Health Center on the Lower East Side was little more than a van dispensing medical care to the needy -- a van that “always got vandalized and eventually burned on the highway,” recalls executive director Wanda Evans. Today, Betances occupies a former Sloan’s supermarket on Henry Street and logs 50,000 visits a year from 7,000 patients. And like some 650 health centers throughout the city, Betances depends on Medicaid, the government program to provide health care to low-income people.

As it celebrates its 40th birthday, Medicaid has been the focus of much attention – not so much for the care it provides as for how much it costs. The New York Times reported recently on billions of dollars in fraud and abuse. Governors demand that the federal government relieve some of the states’ costs. Mayor Michael Bloomberg highlighted Medicaid as a big budget item beyond the city’s control. All of this has prompted an array of proposals and counterproposals about how to reform Medicaid, cut costs or improve care.

Such changes could deeply affect centers such as Betances. These community institutions “provide care and help keep people out of emergency rooms,” said Deborah Zahn, of the Primary Care Development Corporation, which was created by the city to provide financing and other assistance to the health centers. If you cut Medicaid, she said, “you would cut their ability to be financially solvent.”

Unlike a traditional doctor’s office, Betances aims to provide a “one-stop shop” to cure disease and make its clients healthier. On a recent hot summer morning, patients from the neighborhood -- black, white, Asian, Hispanic; young, old; men, women – waited in a room flooded with sunlight from the skylight above. Some wanted to see a doctor, but the center also offers an array of preventive health programs. Betances works with people who are HIV positive to keep their condition from getting worse. It offers acupuncture, tai chi, exercise machines and cooking classes – helping students prepare low-fat versions of traditional fare like rice and beans. While Medicaid does not cover many of these programs, it does cover about 70 percent of the patients at Betances.


Congress created Medicaid to serve low-income people in July 1965 at the same time it established Medicare for the elderly. Back then, Medicaid was a rather narrowly defined program, but it has expanded to provide a wider array of services to a larger number of people. Today Medicaid pays for health care for 50 million Americans and costs about $300 billion a year. The costs are divided between Washington and the states, with richer states, such as New York bearing 50 percent.

Without major changes, everyone expects the bill for Medicaid to grow. For one thing, overall healthcare costs are rising. For another, the population is aging. Although Medicare covers many medical costs for older Americans, Medicaid pays much of the costs of long-term care, including nursing homes.


By any measure, Medicaid in New York State is huge. Some 4 million people -- poor, elderly or disabled -- belong to the system, which handles about 1 million claims a day. Medicaid pays for one quarter of all dollars spent on prescription drugs in the state, one third of the money spent to deliver babies and a full half of the money spent on mental health, according to Newsday.

All this adds up to a $44 billion program, the most expensive in the nation. New York State and its local governments will pay about $10,800 (in pdf format) per Medicaid recipient this year. This costs every person in the state about $2,140 a year.

Supporters of Medicaid say that New Yorkers should be proud of this. “New York gets a really bad rap for having a program that is really good,” said Laura Caruso of Medicaid Matters, a coalition to protect the system.

“Medicaid has been a lifesaver to many people across the state,” said Robin Frank, a vice president at the Health Association of New York State, which represents hospitals and nursing homes. “Medicaid has been critical to people’s lives.”

Critics, though, say we do not get what we pay for. “Even though we spend billions and billions of dollars to meet poor peoples’ health needs, we still have a higher than average rate of mothers who don’t get prenatal care,” said Robert B. Ward, director of research at The Public Policy Institute, a business-oriented research group.

Much of the burden for the high costs falls on local governments. New York is the only state in the country that requires local governments to pay a substantial share of Medicaid costs. Medicaid will cost the city almost $4.9 billion this year -- a number Mayor Michael Bloomberg estimates will reach $5.3 billion by 2009. But that may be conservative, based on the increases over the last five years. The costs pose an even greater burden on some upstate counties. Erie County Executive Joel Giambra has said that “every penny” of his county’s property tax goes to Medicaid.


Experts and advocates offer a variety of explanations for the costs of New York’s program. There is little agreement on the causes of the expense, let alone the solutions.

--The funding formula: The split in paying the Medicaid bill in New York State – with Washington paying half and state and local government dividing the rest – encourages the state to put as many programs as possible into Medicaid to get federal funds. So, for example, New York has shifted some mental health spending into Medicaid while California has not. Similarly, the state’s Medicaid program provides a subsidy to train doctors in teaching hospitals that other states do not provide.

Some people say this makes sense – why not get Washington to pick up the tab? But on the down side, critics say that New York State officials are less fiscally prudent about Medicaid spending than officials in other states because they only pay about a quarter, as opposed to half, of the costs. It's easy to give more services to more people, they say, if you get other people to foot most of the bill.

--The scope of services: The federal government requires that all states provide certain basic services, but makes others, such as vision, dental and podiatry care, optional. New York has elected to provide many of these services.

--Broader coverage: To qualify for Medicaid in New York, a family of four must have a monthly net income of less than $992. But New York State has expanded Medicaid through Family Health Plus and Child Health Plus, which offer health coverage to low-income people who might not normally qualify for Medicaid but who do not have other health insurance. Many work, but their employers do not offer benefits or charge too much for them.

--Who provides the care: Private teaching hospitals, which tend to be expensive, deliver a higher percentage of care in New York than in many states. The Public Policy Institute says the hospitalization rate (in pdf format) in New York is 42 percent above the national average. Similarly the state has more people in nursing homes, as opposed to providing less restrictive – and cheaper – long-term care in the community than many other states.

--Payments for care: Others charge that the state simply pays hospital and nursing homes too much. But some dispute this, saying reimbursement rates in New York remain too low. Nursing homes in New York receive $21 a day less in Medicaid reimbursement than what the care actually costs, according to Monica Mahaffey, director of government affairs for the Health Association of New York State. Reimbursement for emergency room care, set in the early 1990s, the group says, covers less than a third of costs.

--Politics: Hospitals, other medical providers, health care unions and advocates for the poor form a politically powerful coalition to boost spending on health care. For example, in 2002, Dennis Rivera, president of Local 1199 won a 13 percent raise for his members from the state and then supported Governor George Pataki’s campaign for re-election. Higher salaries increase health-care costs and eventually show up on the state’s Medicaid bill.

--Bad management: New York does not police its system well, giving out hundreds of million, if not billions, of dollars a year in fraudulent claims. While experts differ on the magnitude of the problem, all agree it exists.

Ward of the Public Policy Institute thinks the reason for New York’s high costs go beyond any single cause: “All of this points to the conclusion that, unlike other states, New York has never even believed Medicaid should be affordable.”


Most proposals for cutting costs fall into five major categories: shifting funds, reforming care, improving efficiency, cutting services and eliminating fraud.

Shifting Funds

Mayor Michael Bloomberg and the state’s county executives would like to see the state assume all the costs of Medicaid. And many budget watchdogs support them. In 2004, the Citizen Budget Commission called for full state funding of all Medicaid costs not covered by the federal government as one of 10 proposals (in pdf format) to fix the state fiscal practices.

But shifting the funding collides with the state’s budget problem woes. "Merely redistributing the burden is not enough," Pataki said in his 2005 budget address. "The state can no more afford to pay for the current and future costs of Medicaid than counties can."

Delivering Care Better

New York has already taken one major step to try to improve the delivery of health care for Medicaid recipients. Since 2002, most people on Medicaid in New York City have to enroll in a city-approved managed care plan. This was intended to control costs and give beneficiaries better access to primary care and more coordinated help. A 2003 report (in pdf format) by the United Hospital Fund found that managed care could be improved but noted, “We have found no constituency in New York arguing for a return to the old fee-for-service program.”

Today, some experts say the system needs to focus on treatment of patients with particularly vexing problems. A fifth of Medicaid users in the state account for 70 to 80 percent of expenditures, according to the United Hospital Fund. Many of these people have substance abuse problems and more than one chronic medical condition. Providing them with a doctor who could coordinate health care and help them obtain housing and social services could keep them out of very expensive hospital emergency rooms. More coordinated measures could also help patients with chronic problems, such as asthma, diabetes and heart conditions, avoid expensive hospital stays.

Similarly, shifting some patients from traditional nursing homes to less restrictive settings is seen as another way to save money and improve the life of the patient.

And, paradoxically, some say Medicaid could save money not by cutting people from the rolls but by adding them. Getting patients into the system, they argue, means they will get care sooner before a health problem becomes a crisis and when it is cheaper to treat. Now, says Deborah Zahn, bureaucratic hassles force people off Medicaid. Many return -- often with health problems that they allowed to fester when their coverage lapsed.

And when people without Medicaid finally seek help, said Denise Soffel, a senior policy analyst with the Community Service Society, “they come in sicker and need care that is much more costly.”

Making the System More Efficient

Almost everyone sees the potential for savings in the bill for drugs and supplies, which accounts for about 15 percent of Medicaid spending in New York. This would involve greater use of cheaper generic drugs and perhaps bulk buying of medicine. The state this year took some steps in this direction, agreeing to a list of generic drugs that could save about $61 million a year, according to the Institute for Competitive Government.

New York currently has more hospital beds than it needs, This, Erie County Executive Giambra has said, drives up the cost of health care including Medicaid, “with no tangible improvement to patients.” Closing hospitals is never popular – workers lose jobs and communities may lose a valued local institution—but many believe it will be necessary.

And some look to technology to cut costs. Mayoral candidate Anthony Weiner, for one, has suggested using electronic records to enroll and keep track of Medicaid recipients.

Reducing Services

Medicaid advocates fear the federal government is laying the groundwork for widespread cuts in services. Although negotiations in Congress continue, they believe much of an anticipated $10 billion cut in federal spending will come from Medicaid. “It’s the big elephant in the room,” said Laura Caruso of Medicaid Matters.

Many governors have called for such reductions as tightening the eligibility rules and increasing the amount of money -- the co-payment -- that recipients must pay for services. Arkansas Governor Mike Huckabee, who heads the National Governors Association, said that the only way to save Medicaid “is to make if a more efficient, responsible program.” As part of this, he would increase co-payments.

In his report on cutting spending in New York, Edmund McMahon of the Manhattan Institute called for larger co-payments for such services as prescription drugs. This does two things: It may make recipients more selective about what services they choose and it reduces the state’s cost for the services the patients do select.

But Medicaid advocates say those proposing increases in co-payments ignore the reality that most people who receive Medicaid have very little money. Soffel cites a Community Service Society survey that found that one third of New Yorkers living in poverty do not have even $100 in the bank. And a Minnesota doctor told the Associated Press that, after that state raised the co-payment for prescription drugs, one of his patients could no longer afford both her diabetes medicine and her grandson’s diapers; she had to choose.

McMahon would also reduce Medicaid rolls by relaxing regulations on private insurance companies to encourage them to provide health insurance to low-income working families. To take this further, Governor Jeb Bush of Florida has proposed giving Medicaid recipients money they could use to purchase their own insurance, choosing from a variety of options offered by private companies, with money left over going into an individual account for medical expenses

Eliminating Waste, Fraud and Abuse

James Mehmet, a former chief state investigator of Medicaid fraud, estimates that at least 10 percent of Medicaid money in the state goes to fraudulent claims, according to the New York Times. Another 20 percent to 30 percent of spending, Mehmet said, while probably not criminal, is unnecessary or abusive. Together, the improper claims could total $18 billion a year.

The Times told of Dolly Rosen, a Brooklyn dentist who billed Medicaid for as many as 991 procedures a day. Medicaid reimbursed her, sending her and an associate $5.4 million in 2003. And it cited a recent federal audit, which found, that between 1993 and 2001 the New York City schools misspent $870 million in Medicaid payments for speech therapy, hiring unlicensed people and providing therapy to students who did not even need it. “The city schools are portrayed in the audit as having vigorously tapped into an antipoverty program, while doing a haphazard job at best of adhering to federal regulations,” the Times reported.

Despite such abuses – and even though some 400 million Medicaid claims were filed in New York State in 2004 -- the state health department managed to uncover only 37 cases of suspected fraud. Part of this reflects the lack of staff. About 50 state employees fight Medicaid fraud, down from more than 200 in the late 1980s. The series faulted both Governor George Pataki and Attorney General Elliot Spitzer for not doing more to fight abuses.

In response, Pataki announced a series of steps to fight fraud, including an overhaul of state agencies involved in the issue and creation of an independent inspector general’s office.

The governor’s announcement encountered some skepticism. “Shamed, embarrassed, caught with his pants down and lacking a good explanation for the loss of untold millions of taxpayer dollars, Governor Pataki said he was establishing an inspector general to battle a tsunami of fraud in New York’s $44.5 billion Medicaid program,” the Daily News said in an editorial. “Ooooh, an inspector general! That’ll throw a fright into the thieves who are robbing the program blind.”

“Certainly there’s a lot of waste in New York’s health care system,” said Laura Caruso of Medicaid Matters. “It’s not just Medicaid.” But, she cautioned that the state must take care in that, in cracking down on abuses, it “doesn’t mean putting people through the ringer to get the benefits they need.”

And Ward says that while fraud is a problem, “the real scandal is what’s legal.” As an example, he cited patients who know -- or who hire experts who know -- how to manipulate the system. Critics cite the case of a Long Island millionaire who managed to get Medicaid to pick up the tab for his wife’s nursing home care while he gave a huge contribution to a local college.

The story, reminiscent of Ronald Reagan’s welfare queens, may be apocryphal, but eldercare lawyers do advise people on how to rid themselves of their assets so they can qualify for Medicaid. How much such people cost the system is open to dispute. Soffel thinks cracking down on that would save only “a little money on the margins."

But many experts believe that any solution can only go so far to cut Medicaid costs in New York or anywhere else. Medicaid will be huge -– and costly -- as long as we have an ever-more costly health care system, in the words of a recent essay,"whose expenses will soon exceed $2 trillion -- more than the gross domestic product of Great Britain or France -- yet leaves 45 million Americans uninsured."

Photos by Jeannine Coppola

For More Information


AARP Policy and Research
The policy arm of the American Association of Retired Persons

1199 SEIU
The Web site of the union that represents health care workers. It works to oppose cuts in Medicaid.

Greater New York Hospital Association
A trade association representing more than 250 not-for-profit hospitals and continuing care facilities, both voluntary and public, in the metropolitan area and the surrounding region.

Heritage Foundation
The page from a national conservative think tank includes links to research and articles on Medicaid.

Manhattan Institute
This page from the think tank includes links to many of its articles on Medicaid.

New York City Department of Health and Mental Hygiene

New York State Department of Health

Medicaid Matters New York
A coalition that advocates for Medicaid

United Hospital Fund
A nonprofit that works to improve health care in New York.


Finding a Better Way
A report by Medicaid Matters, a coalition that supports Medicaid, on ways to cut costs and improve care.

Low Income Consumers’ Experiences: Results from a Citywide Survey of Managed Care Consumers in Medicaid, Child Health Plus, and Family Health Plus (in pdf format)
A paper by the Community Service Society on a survey that highlighted the advantages and problems of moving Medicaid recipients into managed care.

Medicaid Watch 2005
A series of short papers by the Public Policy Institute, a business-oriented research group, on the costs of Medicaid in New York State and proposals to reduce those costs

The Myth of the Uncontrollables (in pdf format)
A report by the Citizens Budget Commission about how the city can pare some expenses it says it has no control over, including Medicaid.

New York Medicaid Fraud May Reach Into Billions
The New York Times article documenting widespread fraud in the state’s Medicaid system.

New York City's $4 Billion Medicaid Bill: What Is Driving the Rise in Costs?
A report by the Independent Budget Office

Understanding Medicare, Medigap and Medicaid
(AARP Magazine) A primer on how the system works.


Mayor's Testimony Before the Financial Control Board On The City's Health


Today, for the fourth time as mayor, I come before the members of this board, and the people of New York, to report on the fiscal health of our city.

The contrast between the harsh conditions that New York City faced the first time that I was here, and the far more encouraging ones that we enjoy today, is truly striking.

The combination of 9/11 and a steep national recession had taken a terrible toll on our city’s finances. During the final quarter of 2001, the city’s economy had lost nearly 100,000 jobs. Our tax revenues had plummeted, and the city faced its worst fiscal crisis in nearly 30 years.

But even in the bleakest times, our Administration remained confident that, if we made not just the hard decisions, but the right decisions, New York would recover, and that we would retain our status as the greatest place in the world to live, work, and do business.

Following 9/11, it was clear that City government was going to have to do more with less. In response, we have cut City tax levy spending by $3.6 billion. Yet today, the quality of services is better, our economic prospects are brighter, and the promise of opportunity for all in our city is greater than it was four years ago.

That was borne out in May, when Standard & Poor’s cited both our diverse economic base and our Administration’s sound fiscal management in upgrading the rating on New York City’s general obligation bonds from “A” to “A+.” That is the highest rating we have ever earned since they began evaluating New York G-O bonds 50 years ago. What a contrast to the era when this board was established—a period when New York City’s financial practices were so discredited that its bonds were unrated, and the city was shut out of the private credit market.

Clearly, our Administration has succeeded in improving the services that keep this a city where people want to live and businesses want to locate and expand. That is precisely what has happened. Today our city’s quality of life is improving… our economy is growing… and our finances are on a firm footing. While we continue to face serious challenges, if we stay on the course we have set, New York’s best days are still ahead.

Government’s first responsibility is public safety. In recent days, we have all appreciated how the New York City Police Department has risen to the challenge of providing the additional security on our streets and in our subways that the times demand. But even as our police department has dramatically increased all of its counter-terrorism and intelligence-gathering activities, it has also continued to drive crime down to levels not seen since the early 1960s. Crime today is nearly 20% lower than it was four years ago. Over that period, we have reduced crime in every borough, and in every category. We’ve had three consecutive years with fewer than 600 homicides, and this year we could even break the 500 mark.

Key indicators of other City services tell a similar success story. For the first time since World War II, the average life expectancy for New Yorkers is higher than it is for people in the rest of the nation. New Yorkers should continue to live longer and healthier lives because of our Administration’s successful efforts to help New Yorkers break the smoking habit. Today, there are 130,000 fewer smokers in New York than there were four years ago.

Under our Administration, our municipal hospitals and clinics have improved to the point that they are now recognized as being among the best public facilities in the nation. To build on those gains, and to ensure that all New Yorkers have access to top-quality health care, we’re investing more than $1 billion to modernize and expand Health and Hospitals Corporation facilities.

Our streets are cleaner than they have been in more than 30 years. The number of children in foster care is at a 17-year low. Because that means smaller caseloads, we’re able to reinvest the resulting savings in programs that strengthen troubled families. Over the last two years, we’ve reduced the number of people living in City homeless shelters by 12%, and the number of children in those shelters by 18%. As a result, we’re in the process of closing the largest family shelter in the city at the Carlton House Hotel in South Ozone Park.

Since 2002, we’ve moved 43,000 people off welfare. During that time, the number of New Yorkers receiving public assistance has fallen by 11%.

Over the last three and a half years, we’ve added 300 acres of parkland to the biggest and best city parks system in the nation. We have also launched the most ambitious affordable housing initiative that the city has seen in 20 years. We are on course to meeting our goal of preserving and creating affordable housing for more than 200,000 New Yorkers by the end of 2008.

And while our reform of the public schools—which I believe will be our Administration’s most lasting achievement—remains very much a work in progress, we’ve produced real results that show that we’re headed in the right direction.

This year, our 4th grade students achieved the greatest one-year gains ever on the State English Language Arts test. Students in grades 3, 5, 6, and 7 posted the highest scores and the biggest one-year gains on the citywide ELA and math tests since the City started giving those tests in 1999. Perhaps most heartening, our African American and Hispanic students made impressive gains in closing the achievement gap in our schools, with the biggest one-year test score gains and best performance levels ever.

The four-year high school graduation rate, while still too low, is the highest it has been since we started tracking it 20 years ago. The number of schools in danger of being closed as irreparable failures has been cut in half, and is at an all-time low.

Our Administration has matched these reforms with the highest levels of education funding in the city’s history. Since 2002, we’ve increased City spending on the public schools by $2.5 billion. We have also committed a record $6.5 billion in City funds to a school capital plan that will, when combined with the new classrooms we’ve already created, produce nearly 100,000 new classroom seats in all five boroughs.

In short, because we have made the operation of City government more efficient, we’ve been able to put the city’s finances in order, while also making the strategic public investments that have fueled New York’s dramatic economic recovery.

You can see the evidence of that recovery in virtually all of our key industries. Start with construction and real estate. Over the last few years, we have issued record numbers of new housing permits. In Queens alone, the number of residential permits issued last year was nearly five times greater than it was 10 years ago.

Citywide, the average price of housing has doubled since 1998. Our commercial occupancy rate is better than 90%, and is higher than in any other major city in the nation.

The financial services industry posted healthy profits of $13.7 billion during 2004.

There’s also good news in our all-important tourism industry, which generates $24 billion a year in business activity, and which supports the jobs of nearly 300,000 New Yorkers. This year, our city is on track to break last year’s record of 39.6 million visitors —in large part because the current forecast is that we will have an unprecedented 12 million visitors this summer. International tourism is also on the rise; last year, the number of visitors from overseas, who typically far outspend domestic tourists, grew by 10%--the first such increase since 2001.

The city’s overall economy is growing faster than the nation’s for the first time since 2001. Jobs figures released last week show that we gained 8,500 private sector jobs in June.

That puts us on course to meet or exceed the forecast that we will add 50,000 private sector jobs to the city’s economy this year. Wage earnings in the city are at levels not seen since before 9/11.

Unemployment citywide has now fallen to 5.5%. That’s lower than it was before 9/11. And for the last four months, it has remained below 6%, which is the first time that has happened since 2001.

As encouraging as these trends are, we’re not resting on our laurels. In order to ensure the city’s long-range prosperity, our Administration continues to pursue an aggressive strategy to diversify the economy and invest in all five boroughs.

Yesterday in Queens, I helped unveil the new American Airlines terminal at Kennedy Airport, financed by $1 billion in City I-D-A bonds. It will not only enhance JFK’s role as a major international gateway, but also complement our Administration’s efforts to create a new transportation-related business district in neighboring Jamaica.

In the Bronx, we’ll soon open the new $85 million Fulton Fish Market, the centerpiece of our strategy for bringing more food industry jobs to Hunts Point.

On Staten Island, we’ve begun making $66 million in infrastructure improvements in the Stapleton area that will turn the Homeport site into housing and open space and an economic engine for the borough.

We’re making $71 million of similar improvements to the area around the Brooklyn Navy Yard to support new tenants there, including Steiner Studios, the largest film and television soundstage on the East Coast. Film production continues to be a growing industry in our city. Over the last two years, film and television location shooting days in our city have increased by more than half. And in just six months time, our Administration’s targeted tax credits for television and film production have brought in $330 million worth of new business and provided jobs to 6,000 New Yorkers.

To encourage our manufacturing sector, we’re establishing industrial business zones across the city. And our rezonings of the Far West Side of Manhattan and Downtown Brooklyn have replaced long-outdated zoning regulations, and laid the foundation for private investment that will lead to major future commercial and residential expansion in those areas.

These and other policy initiatives and public investments will keep New York’s economy growing, and reinforce the city’s continued fiscal health.

The FCB’s staff report acknowledges the City’s strong fiscal position. As the report points out, City revenues have been so strong that the City was able to end Fiscal Year 2005 with a balanced budget while also pre-paying $3.5 billion in expenses for Fiscal Year 2006.

This permits us to balance next year’s budget while also enacting a range of much-needed and well-deserved tax relief measures for New Yorkers.

As it did last year, the $400 property tax rebate will repay those who made the greatest sacrifices in helping secure New York’s future. The Earned Income Tax Credit, included in the City budget for the second consecutive year, will also make a huge difference in the lives of hard-working New Yorkers who earn less than $36,000 per year.

The elimination of the City sales tax on clothing and footwear priced at less than $110, which the Governor signed into law on Monday, will help New Yorkers clothe their families. And virtually all of the money returned by these tax relief measures will be spent in our city, supporting local businesses, and creating local jobs.

Your staff report also makes note of the recent binding arbitration decision concerning the Patrolmen’s Benevolent Association. I want to call attention to the fact that the Public Employees Relations Board decision sets out productivity measures that the PBA must accept. That provides very important validation for our Administration’s position that raises for City workers must involve offsetting savings in the way that we do the people’s business. Weaving that principle into future collective bargaining agreements is fundamental to the city’s long-term fiscal health.

We remain hopeful that we will also reach a contract agreement with the United Federation of Teachers. And while we certainly will not negotiate that contract in public, I want to stress that it too must include productivity measures.

If the City were to compromise on that point in these negotiations, it would undermine our position with all of the other City unions, especially those that we are now having contract talks with.

Our school principals—the frontline managers of the school system—also must have greater flexibility and autonomy in doing their jobs. That will make a huge difference for the future of our schools and our students.

The future of our city also demands both fiscal prudence at the local level, and also urgent efforts at all levels of government to control the non-discretionary expenses borne by City taxpayers.

The current City budget illustrates this problem clearly. Between Fiscal Years 2005 and 2006, discretionary spending by City agencies is expected to grow by $139 million. But non-discretionary expenses, including pension and employee health benefit costs and the local share of Medicaid, will increase by $2.5 billion. Pension costs alone will account for $1.4 billion of that figure.

The continued growth of these non-discretionary costs is why we are projecting a $4.5 billion gap between City revenues and expenses in Fiscal Year 2007.

Action by State leaders to control these expenses is imperative. In the area of pension costs, for example, our rising expenditures are largely the product of pension “sweeteners,” enacted by the Legislature and passed on to the City as unfunded mandates that we increasingly cannot afford. This simply cannot go on.

Zero tolerance for inefficiency, waste, or fraud in the expenditure of any public dollars is also essential to balancing our budget in the out-years.

The recent reports of widespread fraud in the Medicaid program are highly troubling, and, if they are true, especially scandalous. This is not a “victimless crime”; far from it. The mounting costs of the Medicaid program translate into fewer dollars for our libraries, senior centers, and after-school programs, let alone such essential services as police and fire protection. The kind of cynical defrauding of the Medicaid program that we’ve been reading about is a crime against the people of New York that must be stopped, and its perpetrators must be punished.

Year after year, our Administration has joined the state’s county executives of both parties in asking Albany for Medicaid relief. The soft cap on local Medicaid expenditures enacted last year was a good beginning. But until a full audit of the program has been completed, and instances of fraud have been identified and eliminated, I believe the Legislature must refrain from any further enhancements to this program.

The City must also do its part to ensure fiscal prudence. In that vein, I’m glad to report that there is an emerging consensus among the members of the City Charter Revision Commission that the wise financial practices required by the State Financial Emergency Act should be made part of the Charter.

Our Administration will without reservation continue to apply those principles to overseeing the City’s finances. We look forward to continuing to work with the governor, the State and City comptrollers, State and local legislative leaders, and the FCB to safeguard our fiscal future.

And before closing, I would like to say, Governor, how much I appreciate everything you have done for our city and for our entire state, not just over the last three and a half years, but during your entire tenure.

In your remarks yesterday, you spoke from the heart about how the example of your parents taught you the intense satisfaction that comes from making life better for the whole community. Whatever path you choose to follow in the future, I hope that you find it rewarding, and that it gives you the kind of opportunities to serve others that you continue to exercise so well as governor of our state.


Nonsmoking New York?

Standing outside the cafe he owns in Astoria, Kosta Litzeris smokes a Salem cigarette as he greets a stream of regular customers with kisses on the cheek and pleasantries in Greek. Some customers, once they move through the door and settle in for ouzo or espresso, light up their own cigarettes, despite city and state laws forbidding it.

Litzeris has accepted that $1,000 fines are a regular cost of doing his brand of business. According to the city's Department of Health and Mental Hyigiene, Litzeris' establishment, Café Kolonaki, is one of the die-hard resisters of New York's two-year old smoking ban. It recently included the café among nine restaurants and bars that "willfully and continuously violate" the smoking ban.

But Litzeris says pressure from the city has made it clear that the time has come to change his ways.

"We're trying to push [the smokers] outside now, because the weather is good," he said. "We're trying to take it on slowly."

In the past few years, New York has become a far less friendly place for smokers. Cigarettes cost about $3 more in New York City than the national average, thanks to heavy state and local taxes, and there are far fewer places to light up thanks to state and local bans on smoking in workplaces. The city and state have also been focusing increasingly on programs to help smokers quit. As a result, say city and state officials, fewer New Yorkers smoke, and New York has served as a model for other places wanting to take similar antismoking actions. Antismoking advocates see this as part of a sweeping nationwide, and even international, trend that goes beyond government initiatives.

"A major social change has been underway for a long time," said Russell Sciandra of the Center for a Tobacco Free New York. "The enactment of [the smoking ban] was a landmark in that social change, but it was happening anyway without legislative action."

But recent studies shows that New York is failing to collect its taxes, even as the smoking ban seems to have taken a strong hold. Increasingly restrictive legislation is also being considered: some state lawmakers want to raise the smoking age to 19, while starting last week, 18 year olds in Suffolk county are no longer able to buy cigarettes legally.

As they work on those policies already in place, even some antismoking advocates have begun to wonder if New York's anti-smoking fervor is headed in the wrong direction.


In 2002, New York City imposed a tax of $1.42 on cigarettes -- adding to a similar state tax -- and banned smoking in all workplaces, most notably bars, nightclubs and restaurants. Suddenly, New York City had the most expensive cigarettes in the country at about $7 a pack, and the country's strongest ban on smoking in public places. Statewide, cigarettes cost about $6 a pack, as opposed to about $4 for the nation as a whole.

The effect, officials say, has been a drop in the number of smokers. Mayor Bloomberg recently claimed that there are 130,000 fewer smokers in the city than there were in 2002, while an independent assessment (in pdf format) of New York State's antismoking efforts show that cigarette sales in the state are dropping faster than they are in the country as a whole.

Can New York Collect The Tobacco Tax?

The tobacco tax was described as a way to discourage people from smoking, rather than as a way to raise money. Bloomberg has said that he would prefer that the city tax be so high that it adds no revenue to the city's coffers. Both city and state taxes are generally given a lot of credit in driving down the number of smokers. Heavy taxation of tobacco, say antismoking advocates, is particularly effective in discouraging young people from smoking because they are less affluent and less addicted than adult smokers.

But those who have analyzed the numbers measuring the tax's success say that may be deceptive, because the high tax has simply sent many smokers to the black market.

In a recent analysis Andrew Hyland, who studies health policy at Roswell Park Cancer Institute, claims that smoking rates have not dropped as quickly as one would expect considering the price increase. In addition, his analysis shows, New York State is losing between $470 million and $635 million annually in tobacco taxes.

"I think that one of the primary reasons for that is that smokers have switched their purchasing patterns," said Hyland.

Plenty of places remain where New Yorkers can buy tax-free cigarettes. According to the Bureau of Alcohol, Tobacco and Firearms, 45 percent of New York State residents "sometimes" or "always" bought tax free cigarettes in 2003 and 2004, either by traveling to American Indian reservations or other states, or by buying cigarettes over the phone or online.

Thomas Frieden, the city's health commissioner, said in a recent interview that for the city's antismoking policies to truly be effective, state and federal enforcement efforts are key.

The state has taken several steps. Governor George Pataki recently signed into law a bill that would stop non-Indians from buying tax-free cigarettes on American Indian reservations. New York State has been failing to pursue this uncollected revenue, something which Hyland says costs it up to $300 million annually.

The state attorney general's office and the federal Bureau of Alcohol, Tobacco and Firearms also came to an agreement with credit card companies in March to stem Internet sales. Such sales have long been illegal in New York because it is impossible to verify a consumer's age online with any degree of reliability. Because credit card companies generally have policies that forbid cardholders from using their cards for illegal purposes, the companies agreed to stop allowing their cards to be used for online cigarette purchases at all.

Advocates are waiting to see how well such measures are implemented before counting them as a victory. The state attorney general's office says that it has anecdotal evidence that online tobacco retailers -- who it sees as criminals -- have been harmed by its agreement with the credit card companies.

But other illicit online industries, such as gambling, have found ways around similar restrictions in the past. Both advocates and officials are convinced that online tobacco retailers will find such a way to adapt to this measure as well.

Have Fears About The Smoking Ban Come True?

Banning smoking in bars and restaurants has arguably been the most controversial thing that Bloomberg has done in his four years as mayor. Signs can still be seen near outdoor ashtrays outside of Manhattan bars showing the mayor with his pants down, urging him to "Butt Out," and it is not difficult to get those who object to the idea of a ban to explain their reasoning at great length. But despite some persistently loud opposition, implementation of the smoking ban has presented less serious problems than implementation of the tax.

The ban was originally envisioned as a workers' safety issue. By having to inhale second hand smoke, proponents of the law argued, bartenders, waitresses and others were being forced to work in unreasonably dangerous conditions. Opponents said they objected in principle to such "government nannyism", that bargoers would wreak noisy havoc on city streets once forced out of doors, or that smokers would feel so shunned by the law that they would simply refuse to patronize bars and restaurants.

City and state officials say that the past two years have vindicated those who supported the law. A year after the ban went into effect, the city said that the level of cotinine, a byproduct of nicotine, had dropped 85 percent in nonsmoking workers at bars and restaurants, a sign that it took to indicate success in its primary goal.

Further, both city and state studies show there has been no nightlife crash. The state's Department of Taxation and Finance published a report last month that analyzed tax revenues, showing that business suffered for about six months after the ban, but then picked back up. Bars did the worst -- their business was six percent lower in the first three months after the ban compared to the same period one year earlier. The next year, however, business had crept back up five percent, still slightly lower than it was before the ban in 2002, but on the upswing.

Neither the state nor those who remain opposed to the ban believe such broad statistics tell the whole story, because they do not take into account factors like the improving economy or changes in state taxes.

Some opponents of the ban, who admit that the restaurant and bar industry as a whole may not have suffered, still argue that certain businesses have been hurt badly nonetheless. One Web site has a list of bars and restaurants that claim to have suffered from the ban, including a dozen establishments that have supposedly gone out of business at least in part because of it. Litzeris claims that Café Kolonaki didn't allow smoking for the first month of the ban, but suffered from such a dramatic drop in business that he had to change tact. He is gloomy about being forced to comply with the law he has flouted for the last two years.

"It will shut us down," he said.

Charles Hunt, executive director of the New York City chapter of the New York State Restaurant Owners Association, questions whether businesses that go out of business can reasonably blame the ban, but he does believe that a certain type of business has been harmed.

"The neighborhood tavern where they open the doors at eight in the morning and sixteen retired guys sit around smoking and played cards - or did. These are the places that got hurt," he said.

Hunt's group opposed the city ban, but he is not the ban's only political opponent who said that he personally enjoys the lack of smoke when he goes out.

Meanwhile, antismoking advocates -- Mayor Bloomberg included -- point out that New York's positive experience is spreading momentum for bans in other places. Since New York City and New York State passed bans on smoking, the pace at which other areas passed bans increased dramatically. In 2004, 69 cities implemented smoking bans, compared to 34 in 2002, the year before New York's bans took effect. Ten states and several countries including Italy and Ireland have decided to implement bans of some sort, and over 100 million Americans now live in places with smoking bans (in pdf format), according to the American Nonsmokers' Rights Foundation.

While it is difficult to credit New York for directly inspiring any of these laws, the health department says it has been fielding a stream of inquiries from other jurisdictions interested in implementing their own bans. Even detractors of the ban agree that its effect has been profound.

"I knew that if New York City went, the rest of the country would go," said Audrey Silk, the founder of New York City Citizens Lobbying Against Smoker Harassment, a group opposing smoking bans and increased tobacco taxes. "Not to be snobby New Yorkers, but we're trend setters: 'If New York can do it, we can do it.' And we saw that happen immediately."


Advocates still find plenty of shortcomings in New York's tobacco control efforts. The billion dollars coming in annually from the tobacco tax and the hundreds of millions that the state receives from a nationwide legal settlement against tobacco companies do not translate into more money for such efforts. The state currently spends $40 million a year on tobacco control, less than half of the Centers for Disease Control's recommended level. The tobacco companies spend 200 times that amount promoting its products in New York State annually, according to the American Lung Association of the City of New York.

But Blair Horner of New York Public Interest Group believes that the tobacco tax and the smoking ban have caused a significant political shift, weakening the tobacco companies' traditionally powerful influence on New York State policymakers.

According to Horner, this trend actually started in 1999 when a scandal broke out over Philip Morris (now Altria) illegally giving gifts to state legislator. (Horner detailed the scandal in an online book). The scandal led legislators to prove their good intentions towards tobacco control measures according to Horner. "Once lawmakers got used to passing pro-health measures -- or anti-tobacco measures depending on how you look at it -- it seemed to create its own momentum," he said.

There is evidence of the anti-tobacco momentum in New York City and State. The city is in its third year of an expanding program to give away free nicotine patches, with Pfizer, a company that manufactures the patches, donating millions of dollars worth of its product to the city. New York State's average annual tobacco control budget this decade is ten times higher than it was in the 1990s. It is the only state in the country to have legislation mandating that efforts be taken to manufacture cigarettes that are less likely to start fires.

Also, within the last month there has been movement in Albany to raise the smoking age to 19, a measures that Long Island's Suffolk County has already adopted on the local level.

The prospect of raising the smoking age has left some antismoking advocates feeling that their regular allies are overreaching. Smoking is, after all, legal, and 18 year olds are adults, said Horner, adding that this particular measure has not been effective in other states that have implemented it. Other antismoking advocates have said that even if they do agree with raising the smoking age, it should take a secondary role to other efforts like antismoking advertisments; health commissioner Frieden says he has no opinion on the subject.

For pro-smoking activist Silk, the movement to raise the smoking age is just another sign that legal prudishness is spreading. Junk food and other unhealthy behaviors, she says, may be next.

So while the atmosphere is distinctly hostile to her views at the current moment, Silk holds out hope that the antismoking trend will not always be in vogue.

"Alcohol prohibition lasted 13 years and there was a constitutional amendment, but it was overturned eventually," she said. "It's fashionable now to beat up on smokers, but liberty could be fashionable again ten or fifteen years from now."

The New York Libertarian Party has nominated Silk to run for mayor, and she says that her candidacy will be a way to voice the pro-smoking perspective. She does admit that her campaign is going slowly, though. The reason, says Silk, is that she refuses to go to Libertarian party meetings because they make her go outside to smoke.



New York City Department of Health
Tobacco Control Page
Center for a Tobacco Free New York
New York City Citizens Lobbying Against Smoker Harassment
Americans for Nonsmokers' Rights
American Lung Association of the City of New York

Gotham Gazette Articles

Smoked Out (July 2001)
Smoking in New York (July 2002)
New York City's Blue Laws (May 2003)

Reports Etc. (in .pdf format)

First Annual Independent Evaluation of New York State's Tobacco Control Program (by the Tobacco Use Research Program at Research Triangle Institute)
The State of a Smoke Free New York, A One Year Review (by the City of New York)
List of Places With Indoor Smoking Bans (by the American Nonsmokers' Rights Foundation)
Blowing Away the Smokescreen: The Case Against Big Tobacco (by the New York Public Interest Research Group)



AIDS In New York City

Representation of the
Human Immunodeficiency Virus

Related in Community Gazettes:
• AIDS 50+
• Fighting AIDS with Needle Exchanges

On a trip to visit family in South Carolina, Niko Flowers, who lives in Kew Gardens, Queens, asked after a cousin. The cousin recently died of AIDS, her family told her. Flowers was surprised: Nobody had even mentioned that her cousin was infected.

But she understood. "When I got diagnosed," Flowers said, "I didn't tell anybody for four years."

Flowers has been living with AIDS now for 15 years, after contracting it from a boyfriend when she was in college. She is no longer silent about it. She works for Love Heals, which sends people with AIDS to speak out about the disease.

The teenagers to whom she speaks, though, do not always like to talk about it. Neither do most New Yorkers, who may see it as a distant disease, a manageable disease, a gay disease, or an African disease -- as nothing connected to their own lives, or even to their own city.

Last month, the city began to speak about AIDS once again with a sense of urgency, when City Health Commissioner Thomas Frieden announced that a New York man had been infected with what appeared to be a new, drug resistant strain of AIDS.

Even though the scientific merits of the case were immediately brought under question, Frieden's announcement inspired more media attention around AIDS than there had been in years.

The frenzy soon faded; the silence resumed. Many advocates, though, say that the recent discussion was never about the real threats from AIDS. The issues, they say, persist.


New York has long been known as the center of the domestic AIDS crisis. The AIDS rate in New York State remains at about double the national rate for men and triple the national rate for women. There are 90,298 city residents known to be living with AIDS, and up to 45,000 more who don’t know that they’re infected. In the quarter century since the AIDS epidemnic began, the city has suffered 16 percent of the national death toll, with over 85,000 AIDS casualties to date. (summary of most recent NYC AIDS statistics in pdf format).

The reasons cited for New York's high AIDS rates include the city's high levels of drug use, a permissive sexual atmosphere and widespread poverty. The combination of these factors is what makes New York’s epidemic distinct.

While the number of new AIDS cases in New York has continued to decline since 1995 -- there were 5,552 cases in 2002 and 4,205 in 2003 -- experts see worrisome signs. Nationwide, the number of new HIV diagnoses has been increasing slightly since 2001, in a reversal of a previous trend, according to the Centers for Disease Control and Prevention. Some see this as evidence of the growing ineffectiveness of safe sex campaigns throughout the nation. And there is plenty of evidence that such campaigns are increasingly ineffective in New York as well. In a 2003 survey (In PDF format) by the Department of Health less than half of gay men said they used a condom the last time they had sex (in pdf format). Condom use among straight men and women was even lower. Experts also point to a rising number of syphilis to show that more New Yorkers are having unsafe sex. It is just a matter of time, some worry, until the number of AIDS cases in New York will start to follow the national upswing.


Most new HIV infections in New York City are still contracted by men through sex with other men, but the proportion of new infections being passed through heterosexual sex is rising sharply. In the first quarter of 2004, 22 percent of new diagnoses were among heterosexuals, up from 16 percent a year before. The disease is also becoming an increasing problem among women, according to a recent report by the Department of Health (in pdf format).

Like other issues where economic wellbeing plays a role, minorities suffer disproportionately. Blacks are three times as likely to be HIV positive than whites; Hispanics are twice as likely. People of color are also much less likely to know their status; six of ten black New Yorkers diagnosed with HIV find out their status on the same day they are diagnosed with full-blown AIDS. Once infected, people of color die at higher rates than white New Yorkers do, mainly because they have poorer access to medical care.


Overall, death rates have been declining drastically since the advent of better drug treatments in the mid-1990s. This success has come with new challenges.

Aside from making it harder to keep AIDS in the public consciousness, lower death rates have meant more people living with AIDS. Some 67 percent of people with AIDS are now over the age of 40; 28 percent over the age of 50. As they age, new problems surface: Most AIDS drugs, for example, have only been tested on younger people; the potential side effects or effectiveness of certain treatments for older people are unknown. (See the article on AIDS Over 50 in the Community Gazettes for Greenwich Village.)

New York’s AIDS housing system is facing an impending crisis, according to a recent report commissioned by the city (in pdf format). As people live longer, healthier lives, they are also more likely to be able to return to work, leaving advocates and the city to design back-to-work programs tailored to the needs of people with AIDS.


If AIDS has been particularly brutal in New York, it has forced New Yorkers to become especially effective in fighting back.

New York’s efforts on AIDS are largely carried out by a network of community organizations, which city officials cite as a vital part of the response to the disease.

These organizations spend significant energy advocating various approaches that the city government should focus on. The debate, say activists and city officials, helps both sides by disciplining them. Activists praise the Bloomberg administration for engaging in this debate in a way former Mayor Rudolph Giuliani was never willing to.

Needle Exchange

Mayor Michael Bloomberg’s approach to AIDS centers on encouraging people to know their HIV status by expanding the places where people can get tested and making the testing process quicker and easier.

He also has focused on syringe exchanges. Advocates see this as the Bloomberg administration’s most tangible success on AIDS. Last year, the city opened the first needle exchange in Queens, the last borough without one, and is planning several more. ( See Fighting AIDS With Needle Exchanges" in the Community Gazette for Long Island City)

In the first quarter of 2004 the number of people with injection drug histories who were newly diagnosed dropped to 88 from 156 the year before.

Testing And Information-Gathering In The Face Of Stigma

When New York City Health Commissioner Thomas Frieden announced that a man had become infected with what seemed to be a new strain of AIDS that progressed rapidly and resisted medicine, the scientific community was not immediately convinced that the new case merited all the attention it was receiving. The long-term clinical significance has yet to be determined. Meanwhile, the health department has been accused of being alarmist.

The health department said the possibly new strain of AIDS has made it all the more important that people be tested for HIV, something the agency long had been promoting in any case. While some activists publicly contemplated radical measures, Frieden said he would like to change at least one law to allow better information-gathering on the disease.

The commissioner said that he has no intention of rolling back confidentiality protections, but some say that for some time he has been hinting at doing just that. His past record of encouraging forced hospitalization for tuberculosis patients has led some to question his judgment on the balance between civil rights and aggressive medicine.

Critics say that civil liberties require particular care with regards to AIDS because stigma about the disease still poses an obstacle to prevention efforts. "Frieden comes from a tuberculosis approach,” said Julie Davids of Community HIV/AIDS Mobilization Project. “I don't think his means are going to get the ends that we need.”

Isacc Weisfuse, the department’s deputy commissioner for disease control, says that the department is looking at the success in reducing tuberculosis rates for inspiration in working with AIDS, but he acknowledges that not all techniques will transfer. He bristles at the suggestion that privacy could be compromised.

AIDS And The Public Schools

The school system is seriously lacking in health teachers, and 63 percent of school districts don’t meet state requirements for the number of teachers trained to teach about HIV/AIDS, according to a 2003 report by State Assemblyman Scott Stringer. Many schools, he says, simply avoid talking about AIDS altogether; some bring in outside groups like Love Heals instead of having their own teachers take the responsibility of informing the students.

When public schools do teach about AIDS and other sex education topics, the guide they use describes AIDS as a disease that primarily affects gay men, talks little about how it has affected communities of color, and informs students on the use of birth control methods that were discontinued years ago. Neither the overall health curriculum nor the HIV/AIDS curriculum has been updated since 1991.

After sustained pressure, the Department of Education says that it has drafted replacement curriculums for health and HIV/AIDS. Activists have criticized the HIV/AIDS curriculum for avoiding frank discussions of drug use; the health curriculum, they complain, doesn’t cover sexual orientation. After input from parents and advocates, the health department says the new lessons will be in place by September.

The New York AIDS Coalition is working with the city, but is not convinced their partner is committed. “When it comes to the Department of Education, they have other priorities,” said Kazanas. “If it’s not about reading and writing scores, it’s really not on their radar.”


When Bloomberg decided to focus on needle exchanges he was defying the official wishes of the federal government, which has banned the use of federal funds for syringe exchanges since the late 1980s. New York’s ability to run its own program illustrates one of the city’s major strengths: it has its own money.

New York City and New York State are recognized as places that put more taxpayer money towards HIV and AIDS programs than elsewhere. The flexibility afforded by these funds has long allowed New York to innovate with HIV/AIDS policies.

In this year’s proposed budget, Bloomberg has proposed a permanent allocation of $5 million to the Department of Health’s budget for prevention efforts in communities of color. The money itself is not new; the City Council has been putting it aside for several years. But making it permanent will make it easier to plan ongoing programs.


As elsewhere in the country, the majority of funding for AIDS prevention and services in New York comes from the federal government.


Funding for those who need expensive treatment is declining on the federal level. President George W. Bush has proposed sharp cuts for Medicaid, and the Ryan White CARE Act, two of the major ways in which people with AIDS get medical treatment. There is also less money for federally funded AIDS housing.


New York is at the center of efforts to develop an AIDS vaccine. Researchers at the Aaron Diamond Research Center began enrolling New Yorkers in the first critical trial of a new AIDS vaccine, called ADMVA. The federal government funds virus research at Columbia University and the New York Blood Center. And the blood center is the Manhattan trial site for a vaccine effort by Merck Pharmaceuticals. Likening such efforts to the long quest for a polio vaccine, experts caution that similar efforts to stops AIDS will require money and commitment.

But after a large increase in the 1990s, the federal AIDS research budget (which is now about three billion dollars a year) has leveled off, according to Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, which supports and conducts AIDS research.


For those working on prevention, not only is funding being cut, but the type of work that is being funded is also being redefined.

In 2003, the Centers for Disease Control, frustrated with the nation’s lack of success in HIV prevention, developed a new strategy that put an increasing focus on preventing new infections by identifying people who are already infected and working with them to cut down on interactions through which they might infect others. It insisted that those organizations that receive funding for prevention do the same.

The agency describes its decision as a way to bring discipline to AIDS prevention. But private AIDS organizations, many relying solely on federal grants to stay in existence, say they are seriously burdened by the new approach.

"Because certain people pull the purse strings, one feels that one doesn't have a choice but to go along with the way they do things,” said Tokes Osubu, executive director of Harlem-based Gay Men of African Descent, which has seen its budget cut by about 80 percent.

Activists regularly complain that groups working primarily with gay men have the most trouble getting funding. Because the current administration has been encouraging abstinence-only sex education, those teaching about safe sex often feel left out.

Aside from hampering the actions of specific organizations, many feel that the federal government’s controlling approach has taken away one of the best ways to keep AIDS prevention effective: allow those working among particular communities to adjust to the specific needs of each community.

By adopting a nationwide standard, says Kazanas, the federal government is ignoring the complexity of an epidemic that is different in every place it is present.

“We have a better grasp and a better handle on the needs of our particular epidemic than somebody sitting in Washington.”


New York City Department of Health and Mental Hygiene
New York State Department of Health
Housing Works
New York AIDS Coalition
Gay Men’s Health Crisis
Harm Reduction Coalition

Coalition Searchable Database of AIDS information
Directory of New York Department of Health Studies on AIDS
Henry J. Kaiser Foundation Introduction to HIV/AIDS in New York State















































The Flu -- An Ironic Season

A few short months ago, health officials were worried about this year's flu season because of a sudden shortage of the vaccine. Only two companies manufacture flu vaccines for the entire United States of America, and one of them was unable to deliver the product. New York City started the season in October with 600,000 fewer vaccine shots than officials said they needed and, along with the rest of the county, implemented a policy allowing only people at "high risk" for the disease to receive shots.

Now, health officials are still worried, but for a different reason. There is an adequate supply in New York City for groups at risk. The problem is now the demand. "We don't want those doses to go to waste," said Dr. Julie Gerberding, director of the federal Centers for Disease Control in an announcement in December recommending the list of "priority groups" for the vaccine be expanded.

Fewer Shots, More Flu

Influenza is more than an inconvenience. It causes an average of 36,000 deaths a year in the United States and sends about 230,000 people to hospitals.

Yet, as of December 22nd, only 17 percent of Americans had received flu vaccines, half as many as last year or the year before, according to a Wall Street Journal Online/Harris Interactive health-care poll. And of at-risk adults who qualify for the shots, 47 percent reported they had not even tried to get one this year.

Not surprisingly, flu cases are reportedly on the rise. New York was the first state to report "widespread influenza activity" according to the Centers for Disease Control.

The New York City Department of Health and Mental Hygiene announced on December 21st that it "had identified 21 outbreaks in health care or other institutional facilities so far this season, nearly twice as many as had been reported by this time last year." The department also reported there are now adequate supplies of flu vaccine in New York City and advised the medical community to "make sure patients at highest risk of serious illness from the flu get vaccinated."

No Longer A Shortage For New Yorkers At High Risk

In New York City, the shortage of vaccine shots was addressed when federal health officials made plans in November to divvy up the national supply of vaccine based on the concentration of high risk groups in different areas. The city has already received 900,000 doses of vaccine from the federal government and anticipates receiving over 275,000 more.

To further alleviate the problem, New York City joined Illinois, New Mexico and Cleveland in a bid to obtain additional doses from European manufacturers. However, the federal government is still deciding whether it will allow the vaccines into the country, and flu season may be over by the time it does.

For now, New York City health officials say there is still not an adequate supply to vaccinate everybody, but there is enough for those considered high-risk:

  • People 65 and older. (The city is now considering lowering the age to 50);
  • Children 6 to 23 months of age;
  • Residents of nursing homes and chronic-care facilities;
  • People age 6 months and older with chronic medical conditions, including heart disease, pulmonary disorders (including asthma), diabetes, kidney disease, hemoglobinopathies, and compromised immune systems (HIV or immunosuppressive therapy);
  • Women who will be pregnant (at any gestational age) during the influenza season;
  • Children and adolescents, age 6 months to 18 years, receiving long-term aspirin therapy;
  • Healthcare workers providing direct patient care;
  • and caregivers of children under 6 months of age.

Flu shots are now available for these groups, but media coverage of the flu epidemic has declined, and health officials seem worried the shots will go unused. "Many New Yorkers were discouraged from seeking a flu shot this season, even as more vaccine became available," New York City Health Commissioner Dr. Thomas R. Frieden said in a statement. Because so many people stayed home rather than receiving their annual flu shot, he said, "there are likely to be more flu-related deaths this year."

Is There A Better Way?

Stephen S. Morse, director of Columbia University's Center for Public Health Preparedness, says this is not necessarily true. It is hard to predict the virus's movement or gauge the efficacy of the health department's vaccination program this early in the flu season. "It's always an issue of supply and demand," he said, "and only time will tell if the hard-working health department predicted the demand correctly." Last year, he added, the companies producing the vaccines anticipated too large a demand and over-produced the shots. "They ended up throwing out 10 million doses nationally."

It is especially hard to make predictions when the two major forecasters each year, public health departments and private drug companies, have different agendas. For the drug companies that produce the vaccines, profits remain an issue -- and flu vaccines are generally not very profitable. For one thing, they are only administered once; other drugs may be taken several times a day for long periods of time.

Additionally, the cost is high for identifying the particular strain of flu set to arise each year and producing a new vaccine to combat it. And in some cases, scientists make incorrect predictions, meaning months of work -- and months of funding -- are wasted. For these reasons, Dr. Morse said, many drug companies opt not to make flu vaccines. If it turns out that this year's demand exceeds supply, however, more companies, such as those operating only in Europe, may want to jump in.

European countries have avoided shortages by relying on more pharmaceutical companies for the vaccines. Health experts overseas have long criticized the U.S. handling of flu vaccines, according to the New York Times. Britain "spread its order for flu vaccines among five suppliers, precisely to avoid the kind of predicament America now faces."

There are also vaccines that have been approved for use in Europe but not in the United States. More approved vaccines could mean less reliance on a single company. This season, Fluarix, a vaccine used in Europe but not here, was authorized on an emergency basis for use in the United States. Reuters reported that health officials agreed to buy up to four million doses of the vaccine from a plant in Germany.


Drug companies might be interested in producing more than just vaccines. Antiviral drugs can be used during vaccine shortages to treat high-risk groups, such as the elderly living in nursing homes, where disease spreads quickly. Antivirals make it impossible for the virus cells to reproduce in the body and can be used to prevent or treat certain types of flu.

According to a recent study at the University of Vermont Medical School published in the New England Journal of Medicine, amantadine, one of these drugs, was 91 percent effective at preventing the flu in a group of 450 volunteers. Dr. Alan Kendal of the federal Centers for Disease Control said that, ''in special cases, such as an epidemic of flu at a nursing home, amantadine may serve as a useful supplement in protecting high-risk people in the period before the vaccine can take effect.''

Though antiviral medications work well, there are several problems with relying on them for treatment. To prevent the flu, they must be taken within two days of getting sick, according to a report from the Centers for Disease Control. Because they are available by prescription only, people must see a doctor at the first sign of the flu to receive them. Though they can shorten the length of infection, for a typical weeklong bout, the difference in recovery time would be only a day or two. Further, the antivirals only work for type A influenza, not the common cold or other forms of the flu.

For the most part, antivirals are used in combination with vaccines to treat people at risk of complications from influenza. According to the statement, they are most often used "to control flu outbreaks in institutions, for example in nursing homes, or in hospital wards, where people at high risk for complications from flu are in close contact with each other."

Due to the vaccine shortage, antiviral drugs have been widely used this year. The American Society of Health-System Pharmacists quoted Health and Human Services Secretary Tommy G. Thompson as saying that this year the country would have enough antiviral drugs to care for about 40 million people. It also reported that "the CDC is concerned about the development of drug resistance if the products are used for treatment as well as prophylaxis."

As health departments increase supplies of vaccine and antivirals, and media attention to the issue declines, Secretary Thompson advised people in high-risk categories to be "patient but also be persistent" in seeking vaccine.

For more information about flu, or where to get a flu shot from the Health Department, call 311 or visit the department's flu page.

















































The World Trade Center Health Registry

When federal and city health officials announced in September, 2003 the launching of the World Trade Center Health Registry, they expected it could be the largest public-health investigation ever. Its aim was to understand the health effects of the September 11th terrorist attack and its aftermath by tracking for two decades people who had been exposed to Ground Zero.

More than a year later, there are some concrete findings about health complaints – and perhaps as many complaints about the survey itself.

The Findings So Far

The registry, a collaboration between the New York City Department of Health and Mental Hygiene and the federal Agency for Toxic Substances and Disease Registry, has enrolled more than 70,000 volunteer participants, people who resided, volunteered or worked near Ground Zero.

According to initial health data released recently:

  • 47 percent of those analyzed complained of “new” or “worsened” health problems immediately following the attacks.
  • These included respiratory irritations like shortness of breath (42 percent), wheezing (38 percent), and persistent cough (37 percent).
  • Over 40 percent of respondents in the area around Ground Zero (beneath Chambers Street) reported eye problems as a result of the disaster.
  • Over 20 percent of all interviewees said they experienced severe headaches.
  • Eight percent of enrollees reported experiencing “psychological distress,” including anxiety and depression, in the month preceding the interview. This is a 60 percent higher rate than that of the New York City population in general.

At a press conference announcing the findings, Health Commissioner Thomas R. Frieden conceded that the prevalence of respiratory symptoms “is not surprising” in light of previous research. However, the results do give new indications as to the scope of the impact, according to Frieden: “What this shows is that tens of thousands of people had significant lung symptoms around the time of exposure to the WTC.”

The Criticism

The most recent findings do not impress critics, who see several things wrong with the survey.

Some, like Micki Siegel de Hernandez, director of occupation safety and health for New York State for the Communications Workers of America, say it says nothing new. Union members who worked at Ground Zero have been complaining of illnesses for years, and previous studies have made all the same points.

Some charge it is not scientifically valid.

The New York Committee for Occupational Safety and Health, a non-profit advocacy organization, has long questioned the survey’s design: “The population under study is not scientifically determined; rather, it is a population of convenience.” Relying only on self-reported symptoms would not accurately reflect the effects of exposure to WTC contaminants.

David Newman, an industrial hygienist with the committee, said the registry’s design overlooks distinctions between “different potentials for exposure” among various subsets, including emergency responders, people caught directly in the dust cloud, and people living, working or going to school in the area. Newman believes that since the survey provides only an incomplete picture of those affected, “the utility of the data that’s going to be collected is limited.”

Some critics say there was inadequate outreach.

Despite efforts by community groups and registry staff to conduct special outreach to minority populations, the demographics of the surveyed population are skewed. Enrollment in the low-income, minority areas on the Lower East Side, at 4 to 10 percent of their respective census populations, was significantly lower than enrollment in the relatively affluent neighborhoods nearby, which ranged from 17 to 38 percent.

Kimberly Flynn, a leader of the advocacy group 9/11 Environmental Action, believes “inadequate public input and inadequate outreach” led to a lack of public trust and engagement in the project.

De Hernandez suggested that members of the Communications Workers of America were generally uninterested in enrolling in part because “neither labor nor the community was consulted in any kind of a meaningful way prior to the development and implementation of the registry.”

Some critics say the money could be better spent on direct services.

The registry was intended strictly as a scientific inquiry, with no promises of treatment for enrollees. “There was no direct benefit to individuals” for enrolling, said Health Commissioner Frieden, “but there will be a major direct benefit to New York City as a whole and to other jurisdictions [that] deal with natural or manmade disasters in the future.” In other words, registry data might someday help society bone up in preparation for the next 9/11.

The problem is, individuals still suffering from the last 9/11 think they are long overdue for some direct benefits. Community members have expressed frustration that some victims of 9/11 struggle with immediate healthcare and financial burdens that have not been addressed to this day.

Past and Future Challenges

Philip Alcabes, an epidemiologist at Hunter College who served on the Scientific Advisory Committee of the World Trade Center Registry, said the planners were challenged from the beginning by many factors, including politics, bureaucracy, and, above all, funding: the budget, he said, “was woefully small” for a project of this scope.

Whether the World Trade Center Health Registry will even fulfill its goal of tracking the health of its enrollees over 20 years is uncertain. Currently, the Federal Emergency Management Agency and the Environmental Protection Agency have committed $21.5 million, which will only cover the next four years of research. Officials are hopeful that funding will be extended.

In September, before the House Government Reform Committee, de Hernandez testified, “additional funding should not be provided for the continuation of the [registry]. Rather, this funding should be used to provide real medical services.”

But experts say it would be premature to tie enrollment to treatment before potential illnesses have been concretely defined.

“Treatment for what? We’re not sure yet,” said Lorna Thorpe, deputy health commissioner. “The registry is empirically trying to identify what the health problems are … in the broadest sense.”

As Alcabes put it: “It’s impossible to say ten years down the road what’s going to turn out to be the most important health consequence.” 























Health and Environment

Three Years of Rebuilding:
Ground Zero
Economic Impact
Federal Aid
Health and Environment

How the collapse of the Twin Towers will impact the long term health of New Yorkers is probably the most open-ended question remaining three years after the attack.

Within a week of 9/11, the Environmental Protection Agency announced that lower Manhattan residents were not at risk from the dust created by the collapse of the Twin Towers. Residents and businesses were told to clean dust from their apartments and wash ash-covered clothing separately, but rescue workers at the site were the only ones facing a real health risk.

In a report (in pdf format) issued last summer, the agency acknowledged that the White House's Council on Environmental Quality had "influenced, through the collaboration process, the information that EPA communicated to the public through its early press releases when it convinced EPA to add reassuring statements and delete cautionary ones."

The agency has received widespread criticism for these reassurances, and its subsequent cleanup in lower Manhattan.

Partially in response to this criticism, the Environmental Protection Agency established a panel to examine its own performance after 9/11, and look for unmet health needs that stem from the attack. It has started meeting, and over the next two years will develop a list of non-binding recommendations for the agency.

The city introduced a health registry to track the health of those who may have been affected by the disease. It has attracted over 50,000 people, whose health will be monitored, but not offered medical care.

These efforts have been met with various levels of cynicism - especially from those who have gotten sick.

A study published earlier this year referred to the collapse of the Twin Towers as the "largest acute environmental disaster that has ever befallen New York City." Still, the extent to which the disaster will affect the health of New Yorkers remains uncertain.

""The problem we have now is we don't know the long term, lifetime, health consequences. We just don't know, " said Paul Lioy of the Environmental and Occupational Health Sciences Institute.

The major health problems that have been linked to 9/11 are respiratory diseases like asthma, with some cases proving to be chronic. Nasal and sinus problems and gastrointestinal problems have also been tied to the attack. While no link to cancer has yet been found, and studies have found little danger of people developing cancer due to exposure to dust from the towers, some rescue workers who have developed the disease since 9/11 attribute their illnesses to the attacks.

New Yorkers also continue to suffer emotionally. A significant number of people developed post-traumatic stress disorder and depression after the attacks, and one Brooklyn hospital even saw a distinct rise in heart attacks, which its researchers attributed to post 9/11 stress.

Emotional problems have been on the decline since about six months after the attack, said Dr. Spencer Eth, director of the department of psychology at St. Vincent's Catholic Medical Center. The center has seen about 50,000 patients due to 9/11.

But over the last week, with the stress of the Republican National Convention, St. Vincent's has had to expand its hours to deal with increasing numbers of patients. Many thought they had recovered emotionally from 9/11, only to have their symptoms return.

"Right now, the conditions are there for the people to have that kind of flashback. Susceptible people will," said Eth. "The weather is warm and there are all these heavily armed people patrolling the streets."

A similar spike occurred after the crash of the Staten Island Ferry last year. Eth believes that these instances indicate a sensitivity that is part of a permanent shift in the psyche of New Yorkers.

"If you talk to people in Florida who have been through hurricanes, when the wind starts blowing, they get nervous; that lasts for years and years and years. People in southern California go on alert when they sense an earthquake, when the ground trembles a little bit," he said. "I think people in New York have been sensitized in the same way."


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