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Despite Budget Boost, Public Hospitals Face Cuts


health and hospitals corp., harlem hospital
Jim Henderson
Harlem Hospital is one of 11 hospitals run by the city's Health and Hospitals Corp.

With almost every city agency, the key word this spring has been "cut." Mayor Michael Bloomberg's executive budget calls for operational cuts and layoffs across the board to deal with the yawning budget gap, and the reductions could get worse depending on what kind of budget the state adopts.

One of the very few to see a substantial increase is the Health and Hospitals Corp. In announcing the massive cuts throughout the city on May 5, Bloomberg said he would give the HHC $350 million in order to help it close its $1 billion shortfall. The budget also includes $310 million in capital spending for the agency.

Yet , despite this increase for next fiscal year, the HHC has instituted $300-million budget containment plan for the next four years. Explaining the seeming paradox in a briefing on May 11, HHC President Alan D. Aviles said, "The protracted economic downturn, a substantial loss of federal funding, increasing numbers of uninsured patients, sky-rocketing fringe benefit costs and $240 million in cuts to our Medicaid reimbursements, have created a perfect storm that has saddled HHC with a projected $1.2 billion budget shortfall."

Aviles promised that the four-year downsizing plan was intended to cause the least pain possible. No hospital would be closed, and job cuts would focus on people with administrative titles rather than on caregivers. Some 3,700 jobs will be cut through a mixture of layoffs and attrition.

But Judy Wessler, the director of the Commission on the Public's Health system, a labor-community health advocacy group, said that there will be pain for the public, especially under a plan to close five child health clinics and one dental clinic.

"We are adamantly opposed to that," she said, even though HHC said it selected facilities that are under-utilized. "Any community-based primary care or dental care service are needed and should not be cut."

Shuttering these sites, the HHC said, would save $39 million over four years.

The HHC has a total budget of about $6.7 billion and operates a number of health facilities, including 11 hospitals and more than 80 community clinics.

Path to Privatization

The reorganization, Wessler noted, calls for contracting out some of the agency's management operations to private, which some might say makes more sense for a quasi-government operation like HHC than a mayoral agency.

But Wessler said that many city plans for privatization have been costly and ineffective. IN particular, she cites the CityTime palm scan time-keeping system for city workers, where consultants have charged the city hundreds of thousands of dollars each, helping to send costs to 10 times the original projections.

"Number one, there's not a cost savings and number two, it doesn't do what it's supposed to do," she said. "I think that as a rule privatization does not work."

The HHC, however, said it would save $141 million over four years.

More to Come?

The realignment plan may not mean the end of the HHC cuts. Should the state adopt a budget incorporating many of the cuts proposed by Gov. David Paterson, "it could still be very bad," Wessler said.

And then there's the federal government's commitments, such as the medical assistance payments many low-income people may receive through Supplemental Security Income.

"If, for any reason, these additional supplemental federal Medicaid funds do not materialize, we would be left with a deficit amounting to several hundred million dollars and that would lead to further, deeper and much more devastating cuts," Aviles said.

He recalled that the last time the system was in such straits 15 years ago public hospitals were up for sale. The courts blocked that action but it served as the impetus for an overall revamp of the system, which Aviles said has been largely positive.

Enter ObamaCare

Unlike the operational reductions on tap for other city agencies, the hospitals corporation's cost-containment plan is set for four years. Outside factors could improve the situation by then.

Part of what is draining HHC resources is the cost of uninsured patients entering and receiving care in the system. According to the agency, it serves 450,000 uninsured New Yorkers a year, The overhaul of the health-care system that President Barack Obama signed this year, which will provide millions of uninsured Americans health coverage, could very well ease that burden.

Others see possible hope in Paterson's proposed tax on soda and other sugary beverages. Wessler and Barry Liebowitz, president of the Doctors Council, which represents HHC doctors, think such a tax would not only push New Yorkers toward healthier eating and drinking habits but also would provide another revenue stream for public health.

The proposal though, has run into stiff opposition from the beverage industry, from The The Teamsters, which represents workers in the beverage industry, and from United Food and Commercial Workers Local 1500, which charges it would place a burden on poorer, urban consumers.

Picking Up the Slack

The proposed cuts come at a particularly critical times for the city's public hospitals and clinics. The backdrop for all of this is the closing of St. Vincent’s Hospital. "With the closure of St. Vincent's Hospital, the last vestige of a formerly vast Catholic healthcare system in the city, the viability of our public system, as the primary healthcare safety net for the most vulnerable among us, is all the more critical," Aviles said.

As a Catholic hospital, St. Vincent's turned away no one, making it more like public facility. Because of that, the HHC will have to pick up more of the slack in lower Manhattan than private hospitals. "The private sector has been less than good about taking care of people who are uninsured," Wessler said. "The public hospitals are going to have to continue their very important role."

Further, she noted, plans for Lenox Hill to operate a facility in lower Manhattan offered little consolation. "Lenox Hill has their own financial problems," she said.

Wessler said she heard reports that emergency rooms at Beth Israel and Bellevue have begun to overflow as a result of the closing, which many people in lower Manhattan feared would happen. But Patrick Bahnken, who as president of District Council 37 Local 2507represents city paramedics and emergency medical technicians, said that the 13 Fire Department ambulance tours that replaced the St. Vincent's tours, have not been overburdened yet.

"They're doing a hell of a job," he said of his members.

New Healthcare Law Offers Little to Undocumented Immigrants


New York City Department of Health r

Javier Espinosa had not visited a doctor in 13 years. After crossing U.S.-Mexico border illegally desperate to find work to support his family in Hidalgo, Mexico, Espinosa has held numerous jobs such as bus boy, dishwasher, and deliveryman. But he has never had any medical insurance and could not afford any visit to a doctor’s office.

Having not seen his family for 14 years and struggling to make ends meet in a recession, Espinosa had a panic attack last year and rushed to the emergency room at Elmhurst Hospital in Queens.

"Usually when I get sick, I would just get some medicine from the pharmacy. But this time I thought I was about to have a heart attack,” said Espinosa, now a resident of Jackson Heights and a furniture finisher in a factory in Flushing. "I stayed overnight in the hospital and the bill was over $3,000."

Espinosa is one of the estimated 12 million undocumented immigrants in the United States who are not covered by employer-sponsored medical insurance or eligible for government-supported Medicaid. He hoped that, after months of heated national debate, people like him would finally be covered by the new national healthcare system. But Espinosa's hope was dashed on March 23, 2010 when the House of Representative, by a 219 to 212 vote, passed a healthcare bill with a provision to exclude anyone without papers.

The bill, known as the Patient Protection and Affordable Care Act, aims to expand healthcare coverage to 32 million Americans who are uninsured. The new law also will expand coverage for the poor, impose new taxes on the wealthy and bar insurance companies that refuse to cover people with pre-existing medical conditions. In 2014, it will create an insurance exchange to people who do not have insurance to shop for an affordable health plan subsidized by the taxpayers.

The new law, however, will not make undocumented immigrants eligible for publicly supported Medicaid, and it will not allow them to purchase insurance in the insurance exchange -- even if they pay full price with their own money.

Some believe that, just like access to abortion, coverage for undocumented immigrants were sacrificed in the negotiation over the legislation.

"The bill was passed virtually without any Republican support. So they had to get enough Democratic support to make it happen," said Mark Scherzer, legislative counsel of New Yorkers for Accessible Health Coverage. "So conservative Democrats, particularly from Southern and Southwestern states dictated a lot of the terms. That's why we saw not only the immigration provisions but also the abortion restrictions."

A Haven for the Undocumented?

New York, long considered a progressive state when it comes to public policy regarding immigrants, is one of a handful states that still provide funding for Medicaid to undocumented immigrants.

In order to educate immigrant New Yorkers about healthcare access, The Center for Immigrant Health at New York University's School of Medicine has issued a brochure detailing the medical resources available to immigrant New Yorkers, documented or undocumented. They include Emergency Medicaid, Prenatal Care Assistance Program, AIDS Drugs Assistance Program, Child Health Plus B and treatment at all facilities under New York City Health and Hospitals Corp.

According to the Health and Hospitals Corp., New York City public hospitals and clinics annually serve 1.3 million predominately low-income New Yorkers, including nearly 450,000 patients who are uninsured. An executive order signed by Mayor Michael Bloomberg in 2003 protects immigrants' confidentiality when they go for medical treatment or seek help fro other city agencies such as the police.

But will the new law curtail these benefits?

"One of the wonderful things about the federal reform is that a lot more people are going to get coverage," said Scherzer. "But one of the hard things for a state like New York is that we have been offering extended coverage for a long time, and this new law is going to pull us back closer to the national standard. Some of our progress may be at risk. We are going to have to fight to make sure that we don’t get pulled back."

Getting Help Now

Back in Jackson Heights, Espinosa decided to come clean with the hospital about his status and sought help. After meeting with a social worker, he received a temporary Medicaid card.

"They asked me where I live, who I live with, who supports me and who pays the rent," said Espinosa. "I had no job and no money at the time, and they decided that I needed temporary Medicaid."

He was told to see a psychiatrist and given some medicine.

"They treated me well," said Espinosa. "The only problem is that it takes too long to get an appointment." Espinosa quit after three sessions of treatment for his panic attacks. In the meantime, he had developed some problems with his eyes and had to wait for two month to get an appointment.

"I thought I was going to be blind by the time I get to see the doctor," said Espinosa. Luckily, the problems went away before his appointment.

Unlike Espinosa, many undocumented immigrants take the issue of healthcare into their own hands and look for resources inside their own communities.

Evelyn Lim (not her real name), a native of Ipoh, Malaysia who now lives in Elmhurst, Queens, overstayed her tourist visa, which expired in 2003. She found a Chinese doctor in her neighborhood in a small private clinic that charges her $50 per visit. In her case, the $50 goes a long way because it covers her annual physical, which can cost up to several hundred dollars.

"I just walked into the clinic and asked them," said Lim. "They do blood test, urine test … everything for $50. He is doing the community a service."

While paying out of pocket to see a doctor is common in ethnic neighborhoods, Lim said sometimes there are "traveling doctors" who carry medicine in suitcases and go into communities to give away medicine. But Lim said she would not take anything from them because they might not be licensed.

A Long Wait

Immigrants who are here legally also have concerns about the new healthcare law. In 1996 during the conservative anti-immigrant crackdown, the federal government established a five-year waiting period for new documented immigrants to access Medicaid. In the new law, that provision remains as an obstacle for new arrivals.

"Whether you move to a new place, the first few years you are acclimating, it is probably the toughest time," said Noilyn Abesamis-Mendoza, health policy manager of the Coalition for Asian American Children and Families. "A lot of people come here for other opportunities, to reunite with their family or economic opportunities, they are really here to make a better living for themselves. I think healthcare is probably very low in their priorities as far as why they come to New York.

"When you don’t give people things like healthcare access, they have to make tough decisions. Especially we are in a recession so when they think about it, sometimes their health takes very low priority,” said Abesamis-Mendoza. “If they don't have access to preventive healthcare, they won't be able to get better and help the economy come back up or just be productive residents of New York State, we lose out on that."

Experts on the bill point out that the proposed insurance exchange would be the solution for immigrants, since there will be no waiting period for that.

"Anyone who might have wanted to get Medicaid will be able to get in through an exchange and get decent coverage, at no cost if they are below poverty level," said John McDonough, a fellow in public health at Hunter College. "There will in fact be an affordable coverage option available for legal immigrants without the five-year wait through the exchange."

Calling this "an enormous breakthrough," McDonough said, "It is probably the best healthcare legislation for legal immigrants in the United States ever."

What the Future Holds

In the new bill, a new community health center trust fund will provide additional federal funds of $11 billion for the expansion of community health center programs. According to McDonough, this will make the new healthcare system marginally better for undocumented people than what exists now.

"For the most part, there are very, very few folks in the undocumented community who are going to buy their own coverage unsubsidized. … It's so expensive, they don't have the money to do it," he said. "But the law does make a very large infusion of dollars into federally-qualified health centers, which is a very important point of caring service for the undocumented folks."

The best solution for the undocumented, of course, would be legal status. But Espinosa, for one, remains pessimistic.

"To tell you the truth, I don’t see any hope," he said Espinosa. "I am waiting for Obama to do something. I am giving myself two years. If nothing happens, I will go back to Mexico."

Larry Tung is a Brooklyn-based journalist and media artist.

State Budget Puts Spinal Cord Injury Research in Jeopardy


State trooper Paul Richter was lying on the ground, looking up at the man who had just shot him. Death seemed all but certain. The Queens-born Richter had been shot in the leg, arm and neck while checking out a vehicle that had been used in the robbery of a sporting goods store, and the shooter seemed ready to finish him off.

"Nah, he's dead," the shooter's accomplice said, giving Richter a reprieve. But the 1973 encounter in Lake Placid left Richter paralyzed for months. Eventually he was able to regain some function of his legs and can walk with the assistance of a cane.

Since then Richter has dedicated himself to helping people paralyzed by spinal cord injuries. "I've never got a penny for doing this. I can't golf anymore, so I spend my time and money this way," he joked.

Now, though, the program that Richter created -- the Spinal Cord Injury Research Board -- is slated to fall victim to the state's fiscal crisis. The board is scheduled to be phased out under Gov. David Paterson's 2010-2011 budget proposals. Supporters of the program say losing it will do immeasurable damage, not only to the field of spinal cord injury research but to the state's overall economy as well.

A Program that Funds Itself

In 1998, with the help of friends and influential people like Christopher Reeve, Richter got the state to create the Spinal Cord Injury Research Board, which distributes research grants to facilities all across the state. To fund it, the state placed a surcharge on fines for moving traffic violation.

"It’s a self-sustaining program,” Richter explained. “It was an idea I had to try to raise money, and most spinal cord injuries result from automobile and motorcycle accidents."

Representatives of the budget office say the board is an unfortunate casualty of the state's dire financial situation. Facing a deficit of as much as $9.2 billion the administration says it needs to keep money from the surcharges in the general fund. The budget would cut $6.7 million scheduled to go to the board and instead keep it in the general fund.

Supporters of the board, such as Terry O'Neill, a friend of Richter's who helped get the bill that established the board enacted, say the state cannot do that.

"The statute is written very specifically, saying that the funds must be used for spinal injury research," said O'Neill. "Someone would have to rewrite the law, and I would like to know who that is, and I would go and confront them."

 

But Jessica Basset, a spokeswoman for the State Division of the Budget, contradicts that notion. "The money moves through the general fund first, and the law says a certain amount may be transferred into the (spinal cord) fund--up to $8.4 million. It provides a limit but does not provide a floor," she said.

According to Basset, the state intends to honor over 40 existing contracts that total over $25 million but will not be making any new grants.

Fighting for the Program

Some advocates of the program say they have heard that the health commissioner Richard Daines does not think the program has produced clinical results that are immediately improving lives. Advocates admit they have not heard this directly from the commissioner but the notion is out there. Daines could not be reached for comment.

Jeffrey Hammond a spokesman for the State Department of Health, said that "some tough decisions had to be made during this difficult time." He said the program is being phased out but current contracts will be honored through 2014.

O'Neil has not heard anything specifically from Daines and suggests the cut may be symptomatic of how the budget process works. "I think if it worked as the process usually does the agencies were told to come up with things to cut, and someone just put it on the list to see if anyone protests," he said.

So now the supporters are protesting and publicizing how much they think the program has done in the area of spinal cord injury research. On Wednesday a group including O'Neill, Richter, Ratan and other experts in the field met with legislators to convince them to spare the program. Their final meeting was with representatives of Assembly Speaker Sheldon Silver's office. Silver has been an outspoken supporter of stem cell research. The staffers assured the group that they are looking at the value of each program slated to be cut in Paterson's budget but no guarantees were made to save the program. Sen. Neil Breslin who met with the group earlier in the day said it made no sense to cut a self sustaining program that is attracting more money to the state. He said he had written a letter to Sen. Tom Duane chair of the Senate Health Committee. The board, O'Neill said, "picked a very distinct problem -- nerves don't regenerate--and we've funded different ways of attacking that problem: pharmaceutical, physical therapy, robotics, cell transportation."

For Nancy Lieberman the benefits of the program are immeasurable.

A ski accident in 2007 left Lieberman a quadriplegic, unable to accomplish some of the simplest tasks, like brushing her teeth. As a powerful Manhattan corporate lawyer Lieberman was used to being in total control, but her accident left her at the mercy of others. Thanks to physical therapy involving the use of robotics, therapy she receives at a clinic partly funded by the state through the spinal cord injury board, Lieberman has been able to regain the use of her hands.

"Because of this therapy I can work. I can turn the pages of a book. You tell me how important that is to a lawyer. How do you quantify that? For the first time I can lie in bed and read the New York Times. How do you quantity being a mother with a 10-year-old son and being able to feed him breakfast?" Lieberman said.

Lieberman receives therapy at the Burke/Cornell Medical Research Institute. The process involves strapping her arm into the "wrist machine," as she calls it. Lieberman looks into a screen and is prompted to make certain motions. Repeating the motions builds strength where once she had none.

Usually, Lieberman said people with spinal cord injuries do not continue to improve three years after their accident, as she has. "The further out you go, what you have is what you get, but the opposite is true for me" she said, Because of the strength I have from the therapy at Burke I can now pull a door open. You tell me if that's worth funding."

"The weight the robots put on the nervous system allow the brain and spinal cord to repair and increase function,” said Dr. Rajiv Ratan, director of the institute.

Money Attracts Money

Ratan said the program would not exist if it were not for the funding. He says the state provides a little over 10 percent of funding for his program but because of the state money his program was able to leverage grants from a bevy of other sources. He said the state funding led to his recruitment at Burke and has helped establish a network of researchers across the state who share data on what works.

"The state funds are a magnet for money into the state," said Ratan, adding that the state grants not only lead to grants from the federal and private sectors but also to the creation of more medical facilities and the recruitment of students into the field. "So it makes no sense on a moral level or on a strictly financial level" to cut the program, he said.

Ratan describes a 21-year-old who jumped into the shallow end of a pool and became paralyzed seven years ago. "Seven years later he has regained muscle function. We were able to restore function in ways that are really unheard of," he said.

Richter and his associates have been lobbying legislators on the effectiveness of their program. They point to research the Spinal Cord Injury Research Board funds at Columbia University, the University of Rochester and the University at Albany-- all programs that have demonstrated real results.

Stem cell biologist Sally Temple, whose research at the New York Neural Stem Cell Institute receives about 20 percent of its funding from the state program, won the 2008 MacArthur "Genius" award for her research into treating spinal cord injuries. She says losing funding could lead to layoffs of her staff. She said a number of her colleagues who were considering moving their labs to the region are now looking elsewhere because the program is in jeopardy. The state has built a reputation as a bastion for this kind of research since the program was formed in 1998 and now the network of researchers and the reputation hangs in the balance.

Long-term Savings

O'Neill and Lieberman both say the state should not cut back on funding for this kind of research at a time when so many veterans from Iraq and Afghanistan have suffered head, neck and spinal injuries. "How are we going to tell veterans that we can't fund this research?" asked Lieberman. "They are coming home from Iraq and Afghanistan paralyzed. Do we tell them that they have to live like that?"

Treating people so they can return to work also will save the state money in the long run, Lieberman notes. "They say Medicaid costs are killing the state," she said. "Well, I agree. So they should use the money and put people on these machines. Fund the research that has let me go back to work. I couldn't do anything, but now I'm back at work as a lawyer."

Ratan said the machines cost anywhere from $12,000 to $75,000 to purchase. His main concern is testing the machines to find out exactly which kind of spinal cord injuries the machines benefit and how long therapy should be used. He said plans were underway to start a study of robot therapy on 500 patients. Ratan said the study will not likely take place if the state funding program is canceled.

Lieberman says she knows it will take collaboration and work on a number of different therapies just to help her improve. "There is no silver bullet," she said. "Spinal cord injury is very complicated. No one is going to inject me one day and I will be able to walk the next day. My muscles are atrophied. I would need all sorts of therapy to get that back. It might not be stem cells; maybe robotics, all sorts of electronic stimulation to solve the problem."

But she has made real progress. She can now lift a toothbrush -- an electronic one at that -- to brush her own teeth. When her van is in the shop she now feels capable enough to take the bus home by herself. And she credits all that improvement to the therapy she receives at Burke. She just hopes more people will get the same chance she had.

"I met a man who said the state pays $300,000 a year for his care. Why can't we take that money and put people on these robots?" asked Lieberman. "Think of the money. You can't quantify that -- giving someone back the ability to support themselves."



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