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Fights Over Medicaid Could Threaten New Administration's Health


health care

Politics might be bad for your health. As the state confronts huge budget deficits, Gov.-elect Andrew Cuomo will almost certainly face enormous pressure to slash spending on health care, particularly the Medicaid program for low-income people.

So it may come as a surprise that one expert and key player in state health care policy, Richard Gottfried, who chairs the State Assembly's Health Committee, wants to spend additional money to beef up the state's brain trust.

Gottfried has other goals as well. They include, in his words, "promoting alternatives to nursing home beds and strengthening home care and strengthening primary care to help avoid unnecessary hospitalization," as well as "better integration of health care so that the health-care system can profit by people keeping healthy instead of profiting by increasing volume of procedures." He believes that the federal health-care reform bill, if it survives Republican attempts to repeal it next year, will help the state implement some of these programs.

andrew cuomo
 

"You get no political support for putting money into central administration. That's about as exciting as a Crisco sandwich, but it is absolutely necessary if we're going to make any kind of progress," Gottfried said. "Has anyone ever marched on Albany saying, 'We need more bureaucrats'? They don't arrive in an ambulance when you're having a heart attack; they're at a desk in Albany, hopefully trying to remake the system."

Hands Off Medicaid

Medicaid -- not bureaucrats -- will almost certainly get the attention when the new governor and legislature take office in January. Medicaid expenditures in the state exceed $50 billion per year, making it tempting target for cuts.

In fact, Cuomo, as the state attorney general, won high-marks for investigating Medicaid abuse; last year the U.S. Health and Human Services Department named his Medicaid fraud unit the best in the country. Although McKnight's Long Term Care News reported that Cuomo has vowed a "fundamental restructuring of Medicaid," details of how he plans handle costs when he takes office remain a mystery. Whatever cuts or reforms he might pursue will likely spark opposition in the Assembly and from unions.

Outgoing Lt. Gov. Richard Ravitch suggested, for example, limiting eligibility, such as denying Medicaid to childless adults. And Albany Republicans earlier this year called for a variety of measures that they say will rein in costs. According to a statement from State Sen. Betty Little's office, a March report recommended, "requiring recipients to choose a primary doctor and a primary pharmacist, similar to managed care plans; allowing elected comptrollers, treasurers or other appointed officials to audit Medicaid claims; and preventing individuals from being forced to go to other counties or states for long-term care."

Gottfried warned that such moves would hamper the overall health-care apparatus in the state.

"You are not just cutting the care for people who are on Medicaid," Gottfried said. "If a nursing home or a hospital has to lay off staff because of Medicaid cuts that affects everyone at the institution, rich and poor alike."

Gottfried supports funding Medicaid through higher taxes on the wealthiest 1 and 2 percent of the state’s population.

Shaun Flynn, the director for governmental affairs at the New York State Nurses Association, agreed that Medicaid cuts hurt across the board.

"You don't see cuts in CEO salaries," he said. "It comes out of direct-care staff, which has a huge impact on how patients receive care in these facilities."

To counter that, the nurses association advocates a mandate on all hospitals to maintain a set patient-to-nurse ratio, similar to the one in California.

"It's something that's been pending in our legislature for some time," Flynn said. "We're hopeful that Cuomo will ask the tough questions that no one else has. What New York hospitals say is, 'We can't do it,' but they can't explain why California can."

To help fund this, the nurses association, which is both a union and a professional organization, supports a tax on sugary beverages along with the Doctor's Council (a Service Employees International Union affiliate), on grounds that it would provide needed revenue for health care and reduce obesity. But some unions like United Food and Commercial Workers Local 1500, whose members work in grocery stores, argue that such a levy is a regressive tax, and the bottling industry managed to scuttle a similar proposal earlier this year.

Is Cuomo Listening?

The transition team that Cuomo has appointed to advise him on these issues consists largely of hospital management representatives. Other than nurses association President Karen Ballard, there are "no voices representing the physician community or community health centers," and "few voices from the health-care policy or academic world, or labor," Gottfried said.

Cuomo broke Democratic Party tradition in his campaign this year by heaping blame for the state’s budget mess on state-worker pensions and pay, resulting in few unions backing the nominee and a half-hearted -- and some say short-sighted -- endorsement from the Working Families Party.

So it wasn’t too much of a surprise when Cuomo failed to initially place a representative of 1199/SEIU, the state's strongest health-care union, on his transition team, although he later brought aboard its president, George Gresham, to smooth relations.

But Flynn believes the inclusion of the nurses association indicates that health-care advocates could get their point across. And that's good news to anyone concerned about the other big health issues in the state, whether it is an infant mortality rate one group has called "disgraceful" or the fact that three major hospitals in New York City have shutteredin the last few years.

"It shows a willingness to listen to people," Flynn said of the Cuomo transition team. "From NYSNA's perspective that's all we're really looking for. We believe the strength of our arguments are enough to win on their own."

Low-Income Locavores: City Council Seeks to Expand Access to Fresh Food


greenmarket
Photos by Amanda Kersey
To make it easier for low-income people to purchase fresh, local food, many Greenmarkets now accept food stamps.

The day before Thanksgiving, many New York foodies hustle to pick up heritage turkeys and heirloom vegetables at their local Greenmarket. Meanwhile, food rescue agencies like City Harvest try to persuade the shoppers to donate a bag of produce such as apples, onions or broccoli to food pantries and soup kitchens.

The food pantries trying to help the more than 1 million New Yorkers who cannot afford an adequate supply of food must look to a variety of sources for the food they provide, and much of it originates far from the city. But that could change. A number of programs already try to give poor New Yorkers access to locally grown produce, and several local officials have proposed sweeping efforts that could bring the locavore ethos to low-income homes.

Both Gov.-elect Andrew Cuomo and City Council Speaker Christine Quinn have recently presented plans to get more locally grown food into the city and then to institutions and poor neighborhoods. If implemented, the proposals would bolster grassroots programs that make local food available to people who often have little access to fresh, healthy food, let alone locally produced fruits and vegetables.

City Grown

Several well-established programs already provide poor New Yorkers with Empire apples and root vegetables. The Food Bank for New York City spends up to $500,000 annually on local produce for over 1,000 citywide emergency food programs. The Food Bank's Community Kitchen and Food Pantry of West Harlem runs a Community Supported Agriculture program, where produce comes directly from local farms to consumers, and offers members several plans to pay for it.

In addition, the U.S. Department of Agriculture's Farmers' Market Nutrition Program, established in 1988, gives people enrolled in the Nutrition Program for Women, Infants and Children or in Senior Nutrition Programs coupons that they can use to buy locally produced fruits, vegetables and herbs at participating farmers' markets. All recipients get $20 a year and those in the Women, Infants and Children program get an additional small monthly allotment.

This program encourages people to visit the markets and discover the benefits of eating fresh produce, according to Bob Lewis, who assists the state Department of Agriculture and Markets in farmers’ market development.

Lewis, who co-founded New York's Greenmarket program, said that the city has always worried whether people introduced to farmers' markets by the program could afford to continue to shop there once their coupons ran out. That led Greenmarket to install Electronic Benefits Transfer machines to allow shoppers to use food stamps at the markets.

The Next Steps

Cuomo and Quinn want to take government farm-to-fork initiatives further. In his farm agenda released last month, Cuomo outlined plans to build food-processing facilities and expand urban farmers’ markets. These measures would provide a boost to the state's farmers while providing healthier food to lower-income New Yorkers.

On Monday, Quinn announced the City Council’s own ambitious food policy agenda, called Food Works that addresses all aspects of New York’s food industry, from farming to composting. The plan looks at the way food reaches and then is distributed around the city for solutions to an array of problems.

"For far too long, we’ve ignored a growing crisis in our city and across the nation," Quinn said in her speech. "We’re a city of more than 20,000 restaurants, yet 1.4 million New Yorkers struggle to put food on the table. One out of every four children in New York City is overweight or obese. New York State farmers ... only make half as much per acre as farmers in other parts of the country. Meanwhile, the food system is responsible for nearly 80 percent. of our increased energy use in recent years. "

Both Cuomo and Quinn have stressed the need to update the Hunts Point Terminal Produce Market in the Bronx. The State Department of Agriculture and Markets supports rebuilding the market, constructed in the 1960s, to improve efficiency and food safety and reduce air pollution created by trucks. In particular, the City Council would like to see a large permanent wholesale market at Hunts Points to make it easier for businesses to purchase fruits and vegetables from local producers. The department estimates that rebuilding the market will cost between $300 million and $500 million.

greenmarket
New Yorkers shop for Thanksgiving at the Bowling Green Greenmarket.

"If we only get one thing in Food Works right, it has to be this,” Quinn said Monday. “How are we going to get healthy food to our neighborhoods if we can’t even get it into our city?” Quinn would like to see train service expanded throughout the state to allow more food to reach the market.

Quinn said that, with more local food in the city, New Yorkers, especially those living in poor neighborhoods, would be better able to buy more local produce. “If we want to have New Yorkers make better choices, we need to give them better options,” she said.

For people living in public housing and using food pantries, those options would include enrolling in a Community Supported Agriculture program. Cuomo said he would ensure that people could pay for their membership in installments and with government assistance benefits. In these programs people pay a set fee for a weekly or monthly basket of fresh seasonable produce direct from a local farm.

Cuomo and Quinn have urged schools, hospitals, nursing homes and corporations to buy more local produce and enroll in a Community Supported Agriculture program. In the past, state farmers have struggled to sell produce to the city’s SchoolFood program because it demands year-round, cheap and easy-to-handle food. Although the department has begin to purchase some locally produced fruits, vegetables and milk, the council report said, "This procurement has, thus far, occurred on an ad hoc basis." The council has said that Councilmember Gale Brewer will introduce a bill to require the city to develop new purchasing guidelines that would encourage it to buy from local farmers.

Whatever its shortcomings, though, Quinn used the Department of Education as an example of an institution that has increased its purchase of regional food without increasing procurement costs. "Why can’t every other city agency do the same thing?" she asked.

The speaker wants to keep food production in the city and have producers buy produce from local farmers. She acknowledged that a lot of low-income entrepreneurs who cannot afford to prepare their food in an approved commercial kitchen that complies with the city health department’s regulations. Quinn said the council had helped remedy that issue by building a shared kitchen in East Harlem within La Marqueta.

Finally, Quinn urged producers to minimize packaging and New Yorkers to compost. "We need to stop thinking of food scraps as garbage," she said. The council plans to expand the compost program at Union Square to other farmers markets so that more people will have a place to take their food scraps.

Grassroots Initiatives

While New York politicians drum up support for their initiatives, local leaders have already reshaped their community’s food systems, making seniors in particular not only the recipients, but also the sources of local food.

Through the Healthy Communities Through Healthy Food initiative, seniors work on urban farms, sell food at local farmers' markets and grow food at public housing sites. The program directors said that a large number of older people have been involved in urban agriculture and food for years. Many started gardens in their backyards during the Great Depression or after World War II.

United Community Centers sponsors the East New York Farms! project, which runs two farmers markets that serve East New York, a food desert with one of the city’s highest obesity rates. Project members design gardens with raised beds so that seniors can grow food without straining themselves. They also train seniors to increase the yield of their gardens and to sell more of what they grow at farmers' markets.

Isabella Geriatric Center in Upper Manhattan has organized a senior-run fresh food buyers' club called YUM Food Box that offers regional produce to residents of Inwood and Washington Heights. Only a quarter of food retailers in those neighborhoods sell fresh food, and almost half of residents receive public assistance. Every month the buyer's club distributes about 300 bags of produce, which cost members $20 per share or $10 for a half-share. The club differs from Community Supported Agriculture in that members don't pay upfront for a share, which typically costs several hundred dollars.

Myrtle Avenue in Fort Green and Clinton Hill separates brownstones from the projects and those likely to eat fresh food from those who are less likely to do so. The Myrtle Eats Fresh initiative, led by seniors, tries to level that class disparity by creating farmers' markets, small urban farms on public housing land and fresh-food advocates.

Rikers' Regulars


Photo (cc) Norm Walsh

Lee Gary is an intimidating man, towering over most -- if not all -- the people he meets. Sitting in the offices of CASES -- a nonprofit group in Lower Manhattan that assists the formerly incarcerated -- Gary, built like the largest of linebackers, spilled over his black rolling chair, obviously uncomfortable.

He fidgeted. He seemed nervous.

But this was not the most compromising situation he has ever been in.

According to his estimate, Gary has been arrested 30 times in the last eight years, spending a total of a year and a half on Rikers Island -- the 400-acre facility yards from LaGuardia Airport that houses many of the city's accused and convicted criminals. Gary, a 49-year-old Bronx resident who is diagnosed with bipolar disorder, spent half of his time in a mental observation unit there. The rest was clocked in at the prison ward of Bellevue Hospital Center.

"It's horrible," Gary said of Rikers, anxiously rubbing the sides of his legs with his large palms. "You get guys hoarding food. You get guys that want to fight."

"The officers are not there to help you," said Gary. "You'll just sit there to rot."

But Gary had company -- lots of it.

The percentage of Rikers inmates with mental illness has reached its highest level in eight years. While the number of people sent to Rikers Island every year continues to fall -- bucking a national trend-- those that remain, like Gary, keep coming -- often.

In what one expert refers to as a "population distillation," the number of people classified as mentally ill on the island has gone from 25 percent in 2004 to 32 percent today, according to the city Department of Correction. If the trend continues, Rikers Island could resemble the shuttered mental institutions of the 1970s instead of the correctional facility there now.

"Mentally ill inmates are less likely to be released. They are perhaps not as well equipped to manipulate the system. Their cases are more complex," said Martin Horn, the former commissioner of the Department of Correction. "All of those things, make them harder. They are the ones most likely to be there."

Advocates and experts acknowledge the city has taken steps to address the challenges this population presents. But following a decade-long court case over the quality of mental health care, they claim inmates with mental illness continue to fall through the cracks. They say more needs to be done to tackle the treatment, the recidivism rate and the overall number of mentally ill on Rikers -- long term.

These are Rikers' regulars and, for now, they don't appear to be going anywhere.

After Midnight

Circa 1999, it could be 2 a.m. Neon signs might penetrate the pitch-black sky in the middle of Queens Plaza -- a former hotbed of liquor stores, strip clubs and homelessness. Imagine the Rikers Island shuttle bus roaring up, opening its doors and inmates pouring out. Those with mental illness would be among them.

They would have subway fare, but many had nowhere to go.

This chart shows the change in population at Rikers Island since 2004. Brad H inmates are those classified with mental illness.

More than a decade ago, the Urban Justice Center filed a lawsuit, commonly referred to as "Brad H," against the city claiming it failed to provide adequate discharge planning for inmates with mental illness. Advocates and experts contend proper planning for inmates outside of the jail's cement walls will successfully halt the revolving door of incarceration for Rikers' regulars.

Under a settlement reached in 2003, any inmate who stays on the island for more than 24 hours and sees a mental health staffer more than twice must receive a "discharge plan" -- a roadmap to services, housing and hopefully a normal life. When released, inmates must have medication for seven days, leave the island during daylight, be referred to a treatment provider and start the application process for supportive housing or reactivating Medicaid benefits. Inmates are also free to deny these services.

In 2003, the court appointed monitors -- who declined to be interviewed for this story -- to oversee the transition for the next five years.

Because of counter suits, that five-year period was extended until the summer of 2009. The center, which claims the city has not met its discharge planning goals, then asked the court to extend the monitoring for another two years.

In August, the city successfully convinced the courts on appeal that the monitoring period had expired and the Urban Justice Center had no grounds to extend it. The center has appealed to the state's highest court, which will soon decide whether to hear the case.

While the case is on appeal, the monitoring continues at Rikers.

“When people with mental illness are released from city jails today, the services they receive vary widely. Some get real discharge planning, and that’s an improvement from a decade ago -- but too many still do not,” said Jennifer J. Parish, the director of criminal justice advocacy at the Urban Justice Center’s Mental Health Project. “The city has not yet lived up to the commitment they made when they settled the case in 2003.”

Part of the so-called failures at Rikers is communication. There are four city agencies that have some hand in the delivery of health care -- from start to finish -- in addition to a for-profit, private corporation, PHS Correctional Healthcare.

Some say the correctional system itself is the problem -- a jail is not conducive to treatment and its confines aggravate the mentally ill.

Or maybe it's staffing. The department of health, in particular, critics say, has been plagued by high turnover rates. (The department did not provide Gotham Gazette with turnover figures for this story.)

All of this leaves advocates wondering whether inmates with severe mental illness are leaving the island without the proper preparation, reentering society just as unstable as when they left it and destined to return to Rikers.

Left Behind

Marcelene J., according to an affidavit filed with the state Supreme Court, could not get any treatment after leaving Rikers in October 2008. Marcelene, a 23-year-old homeless woman who is diagnosed with bipolar and schizoaffective disorder, was referred to Interfaith Medical Center in Brooklyn upon her release by a Department of Health and Mental Hygiene discharge planner.

When she got to the hospital, she was told she didn't have an appointment. No one knew who she was or that she was coming.

So she left, according to the court filing.

"I was not able to continue my medication because I did not have any place to get ongoing mental health treatment," Marcelene wrote. "I would like to receive psychiatric medication and therapy because I continue to have mood swings and the voices I hear never seem to go away."

Darryl C, according to the court filing, has been bouncing between hospitals, prison and Rikers almost his whole life. A heroin user diagnosed with depression and generalized anxiety disorder, he first received treatment at Rikers in 1990.

During his recent stint there in late January 2009, following an arrest for petit larceny and possession of stolen property, doctors on Rikers refused to treat Darryl, despite his previous medical history, according to the court filing.

He was removed from mental health status the next month.

"I do not want to use heroin again," Darryl wrote. "I want to get help for my mental illness."

According to the most recent monitoring report released in July, many "pivotal monitoring, programmatic and legal issues remain unresolved" in the delivery of discharge planning services. Inmates are misclassified, the report states. Computer files put them in a less severe category of mental illness, while the inmate's physical medical chart may say otherwise. Inmates were not referred to programs that address more serious mental health problems, the report states, and some are still leaving Rikers at night.

The monitors criticize inmates' refusal of treatment, questioning whether discharge planners make an honest effort to convince this difficult and untrusting population to get help.

In response, a spokesperson for the health department said it has been working to increase the accuracy of its electronic records. According to the department, a patient must be "motivated" to receive proper follow-up care. The agency said it is training staff to help engage inmates to get the assistance they need.

Of the 33 areas the monitors evaluate, the city was found "noncompliant" in 10, according to the latest report, which examines a sample of inmates' records. Of those, the city made the appropriate appointment referral only 57 percent of the time. Just 22 percent of the eligible cases received the appropriate referral for supportive housing, according to the report, and 82 percent were sent to the right place for case management. In five areas, results were inconclusive.

Some of the city's figures dispute the monitor's findings and in many cases show it meeting and surpassing its goals. But the reliability of those figures has been repeatedly questioned by the court appointed monitors.

In the areas the health department did acknowledge it failed to meet the court's requirements, staff did perform the relevant tasks, but not within the required timeline, according to the department.

"While it's in appeal, we are complying with the requirements," said Deputy Commissioner Louise Cohen of the Department of Health and Mental Hygiene in response to questions about the lawsuit. "The city is committed and we are certainly committed as an agency to do discharge planning in the best way that we can for the mentally ill."

Should the state Court of Appeals refuse to hear the latest iteration of the litigation or side in favor of the city, Cohen said the city would likely modify its discharge planning process.

The settlement focuses on time restrictions, such as ensuring an inmate referred to the Rikers mental health staff is seen within 72 hours. Cohen said the department would prefer to focus on results. She declined to give specifics on the proposals the department is considering.

"The city would continue to hold itself accountable for discharge planning for those that are mentally ill," said Cohen. "I think it’s a question of what that looks like."

Within Rikers Walls

"Single file, ladies," called Deputy Warden Antonio Cuin down the halls of the Rose M. Singer Center, the women's facility on Rikers Island. Two women in jumpsuits several yards ahead followed the order.

Red and yellow stripes line the floor of the fluorescent-lit corridor. Inmates on either side. Staff in the center.

Asked why the inmates had to walk in a straight line, military-style, Cuin explained: "It's just control. That's what it is."

Later on, Corrections Commissioner Dora Schriro explained further.

"Our primary mandate to focus on is 'Safety Now,'" said Schriro, detailing her new department philosophy. "The statute, at a minimum, expects the Department of Correction to prevent bad things from happening."

Schriro just celebrated a full year on the job. She was previously the head of corrections in Arizona and Missouri and had a brief stint as an advisor on immigration in the Department of Homeland Security.

So, her personal philosophy is still being teased out here on Rikers. Nonetheless, inmates aren't in rehab, although Cuin said they hold daily Alcoholics Anonymous and Narcotics Anonymous meetings and regular group therapy sessions at the women's facility. It's a jail.

Balancing safety with required mental health care can be precarious -- especially when two thirds of the violent incidents that occur at Rikers involve someone classified as mentally ill, said Schriro.

Health care comes second.

"It's only after they have symptoms or behaviors that by the Department of Corrections standards are dangerous," said Dwayne Mayes, executive director of the Howie the Harp program, a peer advocacy group for the mentally ill that contracts with the health department at Rikers. "They are subjective to punitive measures as opposed to health measures."

And some results are mixed.

James, whose first and last name are being withheld due to safety and privacy concerns, has battled schizoaffective and bipolar disorders since 2003, said his mother, Elizabeth, whose middle name only is being used.

But James early this year had been taken off of his medication by a therapist in the Bronx, Elizabeth said. On Mother's Day he was riding the bus when he felt threatened by a female passenger. James found a stray piece of glass, slashed her face and ran away.

He ended up in Rikers' mental health facility -- the Anna M. Kross Center -- in a group dormitory setting, said Elizabeth. Nervous and agitated, he refused to shower, and he was punished for it. When another inmate punched him unprovoked, he ended up in the hole (or solitary confinement), said Elizabeth.

"People who don’t understand people with mental illness, they don’t get it," Elizabeth, who has been communicating with her son and advocates on a daily basis. "We get up and bathe every day. People don’t understand that."

On other occasions, Elizabeth said, her son was so overmedicated he was to the point of drooling. As of Friday, Elizabeth was able to get James his own cell back at the mental health facility and on the right medication. But she and advocates wonder what happens to inmates who don't have someone pushing from the outside.

Moving Forward

No one questions that since 1999 the city has made improvements in how they handle the mentally ill on and off of Rikers Island.

For the past year, Schriro, has been ruminating over population statistics and procedure. In August, she unveiled her first major policy shift as the head of the country's second largest jail system (the first is Los Angeles County).

Photo (cc) reivax. The Bronx barge will relocate to Rikers under the new facilities plan.

She is going to build a new jail and tear down the dilapidated temporary facilities erected during the crack epidemic of the 1980s (facilities that resemble small white spacecraft instead of jails). Hailed by criminal justice advocates, the commissioner is also centralizing the intake procedure, making sure inmates are classified up front. She plans on consolidating staff and some of the mental observation units, streamlining the process. There are now seven separate units spread out throughout the island.

Starting this month, Schriro launched a pilot program to provide corrections officers with additional training on mental health issues. The commissioner says she is approaching correction and health department staff "as a team who together can create a continuum of custody and care that can be carried out not only in the hours and days that our clinical staff is there."

Advocates have called for additional training for a very long time.

The department of health also has almost completed its electronic patient records system on Rikers (now active in several jails). The new system will make sure there is an ongoing record of those with mental health issues on the island.

Should an inmate come back, officials don't have to start off at square one. They can pick up where they left off, said Schriro.

Advocates commend the effort.

"Commissioner Schriro is making really valiant attempts to do something about this," said Joel Copperman, the chief executive officer and president of CASES. "She recognizes the reality that people are coming back to Rikers Island, so what she wants is to understand it, to develop treatment plans."

These represent steps in the right direction, advocates said. But a more seamless transition to society is still necessary to make sure those without advocates or parents by their side can get help too, they add. That means better communication between the agencies overseeing health care and the service providers on the outside. It means getting the proper diagnosis and classification as soon as one enters the system.

Back at CASES, Derrick Neptune, a 36-year-old diagnosed with schizoaffective disorder who has been to Rikers four times, called his treatment off and on the island "helpful."

After spending five years in the shelter system, Neptune now lives in Flatbush in Brooklyn. He attends barber school. He is taking medication and quit smoking marijuana -- the so-called cause of many of his psychotic episodes.

"You learn a lot from being in jail," said Neptune.

So much that he hopes he won't have to go back.



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