Gotham Gazette https://www.gothamgazette.com/component/tags/tag/632 Thu, 21 Nov 2019 23:39:15 +0000 Joomla! - Open Source Content Management en-gb webmaster@gothamgazette.com (Webmaster) How the City's New Jails Plan Accounts for Those with Serious Mental Illness https://www.gothamgazette.com/city/8910-how-city-close-rikers-jails-plan-serious-mental-illness https://www.gothamgazette.com/city/8910-how-city-close-rikers-jails-plan-serious-mental-illness Rikers Island inmate detainee

(photo: Michael Appleton/Mayor's Office)


In an historic vote last month, the New York City Council approved the plan to close the Rikers Island jail complex and replace it with four borough-based jails by 2026. When the Council voted through the plan, estimated at $8.7 billion in new construction costs, it also announced, with Mayor Bill de Blasio, a $391-million package of citywide and community investments in criminal justice reforms and initiatives to responsibly accelerate the reduction of the city’s jail population.

For city officials, one of the most complex issues they face is ensuring that the new system is less punitive and more rehabilitative, particularly for the 43% of incarcerated individuals who suffer from some form of mental illness. Experts and advocates say the plan is taking an appropriate approach to that issue but also insist that it provides a novel opportunity to rethink how the criminal justice system deals with the mentally ill, especially those suffering from more acute problems.

Given that one of de Blasio’s signature programs as mayor is the ThriveNYC mental health “roadmap” spearheaded by his wife, Chirlane McCray, the mayor’s approach to services for those with severe mental illness, particularly those who wind up involved in the criminal justice system, has been the source of intense scrutiny, again heightened as the new jails plan was crafted.

With most major crimes at or near record lows in the city and recent shifts in law enforcement and prosecutorial policies, particularly around non-violent offenses, the number of people incarcerated in city jails has been consistently declining. That drop has been so sharp that the de Blasio administration projects the average daily jail population to fall to 3,300 by 2026, when Rikers is set to close, down from about 7,000 this year and aided by state bail reform that will go into effect in January.

The Rikers closure plan will involve building four new facilities in every borough except Staten Island, with roughly 885 beds each. The facilities are meant to be fairer and safer than the dilapidated jails on Rikers. Another 250 new beds will be created in existing public hospital facilities for those individuals who require continuing access to specialized medical services.

Mayor Bill de Blasio himself has acknowledged that the city has its work cut out for it when it comes to individuals with mental illness who are locked up in jails. The day after the Council’s vote, the mayor made his weekly appearance on WNYC’s The Brian Lehrer Show and a caller named Winston who was formerly incarcerated on Rikers prodded him on improving access to mental health services. De Blasio emphasized the decarceral aspects of the plan, which include greater investments in alternatives to incarceration, supervised release programs, and mental health initiatives.

“This thing is not in isolation. Six years of changing the approach to criminal justice and it’s all been consistent with reducing crime at the same time and I’m very convinced that this is the right approach,” said the second-term Democrat. “But you’re right, it will take some important adjustments and investments and getting people more access to mental health services, which is the whole concept behind the Thrive[NYC] initiative, is absolutely necessary going forward, and providing better and more consistent mental health for those who do happen to be incarcerated, which is also in this plan.”

One of the key elements of how things unfold will be the dichotomy of mental health services for those with serious mental illness who need treatment while serving jail time versus those who can be removed from or kept out of jail given appropriate treatment options and enrollment in such programming.

City Council Speaker Corey Johnson, in a statement to Gotham Gazette, said, “The time of locking people up because they're mentally ill has to come to an end. This is why we are creating new Intensive Mobile Treatment (IMT) teams to provide intensive treatment to adults with recent and frequent contact with the mental health, substance use, criminal justice, and homeless services systems. It is time to eliminate an unjust system that has criminalized mental illness and destroyed so many of our communities.” 

In a background briefing, an official from the Mayor’s Office of Criminal Justice, which took point on the jails plan, laid out the various pillars of the city’s approach. The official reemphasized what de Blasio said on the radio: that the administration’s focus is to minimize the number of people in jail with behavioral health, mental health, and substance misuse problems, and to prevent reincarceration by providing services that address their needs.

Correctional Health Services, an arm of NYC Health+Hospitals, is charged with providing medical services to the city’s jail system, from pre-arraignment through reentry. According to a H+H spokesperson, roughly one-third of the 43% of detainees who receive a mental illness diagnosis have severe mental illness – schizophrenia, bipolar or depressive disorders, and post-traumatic stress disorder – making up about 16% of the total jail population. For a population of about 7,000 detainees, that means just over 1,100 people with serious mental illnesses at any given time.

Currently, each jail has what H+H says is the equivalent of an outpatient clinic. For detainees with serious mental illness, intellectual disabilities, or who might be more vulnerable in the general jail population, there are 18 so-called mental observation (MO) units across the 10 jails and Horizon Juvenile Center. There are also inpatient psychiatric beds at Bellevue Hospital for men and at Elmhurst Hospital for women, all of whom are considered part of the city’s jail population while being treated.

The community investments package that the City Council and mayor agreed to includes an expansion by Correctional Health Services of two programs that provide discharge and reentry services to the formerly incarcerated, the Community Reentry Assistance Network (CRAN) and Point of Reentry and Transition (PORT) programs.

Though the city is hoping for the best, it is planning for the worst. About 40% of the beds in the new borough jails will be therapeutic housing units to account for the percentage of the jail population that suffers at least some kind of mental illness.

The city plans to reduce the population through various efforts, including implementing recommendations from the city’s Crisis Prevention and Response Task Force announced last month, which will change how police respond to people experiencing mental health crises. The city is putting $23 million in total towards those recommendations by 2023, which includes adding four Health Engagement and Assessment (HEAT) teams of clinicians and peers who have experienced mental illness to handle non-emergency responses, and six more mobile crisis teams (mental health professionals who respond to calls to the NYC-WELL hotline) to conduct home visits and respond to urgent situations.

These programs aim to ensure that people suffering from mental illness do not wind up in jail, or back in jail as the case may be.

Additionally, the city is investing $11.2 million to add 380 beds of “justice-involved supporting housing,” for a total of 500 across the city, and is increasing the number of post-release transitional beds for those with mental health needs and a history of homelessness to 500 with a $25 million investment.

About $27 million in new funding will go to mental health services (for a total of $37 million) through various programs. And the Council also passed the Get Well And Get Out Act, which will allow those with serious mental illness to push for their release from custody if they improve with treatment.

But the official from MOCJ conceded that there will inevitably be individuals with serious mental illnesses in jails, despite the city’s best efforts to reduce that population, which has stubbornly hovered in the 10-15% range even as the overall numbers of detainees have fallen. Almost all of the people held in city jails are either awaiting trial, locked up due to a parole violation, or serving sentences of under one year.

The new borough facilities and the Rikers plan account for the fact that some detainees will suffer from serious mental illnesses by expanding two key programs that address this population: Clinical Alternative to Punitive Segregation (CAPS) and Program to Accelerate Clinical Effectiveness (PACE).

The Council’s agreement with the mayor includes $12.8 million to double the number of existing PACE units by the end of the current fiscal year. The city has yet to decide the breakdown of those units in the borough facilities, the MOCJ official said.

The 250 new Outposted Therapeutic Units outside the jail system, however, will be dedicated to those individuals who have some form of substance abuse disorder, mental health or behavioral health issue as well as a complex need for medical care. The MOCJ official said they had identified a gap in the current continuum of care for these detainees, who don’t necessarily require inpatient hospitalization but benefit from proximity to specialized care. They can spend hours going to and from hospitals for even the shortest of check ups with specialists. 

The city is currently in the process of identifying vacant sites for those units and has contracted Lothrop Associates to conduct a feasibility study that is expected to be concluded by the end of the year, the MOCJ official said. The study will help determine the costs and needs of the new facilities and the city will then put out solicitations for redesigning the new spaces to accommodate incarcerated individuals. The project is separate from the borough-based jails plan and the official said it would likely move much faster since it would not require approval through the city’s land use process.

Insha Rahman, director of Strategy and New Initiatives at the Vera Institute, said a larger goal of the Rikers closure plan should be to minimize the harm that jails do to inmates, not just those with mental illness.

“If we're going to say, ‘We are still going to have incarceration in this city,’ which we are, for the foreseeable future, 5, 10, maybe even 20, 30 years from now, we should be constructing these new facilities as buildings first, and then outfitting them to be places of incarceration so that they're not built with just incarceration and jail design front and center,” she said in a phone interview. 

She cited the example of jails in countries like Germany and Norway. “To the extent that we're thinking about how do we address people's underlying needs and how do we provide therapeutic care and counseling for those who are in custody, anything that looks fundamentally like a jail is going to inflict some amount of harm and trauma,” she added, insisting that the city should look not to prison architects but to behavioral and mental health experts for ideas for the new jails.

Rahman also urged the administration and Council to invest further at the community level in permanent affordable housing, community-based treatment and counselling that can preempt interactions with the criminal justice system.

A stark reality that the city faces is dealing with those individuals with serious mental illness who pose a threat to themselves and others, a concern that was brought to the fore last month when a mentally ill homeless man killed four men sleeping on the street in Chinatown. It prompted the city to review how it implements Kendra’s Law, which allows courts to mandate involuntary “assisted outpatient treatment” for such individuals. That review is meant to be completed by next week. The number of individuals ordered into treatment under the law was 2,476 in fiscal year 2018, down from 2,517 in fiscal year 2017 but up from 2,368 in fiscal year 2016 and 2,176 in fiscal year 2015, according to data provided by the de Blasio administration.

Rahman warned against harsher enforcement of the law. “I think enforcing Kendra's Law more strongly is not necessarily going to get us fewer people in our jails that have serious mental health needs,” she said. “I think the most important initial response is more community-based treatments and figuring out how can we actually resource families and neighbors.”

There is some disagreement on that front, however. D.J. Jaffe, executive director of Mental Illness Policy Org, criticized the city’s ThriveNYC mental health initiative and called for an expansion of Kendra’s Law in an op-ed in the New York Daily News following the Chinatown murders.

Jaffe argues the City Council should require “the city’s Department of Health and Mental Hygiene to start evaluating all seriously mentally ill people being discharged from Rikers; all seriously mentally ill leaving shelters; and all mentally ill patients being discharged from city hospitals after an involuntary commitment. Those are the three highest risk groups; evaluate them all to see if they are eligible for Kendra’s Law and get them into it if they are.”

Minister, Dr. Victoria A. Phillips of the Urban Justice Center Mental Health Project echoed Rahman’s view, but also stressed that the new jails should prioritize interactions between detainees and health care workers, rather than with corrections officers.

“Behind correctional walls, it’s never the health staff that takes the lead, and I think the Department of Corrections has shown itself to be unable to change its culture of violence,” she said, pointing to the most recent report by a federal monitor with oversight of the city’s Department of Correction, which showed that use of force by corrections officers has risen dramatically while the jail population has dropped.

Former New York Chief Judge Jonathan Lippman, who led the independent commission that proposed the leading Rikers closure plan, praised the approach the city is taking, while acknowledging that the overarching objective is to keep people with mental illness out of jails. “If you have people who the system decides to incarcerate, then you have to deal with that,” he said in a phone interview. “In an ideal world...people who have serious problems with mental health should get help and not be incarcerated. But, you know, we don't live in the ideal world.”

[READ: 'No One Should Enter the Criminal Justice System for Something Related to Mental Illness']

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by Samar Khurshid, senior reporter, Gotham Gazette
     

Read more by this writer.

Note - This article has been updated. 

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How the City's New Jails Plan Accounts for Those with Serious Mental Illness Thu, 07 Nov 2019 05:00:00 +0000
‘Nobody Should Enter the Criminal Justice System for Something Related to Mental Illness’ https://www.gothamgazette.com/state/8705-new-york-criminal-justice-system-mental-illness-thrive-nyc https://www.gothamgazette.com/state/8705-new-york-criminal-justice-system-mental-illness-thrive-nyc first lady chirl mcc first

Chirlane McCray on Rikers Island (photo: Michael Appleton/Mayor's Office)


A rising number of 911 calls to report emotionally disturbed persons, several fatal encounters between police officers and people with serious mental illness, and an increasing percentage of seriously mentally ill people among those detained in city jails have all raised questions about how New York City and State provide care for those suffering from the most serious mental illnesses.

These questions and concerns don’t have easy answers. The city’s public hospital system, NYC Health + Hospitals; the mayor’s mental health care roadmap, ThriveNYC; services from the city’s Department of Health and Mental Hygiene; treatment within the city Department of Correction; private clinics; mental health shelters; and more combine to create a complex and stratified framework for treating those with a serious mental illness (SMI).

For some, much of what is at times called a crisis of treatment for those with serious mental illnesses like schizophrenia can be traced to the trend whereby the state closed down psychiatric hospitals with many thousands of inpatient beds while requisite treatment systems were not put into place to help people who would no longer be institutionalized, many of them cycling through the criminal justice system and inappropriately receiving their best mental health care while in jail.

There is insufficient use of mandatory outpatient treatment, some critics of the city and state say, with significant recent criticism also aimed at Mayor Bill de Blasio and First Lady Chirlane McCray over how resources have been allocated in their signature ThriveNYC program. Meanwhile, others have focused on questioning that police officers with guns are often first responders to people experiencing a serious mental health crisis, and those critics have been successful to some extent in getting protocols changed, though they say there is clearly more to do.

Dr. Mitchell Katz, president and CEO of NYC Health + Hospitals, says he’s troubled by the gaps in treatment and looking for new answers that would require the city and state to work together.

“The problem with the current mental health system, from my point of view, is for people with serious mental illness, the people we most worry about, the people we sometimes see on the subway or sitting on the bench, that right now there is nothing in between acute hospitalization and traditional outpatient care,” he said in April during an appearance hosted by the Citizens Budget Commission (CBC), a nonprofit think tank.

During an interview after the CBC event on the What’s The [Data] Point? podcast from CBC and Gotham Gazette, Katz was asked for more on his view about how to fill that gap.

He said H+H is working with the state on fixing a system that “drops off too precipitously.” Katz said he was in discussions to create programming to increase services for those who don’t qualify or don’t want to be admitted for inpatient care at a hospital but don’t receive enough treatment or care in the current outpatient system.

“We know in New York City there is a group of people with very serious mental health and addiction problems who rotate between the acute hospital, the shelter, and the jail,” he said on the podcast. “They don’t need to be locked up but let’s provide them a positive residential program that they want to stay at because it’s better than shelter and it’s better than the jail when we know that there are people who get arrested in order to be taken care of in jail.”

Over the course of months since Katz’s April comments, Gotham Gazette reached out multiple times to New York City Health + Hospitals and the Mayor’s Office but didn’t receive any further details on Katz’s vision for the program or whether there are ongoing discussions to make it a reality. State law and the state Office of Mental Health (OMH) have near full authority over the types of mental health treatment options allowed throughout the state, and are essential to the discussion, as Katz indicated.

In a statement to Gotham Gazette, a spokesperson for the New York State Office of Mental Health said, “as New York State continues to transform its mental health system to serve more individuals in the least-restrictive setting possible, we are expanding our reach through community-based services. These treatment models allow people to stay in the communities where they are best supported.”

Serious mental illnesses are not the types of mental illnesses and mental health issues that plague a little under 50 million Americans; according to the National Institute of Mental Health, about 4.5% of American adults have a serious mental illness -- meaning roughly 239,000 New Yorkers based on population statistics.

The three most common SMIs are schizophrenia, bipolar disorder, and major depression – less severe depression and anxiety are not categorized as serious mental illnesses although both the National Institute of Mental Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) agree there is some ambiguity in the cut-off line for what’s considered a “serious” mental illness. It’s also important to note that there are complications with the term “serious mental illness”; it is not a diagnosis itself, but a level of disability or a threshold for having a particularly significant and debilitating mental illness.

In asking how New York treats those estimated 239,000 New Yorkers, there are the unavoidable questions of where they can and should be treated, as Katz indicated. Back in the early 20th century, many people with SMIs were admitted into state psychiatric centers, more commonly known as “insane asylums”; however, over the past 80 years there has been a major shift in placing those with serious mentally illness into inpatient treatment.

In the 1950s, New York began deinstitutionalization – a shift from inpatient care (a patient admitted into a hospital full-time) to community-based outpatient care. According to a 2018 report by Manhattan Institute senior fellow Stephen Eide, the process of deinstitutionalization continues to this day but may have gone too far. According to the report, the city’s public hospital and health care system, NYC Health + Hospitals, is the leading provider of inpatient psychiatric care in the city with only 1,218 beds dedicated to adult inpatient psychiatric care, representing 48% of adult inpatient beds in the city. State psychiatric centers in the city account for 1,058 adult inpatient beds.

ThriveNYC, led by McCray, has come under fire on multiple fronts, including general money mismanagement and lack of clear outcome-tracking, but also for how it helps -- or doesn’t help -- those with serious mental illnesses. During a City Council budget and oversight hearing on March 26, McCray was pressed on the issue several times, including pointed questions about how much of the ThriveNYC budget is dedicated toward treatment for those with SMIs.

At one point she said, “All of Thrive is really focused on the seriously mentally ill,” but she and others who testified about the program eventually offered more clarity.

Thrive, which is called a “roadmap” and spends around $200 million per year on programming and coordination, does include services solely focused on those with serious mental illness, but its main objective is to plug gaps of already existing services run by H+H and the city Department of Health and Mental Hygiene (DOHMH), while reorienting health care to always include mental health care and extend awareness and treatment into all of the city’s communities.

“Thrive is dedicated to prevention when possible, early prevention, treating people in crisis, and making sure people are stabilized when they do reach a crisis point,” McCray said. In arguing that all of Thrive is aimed at serious mental illness, she argued that untreated lower-level mental health issues can spiral.

Thrive, in the context of treating those with SMIs, is criticized for focusing more on mental health rather than mental illness; most of its 54 initiatives are focused on combating stigma, the negative factors that can lead to mental illness, and encouraging people to spot mental health issues in others and themselves, and to seek help.

In a May op-ed in the New York Post, DJ Jaffe, the executive director of Mental Illness Policy Org, and Eide of the Manhattan Institute called for the reallocation of ThriveNYC’s entire budget to focus on those with serious mental illness. They offered specific ways in which to redirect funding into different programs, such as enhancing existing crisis intervention teams, creating an office to exclusively manage the use of Kendra’s Law in New York CIty, and promoting supportive housing for homeless people with serious mental illnesses.

“The most serious cases are the ones most likely to become homeless, arrested, incarcerated, hospitalized and violent if they go untreated,” they wrote. “Yet Thrive virtually ignores this group in favor of people with less severe illnesses.”

Susan Herman, the recently-appointed executive director of ThriveNYC, said during the March testimony, “we are filling strategic gaps and piloting innovative programs for the seriously mentally ill to be able to work with people so they can stay in community by connecting them to services, by helping them connect or reconnect to treatment. We’re helping people both before crisis and after crisis.”

For example, McCray said in an op-ed in New York Daily News that Thrive adds $30 million of funding (about 15% of its budget) to the $300 million the Department of Health and Mental Hygiene already spends directly to help people with SMIs.

“Thrive-supported programs are designed to enhance and complement these existing services, not compete with or replace them,” she wrote.

For someone who voluntarily requests care, they can go to a public hospital for informal short-term hospital care as well as traditional outpatient care. The average stay for someone hospitalized for mental illness is 11 days, according to the New York City Department of Health and Mental Hygiene.

Outpatient care -- preferred by many for its community-based nature -- consists of things like meeting with a therapist or a psychiatrist and getting medication prescribed. Influential 1999 Supreme Court case Olmstead v. L.C. ruled public entities must provide community-based services to those with mental illness whenever possible.

“Lots of people have schizophrenia,” says Dr. Gary Belkin, Executive Deputy Commissioner for Health and Mental Hygiene in the city's Health Department and Chief of Policy and Strategy of ThriveNYC, in a phone interview. “The vast majority don’t end up on the street untreated and that’s because there are things that happen earlier, things that Thrive is working on – getting better care connections, having many points of contact, opportunities for family/friends to bring them mobile help."

Thrive has Assertive Community Treatment (ACT) teams dispatched around the city, often in mental health shelters, to treat people with serious mental illness. There are at least 50 ACT teams in New York with the capacity to serve 3,500 people at any time, according to Herman’s March 26 testimony. Thrive also created intensive mobile treatment teams that mostly go to shelters and provide treatment for homeless people. These outreach efforts mostly help people with outpatient care, but can lead to more intensive intervention, though it is very rare for judges to order people into inpatient hospitalization in New York.

Some of these efforts will now be part of ThriveNYC’s recently-announced outcome-tracking procedures, announced in late June.

The key questions, it seems, are whether Thrive’s efforts and the increased emphasis on outpatient programs on the state level -- perhaps including what Katz of H+H said he’d like to see -- can successfully fill gaps left by deinstitutionalization, while creating a more humane care system, and reduce threats posed by those with serious mental illness to themselves and others.

Deinstitutionalization in New York has been drastic. According to Eide’s report, as of November 2018, the average daily number of people in New York state adult psychiatric centers was 2,267. In 1955, there were over 93,000. Even in just the last four years, the number of state inpatient psychiatric beds -- in other words, the capacity for inpatient care -- has dropped by 19% statewide, from 2,866 in 2014 to 2,335 in 2018.

The drop in average daily patients and inpatient beds has coincided with an increase in the number of seriously mentally ill homeless people in New York and the proportion of inmates with a serious mental illness diagnosis in city jails.

According to Eide’s findings, there are more psychiatric beds in New York City mental health shelters than the number of psychiatric beds in state psychiatric centers and Health + Hospitals facilities combined.

Supportive housing, which provides housing and social services for those with serious mental illness, is also seen as a key tool. There are currently 52,000 units of supportive housing statewide, half of which are funded by the state Office of Mental Health (the other half don’t necessarily serve those with mental illness). Supportive housing, which is built and funded by both the city and state, sometimes in conjunction, is typically run by nonprofit providers who provide onsite mental health care, medication delivery systems, and more.

According to testimony given in a May City Council hearing by the Supportive Housing Network of New York, there are around 33,000 units of supportive housing in New York City. Amid calls for more units, both Mayor de Blasio and Governor Andrew Cuomo have made pledges to develop more supportive housing.

In his NYC 15/15 Supportive Housing Initiative announced in November 2015, de Blasio said the city would develop 15,000 additional units of supportive housing over 15 years. Two months later, Governor Cuomo announced his plan to build 20,000 units over the same 15-year timespan. These announcements came after the two were unable to come to an agreement on what have been known for decades as “New York-New York” supportive housing deals whereby the city and state work together to develop thousands of units.

The New York State Senate and Assembly Democratic majorities see a need for more programming aimed at mental health care and housing, too. Earlier this year, the two bodies unanimously passed a bill creating a temporary commission to study what is seen as chronic underfunding for these housing programs. The commission would “provide policy guidance and recommendations relating to the adequacy of funding levels and need for sufficient staffing in all supportive housing under the auspices of the Office of Mental Health.”

According to a June 25 press release from supportive housing provider Bring It Home, “[t]he bill would prompt a study of current funding and staffing levels across the state and investigate ways the state can begin to remedy its years-long failure to adequately fund mental health housing programs.” Advocates are urging Cuomo to sign the bill so the commission can issue its report in time for the next state budget season.

Another discussion that has played out over many years, at the state level especially, is over how to treat individuals who are too sick to seek help.

Per New York State Law, the criteria to involuntarily admit someone due to mental health is fairly strict – the person can’t understand the need for care or presents a substantial harm to self and/or others, among other standards.

According to a 2015 New York City Department of Health and Mental Hygiene report, 40% of adult New Yorkers with serious mental illness didn’t receive medical treatment in the prior year.

Courts can and do order people to outpatient care: assisted outpatient treatment (AOT) is also known in New York as Kendra’s Law. Originally passed in 1999 in New York State (the first law of its kind and emulated in many other states since), Kendra’s Law allows select people close to a mentally ill person to petition the court to mandate a treatment plan for that person. According to OMH’s website, as of Monday (July 29) there were 3,109 people under active court order via Kendra’s Law, 1,377 of them in New York City.

Jaffe of Mental Health Policy Org, a staunch supporter of Kendra’s Law, estimates around 4,000 people should be in mandated treatment under the law. Critics of Kendra’s Law typically accept the principle but say it’s overly strict, such as the need to show an instance of seriously violent behavior in the last four years. Once a petition to mandate care is successfully filed, the chances of the courts granting the petition are extremely high: 90% of Kendra’s Law petitions were granted statewide from July 29, 2018 through Sunday (July 28, 2019), according to OMH’s website.

Kendra’s Law affects a very small population but has shown signs of working: the state Office of Mental Health says for someone who went through an assisted outpatient treatment program, psychiatric hospitalization was reduced by 64% after AOT, incarceration by 72%, and homelessness was reduced by 61%. Jaffe and Eide in their op-ed call for the creation (and funding) of a Kendra’s Law Office to deal solely with helping the city expand its efforts to get more people into Kendra’s Law.

Meanwhile, ThriveNYC offers NYC Well, a mental health helpline that has the ability to dispatch mobile crisis intervention teams to someone experiencing a mental health crisis. The phone line is something that de Blasio and McCray often cite in their public remarks about Thrive and the city’s efforts to improve mental health care.

Another big piece of the current picture of care for those with serious mental illnesses is correctional health services, which have been needed more and more. Although the daily inmate and detainee population in city jails is decreasing, the percentage of those diagnosed with a serious mental illness has gone from 10.2% in city fiscal year 2014 to 14.3% in fiscal year 2018, according to the Mayor’s Management Report.

Dr. Katz  said on What’s the [DATA] Point? that “In the case of correctional health…we know in New York City there is a group of people with very serious mental health and addiction problems who rotate between the acute hospital, the shelter, and the jail.”

One goal of ThriveNYC is to limit the number of people going to jail due to serious mental illness. The city will open two health diversion centers later this year. Announced in late 2018, the diversion centers will provide somewhere for police officers to take someone who has committed a low-level, non-violent crime but they believe is exhibiting behavioral problems due to mental health. The centers will offer mental health treatment and have overnight beds but stays will be capped at five days.

Skeptics of the idea point out that there will only be two diversion centers, one in the Bronx and one in East Harlem, and each center will only serve its specific community. Plus, the centers will have a “no-refusal” policy that could edge out those with serious mental illness if the centers are at capacity. According to Herman at the March City Council hearing, Thrive plans to evaluate the success of the two programs and possibly create more centers next year.

“We want to catch [people] before entry into the criminal justice system,” said Dr. Belkin. “Nobody should enter the criminal justice system for something related to mental illness. We should be able to reach those people so that doesn’t happen, where they can be treated and managed in a health context before they get ensnared in the criminal justice system. I think everyone wants to avoid that path."

Critics argue, as alluded to by Katz and recently brought up during a Council hearing on recidivism of those with mental illness, that mental health services outside of the criminal justice system are less robust than those offered in city jails. According to Katz, “the fact that we make it necessary for some people to commit shoplifting in order to ensure they’re in a safe place, get their meds, get their food, get their house, when we could do that so much less expensively elsewhere is really a condemnation on us.”

Another option, proposed by Jaffe and Eide, is the expansion of mental health courts, which allows judges to divert those with serious mental illness and charged with crimes to treatment instead of jail. They say current mental health courts cannot offer housing to these people, which weakens its effectiveness.

City Council Speaker Corey Johnson is attempting to prevent those with mental illness from going to jail and to ensure they get better treatment instead. In a speech on criminal justice reform on May 16 at John Jay College, he announced the Council will create a program to house 100 people with SMI caught in the criminal justice system and emphasized the 100 beds are a start, but the program will need further investment and focus to add more beds.

Johnson also pointed out how targeting the legal system can keep people with SMI out of jail; he announced the Council will fund a program to connect social workers with defense attorneys to find alternatives to prison. He also previewed the Get Well & Get Out Act, which would require correctional services staff to keep attorneys informed of their clients’ mental health.

The bill was introduced on June 13 by Council Member Margaret Chin of Manhattan and six other Council sponsors, including Speaker Johnson. The Council quickly held a hearing on the bill that was combined with an oversight hearing on recidivism rates for those with mental illness. The bill has not yet received a committee vote.

How the city handles crisis situations including people with serious mental illness has come under increased scrutiny over the last few years. According to the NYPD and an investigation from THE CITY, calls to 911 involving EDP’s, or emotionally disturbed persons, have risen from around 97,000 in 2009 to 180,000 last year. Fourteen people who appeared to be suffering from acute mental illness have been killed by police officers in the past three years.

The extent to which the city’s roughly 37,000-member police force has been trained in crisis prevention is an ongoing issue. THE CITY estimated that only about 11,970 uniformed officers had undergone crisis prevention training at the time of its March reporting.

In April 2018, de Blasio and McCray launched the NYC Crisis Prevention and Response Task Force to create a strategy to better deal with mental health crises in the city. That report was due in January and has not been publicly released. The Task Force consists of leaders from the Department of Health and Mental Hygiene, ThriveNYC, and the NYPD, among others.

McCray in her Daily News op-ed said serious mental illness and EDP calls aren’t as related as they appear.

“Unfortunately, too many people think of serious mental illness as ‘crazy people in the subway,’ or 911 calls involving emotionally disturbed persons. But not everyone sleeping in the subway or on the streets has an illness,” she wrote. “And emotional disturbance describes erratic behavior at a given time — not a chronic disease.”

In an attempt to treat EDPs, Thrive created what it calls co-response teams that proactively send a police officer with a clinician to people who have shown violent tendencies or behavioral problems in the past. The forensic ACT teams, the mobile intervention teams, and the co-response teams are all a part of Thrive’s NYC Safe program.

It’s possible that the program Dr. Katz spoke about in April -- creating a residential program for the seriously mentally ill to fill in the gaps of treatment between outpatient care, inpatient care, and prison -- is what’s called “Intensive Outpatient Treatment,” or IOT, which offers a much higher intensity of services but still in the patient’s community. Patients under IOT would visit a psychiatrist more often and for longer than traditional outpatient programs.

Already existing outpatient programs must apply for a waiver to the state Office of Mental Health for permission to offer an intensive outpatient treatment program. OMH has approved waivers for 35 clinics beginning in August 2017, according to OMH’s website (they are required by state law to publicly release waiver requests and decisions).

Otherwise, the most intensive treatment with the most consistent care can be found in hospitals, prisons, or homeless shelters.

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by Truman Stephens, Gotham Gazette

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‘Nobody Should Enter the Criminal Justice System for Something Related to Mental Illness’ Mon, 29 Jul 2019 04:00:00 +0000
City Council Looks at Reducing Recidivism for People with Mental Illness https://www.gothamgazette.com/city/8608-city-council-examines-how-to-reduce-recidivism-for-people-with-mental-illness https://www.gothamgazette.com/city/8608-city-council-examines-how-to-reduce-recidivism-for-people-with-mental-illness council comm cj

Elizabeth Ford of Health + Hospitals, left, & Becky Scott of DOC (photo: John McCarten/City Council)


City Council members on Monday held an oversight hearing to examine how New York prevents formerly incarcerated mentally ill persons from returning to jail. The hearing made clear that the de Blasio administration, Health + Hospitals public hospital system, and City Council members all want to reduce the number of mentally ill persons who rely on the jail system for their mental health care and keep those with serious mental illness out of jail altogether.

But, it was evident at the hearing that there is much more emphasis on services for the imprisoned mentally ill than on keeping those with serious mental illness out of jail, whether for the first time or in all-too-common recidivism.

The psychiatric services offered in city jails -- like nurse and doctor staff, therapeutic groups, and medicine -- are robust but someone with a serious mental illness often loses the best care upon leaving jail. This then contributes to high recidivism rates.

The hearing centered several key data points: roughly 43% of those held in city jails are suffering from mental illness (14% have serious mental illness); the recidivism rate in New York City is 20%, but for those with mental illness it’s 47%.

Held by the Council’s Committee on Justice System, Committee on Criminal Justice, and Committee on Mental Health, Disabilities and Addiction, the hearing looked at the different ways the city Department of Correction and Correctional Health Services, a part of New York’s public health care system, New York City Health + Hospitals, provide care for the mentally ill in prison and once they leave. Two pieces of legislation dealing with notifying defense attorneys of their detained clients’ mental health and returning unused commissary money to recently released inmates were also discussed with various stakeholders who testified.

As the overall jail population has declined significantly, the proportion of New Yorkers with mental illness in city jails has risen in recent years: the overall average daily population of city jails decreased from around 11,500 in 2014 to around 8,900 in 2018, and the percentage of people with mental illness increased from 38% to 43%.

The percentage of those with a serious mental illness, defined by Correctional Health Services as anyone with schizophrenia, bipolar disorder, major depressive disorder, or post-traumatic stress disorder, has increased from 10.2% to 14.3% in that same time frame.

Council Member Keith Powers, a Manhattan Democrat and chair of the Committee on Criminal Justice, asserted that the City Council and the different city agencies in attendance all agree that jail is not the place to help seriously mentally ill people. However, jail is often where people with serious mental illness wind up, and jails often offer medical services – city jails have many psychiatric services located in one place (in fact, Rikers Island is the third-biggest provider of psychiatric care in the United States behind jails in Los Angeles and Chicago).

Currently, city jails put inmates diagnosed with mental illness in “mental observation houses” (MOs), where there are advanced levels of service and psychiatric nurses available, or the more intensive option, PACE (Program to Accelerate Clinical Effectiveness) units where there’s 24/7 embedded staff and more therapeutic groups, according to Dr. Elizabeth Ford, who testified for Correctional Health Services.

However, through questioning from Powers, Ford admitted right now there are people who qualify for PACE but due to spacing issues are only in MOs. THE CITY reported in April that the de Blasio administration is well behind on its planned 12 PACE units by 2020 (currently there are six).

Council member questions made clear that there are many mental health services available in prison, but the key organizing question of the hearing was: what happens when an inmate/patient is released? Ford said CHS gives inmates seven days of their medicine so they don’t drop off too preciptiously after leaving jail, a 30-day prescription which can be fulfilled at a pharmacy of their convenience, and many referrals to outpatient treatment programs.

Outpatient treatment is the primary way people with mental illness are treated in New York, most of which are run by New York City Health + Hospitals. Outpatient care requires patients to appear at appointments, as opposed to inpatient care or state institutionalization – mental health care nationwide over the past 60 years has transitioned away from state-run facilities once known as “insane asylums” or “psychiatric hospitals” and towards outpatient care.

When asked how CHS can make sure recently-released inmates follow through on getting care, Ford mentioned they are hiring more social workers and focusing on making sure existing services, like existing mobile care teams, work well rather than accepting “new mandates.”

In terms of keeping mentally ill people out of prison in the first place, Ford brought up the new plan from the administration of Mayor Bill de Blasio of helping mentally ill people go to the Health + Hospitals system, instead of prison.

Furthermore, two diversion centers -- in East Harlem and South Bronx -- will offer police officers a place to bring emotionally disturbed people who exhibit signs of mental illness instead of arresting them. They’re not open yet, but are supposed to open later this year.

Ford hopes the community-based aspect of the diversion centers will be especially useful as the centers will be located to existing outpatient care.

Supportive housing is another way to prevent recidivism, according to Ford. Supportive housing offers mental health services to people struggling to find housing. The de Blasio administration plans to build 15,000 supportive housing units over 15 years.

If the roughly 1,200 city jail detainees diagnosed with serious mental illness were to be released tomorrow, the relatively minor supportive housing options and short-term diversion centers combined with New York’s disinclination towards inpatient care throw doubt on how the seriously mentally ill would be treated without jail-based services.

The city has created what they call Community Re-Entry Assistance Network (CRAN) teams, which are six-month transitional teams to help those with serious mental illness re-enter the community after release.

On the two pieces of proposed legislation being considered at the hearing, the lead sponsor of the defense attorney notification bill is Manhattan Council Member Margaret Chin, while Queens Council Member Donavan Richards is the lead sponsor of the commissary bill.

Chin’s bill, Intro. 1590, would require the Department of Health and Mental Hygiene to notify the defense attorney of a person who is in the custody of the Department of Correction and who has been diagnosed with a serious mental illness.

The bill, co-sponsored by City Council Speaker Corey Johnson and six other Council members, is not supported by Correctional Health Services in its current language. Although Dr. Ford chose to keep some reservations of Correctional Health Services private, she did mention that the agency has a newly-created court liaison program intended to act as a go-between for defense attorneys and medical officers.

The current process for notifying the defense attorney of a seriously mentally ill person who is accused of a crime is the patient must give consent to Correctional Health Services and CHS gives information relevant to the mental illness diagnosis to the defense attorney.

The bill “attempts to break the cycle of imprisonment,” said Chin, as ideally more cases could take mental illness into account.

The most intense exchanges of the hearing occurred in regard to the other piece of legislation discussed Monday. Intro. 0903, Council Member Richards’ bill, would require the Department of Correction to notify all recently-released former inmates if there is money in their individual jail commissary account as well as return that money within 60 days of release.  

A commissary account, which can be deposited into by an inmate’s family, is essentially a bank account that the inmate can use to purchase snacks or personal products while in jail. Currently, the Department of Correction is holding $3.7 million from as far back as 2012 in unclaimed commissary money for the over 140,000 individuals who have not claimed it.

Richards, indignant, heavily implied DOC wasn’t making any effort to return the money, while DOC testifiers stated multiple times they don’t use the unclaimed money for their own purposes.

According to those who testified for the Department of Correction, the only outreach done by the DOC has been to put posters -- only in English -- in the jails. DOC representatives said the often unpredictable nature of inmates’ release schedules as well as the general difficulty in remaining in contact with released inmates makes returning the money difficult. DOC does not support the bill, citing difficult logistics.

In a fitting summary of the hearing, Council Member Diana Ayala of Harlem and the Bronx said if the Department of Correction cannot find people leaving prison to give them their money back, how can they ensure the mentally ill leaving prison get the mental services they need?

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by Truman Stephens, Gotham Gazette

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City Council Looks at Reducing Recidivism for People with Mental Illness Tue, 18 Jun 2019 04:00:00 +0000
Ending Health Disparities That Disproportionately Impact New Yorkers of Color https://www.gothamgazette.com/130-opinion/8548-ending-health-disparities-that-disproportionately-impact-new-yorkers-of-color https://www.gothamgazette.com/130-opinion/8548-ending-health-disparities-that-disproportionately-impact-new-yorkers-of-color woodhull cm cr ar mt jm

Council Member Carlina Rivera, left, one of the co-authors (photo: John McCarten/City Council)


New York City is one of the largest, most diverse, and advanced cities in the country – in fact, New Yorkers are living one-and-a-half years longer than a decade ago and nearly nine years longer than 25 years ago. Yet behind that positive sheen lies a shameful truth – our city persistently falls short in health outcomes for people of color.

As a New York City lawmaker chairing the committee that oversees our city’s largest public health system and as the founder and leader of the city’s largest physician-led nonprofit health care network, we are troubled that despite economic and technological leadership, our city continues to fall short on health basics.

Persistent health disparities are spread across all five of New York City’s boroughs, most noticeably in communities of color. So, with another Minority Health Month in the rear-view mirror, we are hoping to spur solutions and bring much needed attention to these crises beyond just one month. Whether it is tackling the epidemic of diabetes, maternal mortality rates, or depression and suicides, we can no longer take on these issues without highlighting the disparate rates at which these medical issues affect New Yorkers of color.

And the solutions to these challenges can’t just come from one sector. We need policymakers, community doctors on the front lines, and healthcare experts to all fight together for essential access to preventive care, increasing basic health education and literacy, and addressing the social determinants of health.

Our urban reality is stark: compared to their white neighbors, Latinx women are 60% more likely to be diagnosed with cervical cancer and are 70% more likely to receive late or no prenatal care; Asian-Americans are 30% more likely to be diagnosed with tuberculosis and 10% more likely to be diagnosed with diabetes; and African-Americans are 60% more likely to experience a stroke that could end in them becoming permanently disabled.

In addition, key survey findings in SOMOS’s State of Latino Health report highlighted a series of health disparities Latino New Yorkers struggle with every day. For example, 33 percent of Latinos don’t think people in their community get the health care they need, and 61 percent of providers think that Latinos face unique barriers that keep them from accessing health services.

Many of these conditions are exacerbated by what are known as social determinants of health, or more simply, the conditions in which New Yorkers live. These social determinants are attached to economic stability, education level, social and community context, health and health care; and neighborhood and built environment. And, every single one of these factors can determine a wide range of health risk outcomes.

Overall, New Yorkers who live in poverty and cultural isolation, including immigrant and first-generation New Yorkers, live underserved and in a political climate hostile to the historically disenfranchised. Put simply, this crisis is decades in the making, which is why the City Council Committee on Hospitals has been dedicated to examining these issues at our hearings and advocating for solutions from our city’s biggest medical providers.

We must improve health literacy through building awareness – and use cutting edge technology to meet diverse New Yorkers where they live and how they receive information. New York City has more languages and dialects than the United Nations, and we are stronger and more unique for it – yet in many communities our access to internet services is far too low. We need to translate simple, effective health literacy messages from nutrition and exercise to smoking cessation in order to better reach more families and employ digital and handheld technology to carry the message.

We must make sure nutrition and healthy eating are no longer the purview of elites. It’s worth repeating that farmers markets and supermarkets that specialize in natural, low-calorie, low-sugar, low-fat foods are economically far out of reach for far too many neighborhoods. Lowering food costs and making healthy food far more accessible and culturally relatable can make a huge difference in basic health for hundreds of thousands of New Yorkers who want to eat healthily but simply can’t afford it or aren’t exposed to it. And we know that local vendors who partake in farmers’ markets and sell to health food markets would like to reach more consumers.

Together, we are pursuing a collaborative agenda defined by our partnership, expertise and unique lived realities.

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City Council Member Carlina Rivera represents the 2nd district, which includes portions of the Lower East Side in Manhattan, is Chair of the Council’s Committee on Hospitals and Co-Chair of the Council's Women’s Caucus. Dr. Ramon Tallaj is Chairman of SOMOS, a non-profit, physician-led network of more than 2,000 health care providers serving over 700,000 Medicaid beneficiaries in New York City, with providers delivering culturally competent care to patients in some of New York City’s most vulnerable populations.

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Have an op-ed idea or submission for Gotham Gazette? Email opinion@gothamgazette.com

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Ending Health Disparities That Disproportionately Impact New Yorkers of Color Mon, 03 Jun 2019 04:00:00 +0000
What's The [Data] Point? 1,112,975, with Dr. Mitchell Katz, President of NYC Health + Hospitals https://www.gothamgazette.com/city/8430-what-s-the-data-point-1-112-975-with-dr-mitchell-katz https://www.gothamgazette.com/city/8430-what-s-the-data-point-1-112-975-with-dr-mitchell-katz whats the data point


What's The [Data] Point? Episode 71 -- 1,112,975, with Dr. Mitchell Katz, president of NYC Health + Hospitals [You can download What's The [Data] Point? wherever you get your podcasts, including on iTunes]

artworks 000515225592 2py301 t500x500Dr. Mitchell Katz is in charge of the city's public hospital system, which includes 11 hospitals and dozens of other facilities and clinics. Katz came to New York City Health + Hospitals to help turn around the struggling system, especially in terms of its finances, but also in its delivery of care. He recently spoke at Citizens Budget Commission breakfast, after which he joined the podcast to take a few questions -- this episode consists of that Q&A followed by Katz's remarks at the breakfast about what he's doing to change H+H, what progress has been made and what challenges persist.

Listen to the conversation and let us know what you think: Ben Max of GG (@TweetBenMax), Maria Doulis of CBC (@MariaDoulis). Listen below or download wherever you get your podcasts!

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by Ben Max, Gotham Gazette
     

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What's The [Data] Point? 1,112,975, with Dr. Mitchell Katz, President of NYC Health + Hospitals Thu, 04 Apr 2019 04:00:00 +0000
Expanding Health Insurance Enrollment Will Help Heal New Yorkers and Our Public Hospitals https://www.gothamgazette.com/130-opinion/7672-expanding-health-insurance-enrollment-will-help-heal-new-yorkers-and-our-public-hospitals https://www.gothamgazette.com/130-opinion/7672-expanding-health-insurance-enrollment-will-help-heal-new-yorkers-and-our-public-hospitals Carlina Rivera City Council

Council Member Rivera, one of the authors (photo: John McCarten/City Council)


Even in an era of relentless attack on health care by the Trump administration and its allies in Congress, New York City is continuing to reap enormous benefits from the Affordable Care Act. This year alone another 80,000 city residents enrolled in health coverage through our state’s Obamacare exchange.

But a huge number are still being left behind: an estimated 962,000 adults in the five boroughs remain uninsured. These New Yorkers -- many of whom are living in poverty -- often receive no health care until their conditions are severe enough to land them in the emergency room.

The trend is not good for those New Yorkers’ health, as they should have access to preventive care, regular check-ups, and other aspects of quality health care. What’s more, the current situation is also dealing a serious financial blow to our struggling public hospital system (known as Health + Hospitals), whose vital mission it is to serve those in need, including the uninsured. For H+H to avoid financial disaster we need to close the health insurance gap in New York City.

H+H serves over a million patients per year in a network of 11 acute care hospitals and dozens of other facilities throughout the five boroughs. These institutions are by far our city’s largest provider of care to Medicaid recipients, mental health patients, and -- critically -- those who are uninsured.

For decades our public hospitals -- Bellevue, Kings County, Harlem, Elmhurst and others -- have been the ultimate safety net for New Yorkers with nowhere else to turn. H+H’s diverse and committed staff, its proximity to low-income communities, and its sliding-scale fees have helped establish it as second-to-none in serving the neediest New Yorkers.

But balancing the books at our public hospitals has never been easy, in part because Medicaid reimbursement rates are so low. The system’s challenges have only gotten worse in recent years as federal and state safety-net funding has shrunk. And now tectonic changes in the health sector have dealt further blows, as care rapidly moves from inpatient to outpatient services.

The result: H+H is confronting a $1.3 billion deficit this year, projected to balloon to $2.1 billion next year.

This financial strain has real implications for patients, compounding long-running problems in the system. The wait time for appointments at H+H can stretch into the months. Many of the system’s buildings are crumbling, with leaking roofs at Harlem Hospital, deteriorated plumbing at Lincoln, obsolete electric systems at Metropolitan, and elevators throughout the system that are so outdated that their replacement parts are no longer sold.

H+H’s new CEO, Dr. Mitchel Katz, has laid out a multi-pronged plan to address this crisis. He has set out to reduce administrative expenses, more effectively bill insurance companies, and retain more paying patients, among other efforts.

But there is another critical strategy needed to save H+H: New York City urgently needs to enroll more people in health insurance.

Our public hospitals treat over 400,000 uninsured patients each year. That represents hundreds of millions of dollars of lost insurance billing for those eligible for coverage. Providing this health care regardless of ability to pay is the moral thing to do. It also affects the health of all New Yorkers by helping us prevent the spread of communicable diseases.

We need to tap health insurance as a way to make this important work financially sustainable. That’s why it’s critical that we dramatically ramp up our outreach and enrollment efforts.

Today, most funding for ACA enrollment is provided by the State, which spends about $12 million per year on a network of community-based organizations in the five boroughs offering health insurance navigation assistance.

Several City agencies also have dedicated teams doing enrollment, but the numbers are small: only about 50 staff at Human Resources Administration (HRA) and 70 at Department of Health and Mental Hygiene (DOHMH).

We need an aggressive, coordinated plan to take this work to the next level. And we need to be on the ground in neighborhoods. Community-based non-profits make ideal partners for this work, because of their cultural competence and because of the trust they so often have earned in low-income communities.

One group of New Yorkers can’t get enrolled no matter how much we spend on outreach: undocumented immigrants. But there’s a win-win possibility for them as well. By investing in a program to provide them access to primary care we can improve health outcomes and prevent the more costly H+H emergency room admissions that would otherwise occur.

A twin effort to enroll more New Yorkers who are eligible for insurance and to fund access to primary care for those who are undocumented would improve the health of our people while going a long way to shore up the finances of our public hospital system.

That would be a giant step forward to the goal of ensuring that each and every New Yorker, regardless of income or immigration status, has access to the affordable, high-quality care they need.

***
Mark Levine and Carlina Rivera are members of the New York City Council. Levine chairs the Council’s health committee, Rivera chairs its hospitals committee. On Twitter @MarkLevineNYC and @CarlinaRivera.

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Have an op-ed idea or submission for Gotham Gazette? Email opinion@gothamgazette.com

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Expanding Health Insurance Enrollment Will Help Heal New Yorkers and Our Public Hospitals Mon, 14 May 2018 04:00:00 +0000
Under New Leadership and Oversight, City’s Hospital System in Spotlight https://www.gothamgazette.com/city/7515-under-new-leadership-and-oversight-city-s-hospital-system-in-spotlight https://www.gothamgazette.com/city/7515-under-new-leadership-and-oversight-city-s-hospital-system-in-spotlight Carlina Rivera hospitals hearing

Council Member Carlina Rivera (photo: @NYCCouncil)


The new CEO of the city’s beleaguered Health + Hospitals (H+H) public hospital system, Dr. Mitchell Katz, testified in front of the City Council’s new hospitals committee, and its chair, Carlina Rivera, for the first time on Wednesday, discussing the progress of the “One New York” plan to 'transform' and improve the system.

H+H is a public-private corporation that manages the city’s 11 public hospitals, health centers, and municipal healthcare provider, MetroPlus.

“Its mission is to provide quality, comprehensive health services to all New Yorkers, regardless of their ability to pay,” Rivera said. “In effect, Health + Hospitals is the default system of care for Medicaid patients, the uninsured, and other vulnerable populations, and is integral to our system of safety net hospitals.” Rivera noted that approximately 70% of H+H patients are uninsured or on Medicaid.

H+H has faced numerous fiscal challenges over the past few years. When the original One New York report was released in 2016, its intention was to reduce an anticipated budget deficit of $1.8 billion in fiscal year 2020, which begins July 1, 2019.

Last fiscal year, the de Blasio administration provided $1.8 billion in city aid to H+H as its interim leadership also took measures to overhaul its operations and finances, before Katz was brought in from Los Angeles to accelerate that work. (That was an increase from $607 million in fiscal year 2011, according to the Citizens Budget Commission.)

A recent fiscal scare originating in the federal government concerned the potential defunding of the Disproportionate Share Hospital program, which provides additional funding for hospitals that see a disproportionate number of low income patients, who may be uninsured and/or on Medicaid. The threat of cuts, which has loomed since 2014 but has become especially acute since President Donald Trump took office, was averted for the immediate future with a recent two-year extension of funding in the latest federal stopgap measure passed in February. When the cuts take effect, federal and state funding is expected to drop by approximately $800 million.

Meanwhile, after H+H announced plans to file a lawsuit against New York state government for failing to provide $380 million in funding, Governor Andrew Cuomo relented, giving H+H $360 million of the $380 million H+H claimed it was owed in October. Cuomo had initially suggested that the city tap into its reserves to provide the funding.

Tellingly, Katz, who assumed his current role after leading the Los Angeles County Health Agency for seven years and turning a $250 million budget deficit into a $560 million budget surplus, did not focus his City Council testimony on short-term revenue streams coming from Albany and Washington but rather on what he assesses are deficient practices within H+H operations and bureaucracy that are hindering its ability to collect revenue to its full potential.

Katz outlined a seven-point plan to increase revenues without cutting vital services. It includes cutting administrative expenses, which Katz said has begun recently by eliminating outside consultants from the system to the tune of $16 million in savings, and investing in new “revenue generating positions” such as primary care doctors, pharmacists, and nurse practitioners instead of solely ER doctors, a goal Katz outlined at the beginning of his term.

Hiring more people will also cut down on wait times, Katz said, in response to Rivera bringing up the issue. Katz described waits for appointments as “hugely variable.”

“One of the things that I found distressing was at Bellevue, is that the wait for behavioral assessments for a kid is currently months,” Katz said. “Which, frankly, has nothing to do with money, because kids are fully insured.”

But perhaps the more significant stabilization schemes, which were the focus of more attention at the hearing, relate to reforming H+H’s billing processes and bringing more insured patients into the system. Because H+H has a reputation as the hospital network that serves the indigent, many insured people do not use municipal hospital services. As a result, Katz said there is a substantial amount of bureaucratic waste within the system due to poor administrative skills on the part of system workers, who normally work with people who are either uninsured or on Medicaid.

This point was hammered by Council Member Antonio Reynoso, who recently became a father and described his experience as an individual with private insurance at Woodhull Hospital, an H+H hospital “across the street” from his district. Reynoso effusively praised Woodhull’s maternity ward and other services, but chastised billing procedures as inefficient.

Katz agreed that H+H needs to develop better billing procedures, including diagnostically coding bills correctly, checking insurance cards, checking prior authorization, and better communication with insurance companies. He cited a skilled nursing facility that spends roughly $21 million on drugs but only has revenues of $5 million.

“That’s impossible,” Katz said, “because we’re talking about skilled nursing facilities where there are almost no uninsured patients.” Katz claimed that the $21 million was a fair market value for the drugs but that the significant revenue shortfall had its roots in poor billing practices.

The situation at the skilled nursing facility is only the tip of the iceberg. In response to a question from Rivera, H+H Chief Financial Officer Plachikkat Anantharam stated that H+H lost between $130 million and $290 million in 2017 as a result of chronic underbilling.

Further, Katz said that H+H should not be referring patients out of the system and into the private market. Via MetroPlus insurance, H+H by proxy essentially pays private hospital operators to provide care, resulting in a significant amount of lost revenue.

Katz also stated that H+H needs to begin offering services that are “well reimbursed.” He illustrated this point by comparing behavioral health, for which H+H is the largest provider in the city and which is “poorly reimbursed,” and angioplasties, a heart procedure that is well reimbursed by insurance companies, but is rarely performed by H+H, and only at Bellevue Hospital.

Katz also wants, as part of his plan, to “convert uninsured people who qualify for insurance to be insured,” whether through Medicaid or MetroPlus, the government sponsored health insurance provider wholly owned by H+H that insures around a half-million New Yorkers and is offered on the Affordable Care Act exchange. Katz identified 250,000 people in the city who are uninsured but qualify for insurance coverage, out of a total of 667,000 uninsured people in the city.

“250,000. Let’s agree we won’t get 250,000,” Katz said, in reference to not being able to insure every eligible uninsured New Yorker. “That’s a lot of people. But if you got 100,000 of the 250,000 that we believe are currently getting our services and are insurable, that would be huge.”

Regardless, the Council members and Katz acknowledged that signing up tens of thousands of people for insurance is easier said than done. Council Member Mark Levine, chair of the Council’s health committee, asked whether it was possible to enroll patients who walk into a facility on the spot, and why this hadn’t been done in the past.

“Is that another cultural challenge you have to overcome,” he asked. “Is that a resource issue? Or am I making it seem simpler than it really is?”

“No, Council Member, I think you’re right, and accurate. It’s both of those things,” Katz responded.

“I think another part of that is that there’s no -- right now, we haven’t constructed a system to make it that that’s the easiest choice for the person, right, to be able to enroll in insurance,” he continued. “We’ve kind of made it easier to pay $10, which might be the same copay that they would pay if they had insurance. But the difference between what our system and city would receive is huge.”

Katz cited his experience in Los Angeles as evidence that the public hospitals system could be stabilized without attrition, or mass firings in other terms. Indeed, as Citizens Budget Commission noted in its analysis, "Lessons from La La Land," previewing Katz's takeover at H+H, "The good news was all on the revenue side."

“When I started in Los Angeles, there was also a deficit. It was $226 million, which at the time seemed to me like a lot of money, before I came to New York City,” Katz said, eliciting laughter from the audience of healthcare advocates and professionals in the Council’s Committee room. “But when I left, not only did we have a surplus, but we had added 1,500 public sector jobs. So one thing I do know is that you have to take financial problems seriously, but you can grow out of financial problems sometimes more easily than you can shrink out of financial problems.”

Reynoso was particularly fond of that line. “Grow out of a financial problem, that’s a great way to put it,” he said.

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by Ben Brachfeld, Gotham Gazette

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Under New Leadership and Oversight, City’s Hospital System in Spotlight Sun, 04 Mar 2018 05:00:00 +0000
Johnson Hands Over Council Health Portfolio, Including Hospital Crisis, to New Committee Chairs https://www.gothamgazette.com/city/7441-johnson-hands-over-council-health-portfolio-including-hospital-crisis-to-new-committee-chairs https://www.gothamgazette.com/city/7441-johnson-hands-over-council-health-portfolio-including-hospital-crisis-to-new-committee-chairs Corey Johnson health hospitals

Corey Johnson at a rally (photo: City Council)


Before being elected Speaker of the City Council, Council Member Corey Johnson led the Committee on Health for four years. Drawing from his own personal experience as an openly gay, HIV-positive man who has struggled with drug and alcohol abuse and tobacco use, he pushed a raft of legislation to improve healthcare services and outcomes for many of New York’s most underserved populations. In his early days as Speaker, Johnson has indicated that health and healthcare issues will continue to be one of his main priorities over the next four years.

At the same time, though, as he takes on his larger role Johnson has in some ways passed the torch to other Council members who will lead relevant committees related to health and oversee the city’s public hospital system, which is in the midst of a financial crisis that Johnson has been tasked with helping to monitor over the past four years and will now, as speaker, have even greater responsibility for as he negotiates the city budget with Mayor Bill de Blasio.

Among the first steps that Johnson took upon assuming his new leadership position was to create a new committee, chaired by Council Member Carlina Rivera, dedicated to hospitals, especially New York City Health + Hospitals, the city’s municipal hospital system that has long suffered from budgetary difficulties and struggled to remain afloat even as the de Blasio administration has sought to overhaul its finances. Johnson’s move was a clear recognition of the H+H crisis, one that Council members, the mayoral administration, and healthcare advocates agree must be addressed amid threats of federal funding cuts to the city.

The move to make the new committee also comes in conjunction with the beefing up of the Council’s oversight committee, now led by Council Member Ritchie Torres, and a repositioning of the health committee, under new chair Council Member Mark Levine. Levine, taking over the health committee from Johnson, will be able to focus his efforts closely on oversight of the city’s health services and to advance legislation expanding equitable access to healthcare for New Yorkers. There is some discussion among the parties of a city-run single-payer health care system, but it is unclear how far down this road Johnson, Levine, and others may go.

In a recent NY1 interview, shortly before his election as speaker, Johnson indicated his continued interest in pursuing it. “My goal is for this city to be a laboratory for potential ideas that we could achieve,” he said, citing San Francisco’s implementation of a municipal single-payer system as a potential model albeit for a population a tenth of the size of New York City. “This would be a legacy item, it would be a big seismic thing to do,” he added, “but it’s gonna take a lot of work, it’s gonna take cooperation from the governor and from the state insurance superintendent and other folks that are gonna have a say in this. But it’s something that I want us to look at.”

Over the four-year course of the last Council session, Johnson’s committee held 62 hearings, passing 34 bills that became law. Johnson was the prime sponsor on 11 of those bills, which included new regulations on tobacco products and electronic cigarettes, mandated air quality surveys by the city, new animal safety protections, required reporting on health services in city jails, and allowing individuals to change their gender designation on their birth certificates.

The committee also conducted broad oversight of the city’s hospital system, healthcare services provided by city agencies, and the city’s efforts to enroll people under the Affordable Care Act. Naturally, Johnson raised many of the same issues during separate Council hearings to examine de Blasio’s budget proposals over the years. His advocacy also extended beyond the Council’s work: he was arrested in Washington D.C. in July of last year while protesting the Republican-led Congress’ (so-far unsuccessful) efforts to repeal the Affordable Care Act.

“He believes really strongly in universal health access and he talks a lot about the importance of single-payer,” said Claudia Calhoon, director of health policy at the New York Immigration Coalition, discussing Johnson’s record as health committee chair. Johnson’s support of implementing a single-payer healthcare system in the city could only be achieved through collaboration with the state, as Calhoon noted. “It’s really great to have leadership talking about that when you’re trying to advocate for closing gaps and trying to engage the city in doing the work to close the gaps as they are able,” Calhoon said.

In particular, Calhoon praised Johnson’s efforts to create the Access Health NYC initiative, which, starting in 2016, provided funding to community-based organizations for health education and outreach efforts, particularly for underserved communities. “I think he has a very good vision for equity which flows into a lot of different areas,” Calhoon said.

Johnson has spoken openly about coming of age in the 1990s and watching how treatment of the AIDS-HIV epidemic was handled, and about discovering his HIV-positive status and the need for medication and good health care. He represents a district largely made up of Chelsea and the West Village that was and continues to be home to much of LGBT activism, including around equitable health care.

Elizabeth Adams, director of government relations at Planned Parenthood of New York City, praised Johnson’s work in holding city agencies accountable for sexual and reproductive health services, particularly abortion access for young New Yorkers, and to expand health care to immigrants. “During a time of increased federal attacks on abortion and rollbacks of funding for healthcare, it’s really really critical that New York City is examining its own care options and leads the nation in accessible and affordable health care, including abortion,” Adams said in a phone interview.

Taking over the health committee, Council Member Levine has expressed support for issues that Johnson has championed, but he has yet to lay out an agenda of his own. “We are still in the midst of reviewing all the policy issues before the committee, still in the midst of forming our legislative priorities,” he told Gotham Gazette at City Hall last week, not long after being named to chair the committee.

“[Speaker Johnson] did a lot,” as chair of the committee, Levine said. “We look to build on that.” Among broader items, Levine has said he will pursue a single-payer municipal health system, tackle the city’s opioid epidemic, address racial inequities in health outcomes, assess bioterrorism threats, and promote animal protections. “I think all of us need to step up on Health + Hospitals,” said Levine. “It is a crisis and it ultimately could affect every hospital in the city and effect the health of New Yorkers in profound ways and it’s gotta be a higher priority for all of us in this term.”

As Levine noted, perhaps the most significant area of oversight for the health committee has now largely fallen to the newly created Committee on Hospitals, under Council Member Rivera. “Health + Hospitals, it can’t be overstated how important it is to the fabric of the city,” said NYIC’s Calhoon. The system -- comprised of 11 hospitals, six neighborhood health centers, five nursing facilities and more than 60 community and school-based health centers -- mostly treats patients on Medicaid or who are uninsured, including many undocumented immigrants.

In fiscal year 2017, the system treated more than 1.1 million patients according to the Mayor’s Management Report, of which nearly 415,000 were uninsured. But the system faces a projected budget gap of $1.8 billion by 2020. In the current fiscal year ending June 30, the de Blasio administration expects to spend $897 million on the system, of which $784 million will come from the city’s coffers and the rest from state and federal funds. Those costs are only expected to grow over the next few yearsn. Johnson, Levine, Rivera, and other Council members, including new finance chair Danny Dromm, will now lead budget negotiations with the administration.

While the de Blasio administration has put in place a plan to reinvigorate the municipal hospital system, any progress that has been made is threatened by federal funding cuts. The city, and state, have long braced for reductions in Disproportionate Share Hospital payments from the federal government, which help reimburse hospitals for providing healthcare to low-income and uninsured patients. The DSH cuts went into effect in October last year, further exacerbating a trend of decreasing investment from the federal government that city officials have repeatedly cited.

First Deputy Mayor Dean Fuleihan, at a forum hosted by Citizens Budget Commission on Wednesday, said those cuts amounted to about $300 million in lost funding, placing “an additional and unnecessary strain on our hospitals.” And he warned of the larger implications of the federal budget. “[E]very major proposal that’s come out of either the [House of Representative] or the president has had dramatically huge cuts to New York City,” he said. “We’re going to have to balance all of this and be very careful how we proceed.”

At the same time, Mayor de Blasio has repeatedly promised that the city will not shut down any municipal hospitals. “The hospital facilities are going to stay open. We’re also going to constantly look at how to use them better because the previous uses in many cases weren’t working and a lot of them were outmoded,” he said at an unrelated December 12 news conference. In that vein, the new president of Health & Hospitals, Dr. Mitchell Katz, who took over earlier this month, has said he will focus the hospital system more closely on primary care while implementing certain cost-saving and efficiency measures.

Rivera recognizes the responsibility handed to her. “This is probably the most important public system in the city,” she told Gotham Gazette at City Hall last week. Looking back at Johnson’s leadership of the health committee, she said, “I think he was doing as much as he could in trying to cover as many health topics and issues as there are. He passed some great legislation, he worked on policy, and he took some of those issues very personally, which I appreciate in terms of his openness.”  

Rivera agreed that the creation of her committee “does lend an urgency to the issue,” a point echoed by advocates.

In a statement on Tuesday, Rivera noted the numerous challenges that H+H faces, including “closing Health + Hospitals’ growing budget deficit and updating hospital facilities for modern usage, to increasing access and support to community-based clinics."

“We as advocates are really trying to change the narrative around the value of Health + Hospitals,” said Calhoon, “and think about it less in terms of a crisis and think about it more in terms of ‘how do we keep this tremendous resource we have and make it stronger?’” Although she did not fault anyone in particular, she said “it certainly would’ve been better to have that conversation happen early.”

Planned Parenthood’s Adams acknowledged that though Johnson had worked to ensure adequate oversight and accountability at public hospital facilities, that much remained to be done. “It’s really exciting to see this committee be formed and really dig into how to strengthen and support healthcare options and availability of health options to all New Yorkers, regardless of income or immigration status,” she said.

Beyond Health and Hospitals, however, Adams and Calhoon noted a number of policy areas where they hoped to see renewed energy from the Council. Both said the city needs to expand support for community health organizations through Access Health NYC.

Adams said the city needs to prioritize abortion access at H+H, expand free-of-cost contraceptive coverage, and improve sexual health education in city schools along with ensuring that school-based health centers have the resources to provide comprehensive care to students. “Given all the public attention to sexual assault and sexual harassment, and bullying of LGBT students, we’re in a moment where we need to really be examining our health education program and putting in place comprehensive K-12 sexuality education,” Adams said.

Calhoon stressed that all stakeholders need to work to provide better care to uninsured New Yorkers, particularly ensuring quality behavioral and mental health services for immigrants. “That is something that I think there is going to be a really important role for both the Council and the administration, and I do think all entities -- advocates, the Council, the administration -- are gonna have to work together and collaborate to figure out what’s going to happen,” she said, “because we’re obviously in a moment of crisis in terms of the impact that changes at the federal level, the impact its having on immigrant communities.”

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by Samar Khurshid, senior reporter, Gotham Gazette
     

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Johnson Hands Over Council Health Portfolio, Including Hospital Crisis, to New Committee Chairs Wed, 24 Jan 2018 05:00:00 +0000
Amid Health Care Funding Fights, Cuomo Explores Special Session https://www.gothamgazette.com/state/7244-amid-health-care-funding-feud-cuomo-explores-special-session https://www.gothamgazette.com/state/7244-amid-health-care-funding-feud-cuomo-explores-special-session andrew cuomo

Gov. Cuomo with top health and budget aides (photo: Kevin P. Coughlin/Governor's Office)


Governor Andrew Cuomo has been floating the idea of a special legislative session to address federal cuts to the state’s health care programs, as well as other concerns that have developed, since the state budget was agreed to in April.

In that budget, Cuomo pushed to include and won a provision granting him nearly unilateral power to adjust the state’s financial plan mid-year in the event of at least $800 million in federal cuts to the state. In April, the governor said the provision would ensure that “we do not overcommit ourselves financially” and indicated it allowed him to sign off on a budget that did not otherwise account for likely federal cuts. But, it appears as if Cuomo may call lawmakers back to Albany -- likely with agreement from the legislative majorities to an agenda -- regardless of whether the threshold has been met.

When the state Legislature finished its legislative year in June with a brief special session to pass mayoral control of schools as well as several smaller measures, such as $55 million in state aid for businesses and homeowners impacted by flooding around Lake Ontario, unknowns surrounding President Donald Trump’s promise to “repeal and replace Obamacare” loomed large.

As chatter of a special session to address two lapsed federally subsidized health care programs escalated this week, so did a feud between Cuomo’s administration and that of New York City Mayor Bill de Blasio over $380 million that was earmarked to reimburse New York City Health + Hospitals, the city’s public hospital network, for expenses incurred treating uninsured and indigent patients over the last two years.

In recent weeks, Cuomo has sounded the alarm over four essential funding streams to New York health care systems that are being threatened by Trump and a Republican-led Congress. While the federal Graham-Cassidy bill -- a replacement to the Affordable Care Act that would have cost New York $16.9 billion by 2025, according to projections -- was defeated, and parts of Trump’s sweeping tax plan that target blue states are on shaky ground, the federal government failed to renew the Disproportionate Share Hospitals funds, known as D.S.H., by October 1, creating a potential $2.6 billion shortfall that is expected to disproportionately hit New York City’s public hospital system over the next year and a half.

If they remain in effect, the cuts will place a $330,000 burden on Health + Hospitals for federal fiscal year 2018, but the city says the state is also unlawfully holding $380 million in federal funds owed to city hospitals for federal fiscal year 2017, which just ended, for services already provided.

This federal funding, which passes through the state, is allocated for municipal and state-run hospitals that treat high volumes of uninsured and indigent patients.

While it is unclear whether the cut would justify a budget adjustment by the executive branch given the April budget provision, Cuomo appears to be courting lawmakers to return for a special session that could address D.S.H. and other looming health care deficits.

Also lapsing earlier this month is the federal Child Health Insurance Plan (CHIP), which subsidizes New York’s Child Health Plus plan, putting New York in a $1.1 billion hole and potentially jeopardizing the health coverage of 330,000 lower-income New York children, according to Cuomo’s office, though it seems likely a federal deal over the children’s health program may soon be reached. Still, the state has been placed in a precarious position.

In a letter sent Wednesday to Eric Hargan, acting secretary of the U.S. Department of Health and Human Services, New York State Health Commissioner Howard Zucker warned that New York will not be able to continue the current Child Health Plus program if Congress fails to renew $1 billion in federal funding, and he said that Governor Andrew M. Cuomo will “have no choice but to call a special session of the Legislature.”

On Tuesday, Cuomo had dangled the special session idea before 13 upstate lawmakers, and in reality a much wider audience, suggesting in a letter that an extraordinary legislative session could also be used to amplify and speed up relief funding for Lake Ontario flood victims.

“I would support a special session of the legislature to return and appropriate an additional $35 million for this program to fund all eligible applicants in a time frame that recognizes the urgency of the situation,” Cuomo wrote. “There are other pending issues that could also be addressed at a special session, including the financial hardship the State will face from potential federal cutbacks.”

In addition to the 11 public hospitals in New York City’s Health + Hospitals system, the D.S.H. cuts directly impact the state-run SUNY Upstate Medical Center in Syracuse and SUNY Downstate hospitals in Brooklyn, Westchester County Medical Center, Nassau University Medical Center and Erie County Medical Center.

None of these facilities will receive payments until adjustments are made, according to Cuomo’s office.

The state has retained an outside consultant, KPMG, to figure out how to help health care facilities manage the cuts and Cuomo has repeatedly suggested that the Legislature may be forced to reconvene Congress signals that the money will not be restored by December 31. In a press conference on the topic last Tuesday, the governor suggested that local governments step up to offset some of the cuts.

“Nassau needs to help their public hospitals, New York City -- with a $4 billion surplus -- needs to help H+H, and SUNY will need to help Downstate and Upstate hospitals,” he said.

The cuts and Cuomo’s approach to dealing with them have ignited another episode in the feud between the governor and de Blasio and on Friday, the de Blasio administration announced its intention to sue New York State for D.S.H funds which administration officials say were expected by the city’s cash-strapped public hospital system for the federal fiscal year that ended on September 30.

City officials say they had budgeted with the expectation that $380 million would come through and Health + Hospitals Interim President and CEO Stan Brezenoff revealed that that the hospital system had begun to cut back on hiring to account for the deficit and was prepared to take other undesirable and risky measures.

“Our ability to deliver on our mission also relies on all levels of government. Unfortunately, the State is showing a shocking disregard for our mission and appears to have confirmed in public statements that they will not be releasing the $380 million Disproportionate Share Hospitals (DSH) funds that we need and deserve for serving more than one million Medicaid, uninsured and immigrant New Yorkers who relied on our care last fiscal year,” Brezenoff wrote in a letter to staff members last week.

As of Tuesday night, a spokesperson for the mayor’s office said the lawsuit would be filed “in state court,” but could say when it would be filed, or who would be named in the suit. De Blasio himself has said that the state’s withholding of past D.S.H payments designated for H+H, "is not normal and there is no excuse for it.”

Cuomo’s administration maintains that it is withholding its final payment to New York City’s public hospitals for the 2017 cycle in September because it is still unclear whether the federal government will renew the D.S.H. program.

“There’s no way to fund the public hospitals with a $1.1 billion cut unless it is rolled back,” the governor said during a press briefing last week. “In the meantime, we have made no D.S.H. payments to any public hospitals since October 1, which is when the law went into effect. You can’t distribute funding until you know how much you have to distribute.”

Cuomo officials say city hospitals should have anticipated the cut, noting that the program, which is associated with the Affordable Care Act, was always intended to be phased out as more New Yorkers became insured.

“The federal cuts to DSH have been pending for seven years and we are sure that all responsible CEOs of the state’s public hospitals have been accounting for these potential shortfalls in that time,” said Jason Helgerson, New York State Medicaid Director, in a statement. “The suggestion that the state is somehow in a position to reverse federal cuts is willful political ignorance and a distortion of reality -- only the federal government can possibly restore cuts they’ve enacted. Save for the federal government restoring these funds, there is no way the remaining DSH dollars can reimburse all hospitals at 100 percent.”

Cuomo’s office says that it has been in contact with city hospital officials and shared a letter Helgerson sent Brezenoff on September 29, referencing a meeting of healthcare providers to discuss the potentially imminent demise of D.S.H.

“While we implored Congress to act, as the October 1 deadline approaches, it is clear they are failing to do so,” the state Medicaid director wrote. “The Governor convened health care providers on September 19 to discuss the possibility of these cuts and held a press conference with the group outlining how harmful they will be.”

City officials claim that they have been singled out, and that all the state-run public hospitals have received their payments for the past fiscal year.

Regarding the potential lawsuit from New York City, Cuomo spokesperson Dani Lever called the threat “political theatre.”

“A more productive action would be to sue the federal government since they are making these devastating cuts, or if it actually cared about patient care, to use its funds to improve the hospital network that it owns,” said Lever.

One strategy -- requiring a legislative fix enacted through a special session -- would be to disperse the initial $380 million burden across hospitals throughout the state, most of which do not treat a large number of uninsured patients, state budget director Robert Mujica said in an interview with NY1 last week.

“The way the federal law interacts with the state law presently, is the first year of the cuts really impacts H+H first, under the law,” said Mujica. “So does that mean trying spreading the pain across all of the hospitals? That’s something we really have to look at. But always, redistributing is going to be very challenging. We hope it doesn’t come to that. We hope that the feds restore restore the cuts.”

U.S. Senate Democratic Leader Chuck Schumer of New York, who told State of Politics he’s been leading the charge to restore the hospital funding, described the battle in Congress as “neck-and-neck.”

The expiration of CHIP appears less dire; while the funding ended on September 30, states will not run out of the money for several months, and protecting children’s health is an issue that has bipartisan appeal. Schumer, who has been pushing to attach the renewal of CHIP funding to an Obamacare fix intended to stabilize markets and lower premiums, said he is working with his Republican colleagues to find a way to pay for the program.

About one-third of patients at the city’s public hospitals are uninsured and the network currently receives the largest D.S.H share. However, divvied up across state health care institutions, the $380 million burden would only account for less 1 percent of all hospital revenue, according to Bill Hammond, director of health policy at the Empire Center for Public Policy, a think tank.

"The lost money, if you look at just the federal losses, it’s about $330 million and that grows to $500 million in the second year, so it grows more and more every year. Spread across all the hospitals it would not be such a big deal, but right now it’s concentrated among 11 H+H hospitals, which is a problem,” Hammond said.

The ongoing federal health care crisis has also breathed new life into the debate over whether New York State would be well-served by a single-payer healthcare system, which Cuomo recently signalled tepid support for in an interview with WNYC radio’s Brian Lehrer.

A state-level universal health care bill, which guarantees health coverage to all New Yorkers regardless of ability to pay or immigration status, has repeatedly passed the Democratically-controlled Assembly, but has been defeated in the Republican-led state Senate by a sliver of a margin.

Assemblymember Dick Gottfried of Manhattan, who sponsors the bill, acknowledged that even if a version of his legislation was enacted tomorrow, it would take several years to fully implement, but said it warranted a second look given the uncertainty coming from Washington.

"It would not provide immediate relief, but the cuts that are likely to come from Washington will not come all at once, they will like snowball over the next couple of years," said Gottfried. “If we recognize health care as a right and provide health care coverage to every single New Yorker…Under a single-payer system, safety net hospitals and public hospitals would make out much better than they do today.”

Hospitals would save millions of dollars in administrative costs and the state would be in a much better position to bargain with drug companies, as it would represent 20 million patients, Gottfried added.

“Those savings are about the only way, realistically, that we can fill the gaps from whatever federal cuts are coming, without significantly damaging other programs or raising taxes,” he said. Critics, including Hammond, have said that Gottfried’s single-payer plan would be far costlier to the state that the Assembly member suggests.

When reached for comment on the health care cuts and whether the Assembly is prepared to return to Albany to deal with the situation, Mike Whyland, spokesperson for Assembly Speaker Carl Heastie, said, “We care deeply about these hospitals and are closely monitoring it.”

A spokesperson for Senate Majority Leader John Flanagan did not respond to a request for comment. 

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by Rachel Silberstein, State government reporter, Gotham Gazette
     

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Amid Health Care Funding Fights, Cuomo Explores Special Session Wed, 11 Oct 2017 04:00:00 +0000
On Election Day, Federal Policy & Funding Stakes High for New York City https://www.gothamgazette.com/state/6612-on-election-day-federal-policy-funding-stakes-high-for-new-york-city https://www.gothamgazette.com/state/6612-on-election-day-federal-policy-funding-stakes-high-for-new-york-city clinton de blasio inner circle

Clinton & de Blasio (photo: Michael Appleton/Mayor's Office)


Both Hillary Clinton and Donald Trump will be in New York City on election night, and one of them will be the next President of the United States. Through the results of the presidential election, which comes down to one native New Yorker and one New York transplant, and with the congressional elections on the ballot, there’s a great deal at stake for New York City.

According to the fiscal year 2017 budget summary released by the mayor’s office in April, in 1978 almost 23 percent of New York City’s budget came from the federal government. During the late 1980s, that number was at roughly 11 percent. In 2015, the federal government provided slightly under 9 percent of the city’s total budget. Despite spikes in funding during catastrophic times like the September 11, 2001 terrorist attacks or the Great Recession, decline in federal investment in New York City is nothing new, nor is it purely partisan.

While cuts have been made to federal funding for infrastructure, housing, health care, and other important city programs over the years, New York felt a particular sting when President Barack Obama announced in February a significant cut in anti-terrorism funding in his 2017 budget. Mayor Bill de Blasio, frustrated, traveled to Washington to testify in front of Congress to restore the full amount of federal money granted. In May of this year, Congress passed a Homeland Security bill, which included the original $600 million for the Urban Area Security Initiative, more than the $330 million proposed by the White House.

Federal aid in the form of grants helps fund community development, social service, and education programs -- but who is in the White House and party control in Congress have a great deal of influence over amount of such funding. New York City’s current fiscal year 2017 budget is about $82 billion, less than one-tenth of which comes through federal funds. In 2013, New York City  taxpayers sent $57.3 billion in federal income tax to Washington, according to the Observer, which reported in March on  federal disinvestment in New York.

According to the city’s Independent Budget Office, the top three city agencies that received the most federal aid from 2011-2015 were the Department of Education ($8.4 billion), Human Resources Administration ($7.7 billion) and the Administration for Children’s Services ($6.4 billion).

The fiscal needs of big cities like New York sometimes get short-changed in D.C., explained Jonathan Bowles, executive director of the Center for an Urban Future, an independent policy group focused on improving New York City’s economy.

“Because it’s such a big city, because it’s perceived as a liberal city,” Bowles said in an interview. “For whatever reason, it’s struggled to get its fair share of funding.”

Some also point to cities, especially New York, being seen as economic engines not in need of federal support -- saying that leaders in Washington see New York City more as a booster of federal coffers through tax revenue.

Bowles said the next presidential administration has a real opportunity to include urban areas in new budget proposals, after decades of ignoring them.

“Politicians in Washington really didn’t want to talk about urban areas, and they were perceived as the problem,” he said. “But whether it’s public housing, transit funding or so many other things, New York’s needs are clearly not being taken care of by the federal government.”

Over the past year, Mayor de Blasio has campaigned for Hillary Clinton, his fellow Democrat, on numerous occasions and in a variety of states (this, after he delayed his endorsement of Clinton). De Blasio dedicated his time to campaigning for Clinton instead of stumping for Democratic candidates in key New York State Senate races, where control of that chamber will be decided. In 2014, de Blasio and his allies attempted to swing seats to ensure a Democratic takeover of the last Republican stronghold in New York statewide government. The effort failed and “Team de Blasio” is under investigation for some of the fundraising tactics it used.
De Blasio said he is focusing on the federal election this cycle, and in part doing so due to the large stakes at play for New York.

“[This election] will decide the presidency, it will decide the future of the Senate, maybe even the House, but it’s also going to reset the American political dialogue,” de Blasio said at a press conference when Gotham Gazette asked why he was choosing to be involved in the presidential race but not state Senate races. Key pieces of de Blasio’s agenda have been limited or blocked by Senate Republicans in Albany.

“I think it’s some of the time that’s going to be best spent in the next few weeks because if it helps us change the trajectory of the country and the federal government, that’s going to help New York City in a very big and very material way,” de Blasio said of campaigning for Clinton. At other times, de Blasio has acknowledged that he is staying away from the state Senate races because of the “atmosphere” of investigations into his team’s 2014 tactics.

Most federal policies impact New York. According to E.J. McMahon, research director at the Empire Center for Public Policy, the outcome of congressional races may affect New Yorkers more so than who becomes the country’s next president.

“Congress controls the purse strings,” McMahon said by email. “Congress basically wrote the two most important pieces of Obama-era legislation, the [Affordable Care Act] and stimulus. The makeup of Congress will ultimately determine whether there is any significant change in tax or infrastructure policy, both of which have major implications for New York in particular.”

As the city’s economic relationship with Washington continues to decline, city officials seek a presidential administration that would resurrect the stronger partnership it once had. Policy and funding are the two key areas, and they are usually linked. Federal policy on immigration, education, health care, and other key areas greatly affect what New York City does -- and there is a great deal at stake in the presidential race in terms of different policy visions. The same goes for those who might control each house of Congress.

In terms of additional funds from Washington, the city is looking for increased aid for bridges, tunnels, and roads; money toward jobs programs and housing vouchers; and more.

While it is not completely clear how a Clinton or a Trump presidency would differ for New York City -- and control of Congress may come into play significantly -- the two major party candidates have outlined different visions on the overall role of the federal government, as well as on trade, immigration, the minimum wage and a variety of other policies.

Dr. Bruce Berg, a political science professor at Fordham University, said there are three levels on which to assess the candidates’ plans and their potential impact on New York. These include each campaigns’ intended agenda, which party controls the House of Representatives and the Senate, and the candidate’s relationship with the mayor. Berg says the issues most at stake for New Yorkers in this election include infrastructure investment, immigration reform, healthcare, and public housing.

New York City’s Aging Infrastructure
Prioritizing investment in the nation’s infrastructure may be the biggest area of agreement for Clinton and Trump. The aging roads, bridges, and water systems of the United States are deteriorating; government data show in 2014, 32 percent of roads were rated “poor,” up from 16 percent in 2005.

During a recent U.S. Conference of Mayors event in Manhattan, Mayor de Blasio said 160 bridges in New York City were built over 100 or more years ago. The average lifespan for a bridge remains about 40 years. Despite being the tenth largest economy in the world, attracting more and more residents and tourists to the city each year, New York City’s aging infrastructure needs a serious upgrade, according to the mayor, as well as many others. And it’s not just New York, de Blasio explained at the USCM event, but cities nationwide that are losing funding for infrastructure projects.

“In the biggest cities in the country, there are more structurally deficient bridges than there are McDonald’s in the entire country,” de Blasio said. “And if you think about something that unites us all, those golden arches...and then think of a lot of bridges tragically on the verge of falling down.”

Although both Clinton and Trump agree the nation’s infrastructure is crumbling, their plans to pay for related projects differ dramatically. If Hillary Clinton wins the election, her first-100-days plan includes investing $275 billion to rebuild the country’s infrastructure. This includes investing in roads and bridges, but also in water systems, increasing wide-accessibility to internet, and improving the rate of completing these projects.

Former Mayor of Philadelphia and Governor of Pennsylvania, Ed Rendell, a Clinton surrogate, said Clinton’s investment will be over five years and paid for through business tax reforms, including  a one-time tax for corporations bringing profits held overseas back to the U.S. She hopes to allocate $25 billion over five years to a national infrastructure bank, which would fund projects that become held up due to political inertia in Congress. According to Rendell, Clinton also hopes to reauthorize the Build America Bonds program, which would finance infrastructure projects entirely from the federal government.

“It will bring jobs, growth, improve infrastructure, improve public safety, improve our quality of live and make us more economically competitive,” Governor Rendell said about Clinton’s plan at the Conference of Mayors event.

Calling it “America’s Infrastructure First,” Trump also plans to invest heavily in infrastructure. His plan includes spending $1 trillion over a decade. He says he will pay for this plan not by raising taxes, but instead through private companies by offering a tax credit.  While one-sixth of a project’s cost would be funded privately, government-issued bonds would cover the rest

Trump’s proposal, the details of which were released two weeks before the election, would take advantage of low interest rates and encourage construction companies to spend on road and bridge projects that have revenue attached. These include toll roads, toll bridges and airports. This way, according to Trump and his advisors, the plan will pay for itself.

In June, Trump vowed to create the “greatest infrastructure” in the world with his plan. “When I see the crumbling roads and bridges, or the dilapidated airports or the factories moving overseas to Mexico, or to other countries for that matter, I know these problems can all be fixed, but not by Hillary Clinton,” he said. “Only by me.” 

City of Immigrants
Approximately 37 percent of New York City’s total population is foreign-born. Making up roughly 43 percent of the city’s total workforce, immigrants significantly contribute to the city’s economy. The immigration policies under the next President and Congress will greatly impact the city’s immigrants, half a million of whom are undocumented, as well as prospective immigrants, both documented and undocumented.

Alisa Wellek, the executive director of the Immigration Defense Project, a nonprofit, said New York has long been considered a target for deportation and detention of immigrants by Immigration and Customs Enforcement (ICE), a federal agency.

“After 9/11 in New York, the enforcement apparatus really ramped up those efforts in the city and nationally,” Wellek said. “It’s really an unprecedented scale of mass deportations which affects many New Yorkers who are noncitizens and those who are a part of families that are a mix of citizens and noncitizens.”  

Within her first 100 days as President, Clinton plans to create a pathway to full citizenship, defend President Obama’s executive actions of DACA and DAPA, which extended the amount of time immigrant children and their parents can stay in the country, access to healthcare for all immigrants, and end corporation-owned, private immigration detention centers. During the final presidential debate, Clinton discussed how she would enforce immigration laws.

“I don’t want to rip families apart,” Clinton said. “I don’t want to be sending parents away from children. I don’t want to see the deportation force that Donald has talked about in action in our country,” she said.

Clinton also said she wants to bring undocumented immigrants “out from the shadows” and into the economy in order to protect them from “exploitative” employers and wage theft.

Since the beginning of his campaign, Trump’s top issue has been illegal immigration. His plans include building a wall at the country’s southern border, paid for by Mexico, ending sanctuary cities, and creating a “total and complete shut down of Muslims” from entering the country. He has spoken  unclearly about what a “shut down” actually means, referring to “extreme vetting” of potential migrants and refugees, and saying the ban would not be on Muslims, per se, but on people leaving certain areas of the world where ISIS is most active.

In New York City, the Muslim population continues to grow and estimates range from 600,000 to 1 million individuals. Trump’s plan to create a database of Muslims living in the United States and ban them from entering the U.S. could potentially have significant social and economic effects, though the specifics remain unclear. It is also not clear whether these measures would enhance national security.

During a visit to Phoenix, Arizona this summer, Trump discussed his idea of immigration reform: “We also have to be honest about the fact that not everyone who seeks to join our country will be able to successfully assimilate,” Trump said. “It is our right as a sovereign nation to choose immigrants that we think are the likeliest to thrive and flourish here.”

Wellek said she hopes the next administration will overhaul the immigration system by repealing the 1996 immigration laws, ending mandatory deportation and detention and aligning reforms made in the criminal justice system with the immigration system. According to Wellek, New York has recognized the role immigrants play in the city.

“One thing New York City has done, that’s been very progressive, has been narrowing the collaboration between local police and immigration enforcement,” she said. “I think one big act for the next administration would be to end that collaboration fully.” 

What Wellek is referring to is a decision by Mayor de Blasio and the City Council to cooperate less with ICE. Indeed, many elected officials from the city, which is dominated by Democrats, have spoken out against Trump’s immigration agenda and said that it would be especially harmful to New York.

New York Health Care
Since it’s inception, President Obama’s Affordable Care Act (ACA) has helped decrease the number of New Yorkers lacking health insurance by 2.5 percent, from 12.6 to 10.1 percent uninsured. Despite data showing this success, uninsured patients still makeup about 70 percent of stays at public New York City hospitals, Health + Hospitals, which is very costly to the city. Some of these patients are undocumented immigrants who were left out of the ACA, but still use public hospitals. This, along with soaring costs and declining revenue, has New York City’s public hospitals in financial crisis. Health + Hospitals is projected to have an operating deficit of $1.8 billion by 2020. The candidates’ two very different healthcare reform plans have the potential to affect the future of healthcare in New York.

Like most Republicans, Donald Trump disparages the ACA, or Obamacare as it is often known, and Trump plans to eliminate and replace the ACA on day one of office, he says. He called Obamacare “a big fat, horrible lie” and a “catastrophe” -- criticism that has received some boost given recent news about rate hikes under ACA exchanges.

Trump has not explained exactly what he would replace it with, but promises something “far better” and cheaper, and has said the country must eliminate “the lines” that restrict how insurers can sell health insurance state by state.

Trump wants to transform Medicaid, the federal healthcare program for the poor, into state block grants. 

If elected, Hillary Clinton plans to preserve the ACA and attempt to expand coverage for those that do not currently qualify for health insurance under the law. This means expanding Medicaid in every state, lowering health care premiums, and providing citizens a public-option insurance plan, which Clinton hopes to push states to offer their residents. A public option could insure over 400,000 people in New York who were left out of the ACA. If Republicans continue to control the House of Representatives, this expansion of the law has little chance of passing Congress.

Clinton also said she wants to double the funding for primary care services at community health centers over the next ten years, which would increase access to health care for many underserved, low-income, and uninsured New Yorkers. According to her campaign website, she also wants to “expand access to affordable health care to families regardless of immigration status by allowing families to buy health insurance on the health Exchanges regardless of their immigration status” - a move that could have drastic effects in New York City given the financial issues at Health + Hospitals.

Funding for NYCHA
As the largest public housing authority in the country, the New York City Housing Authority (NYCHA) currently serves about 600,000 New Yorkers, including Section 8 voucher holders. Based on the July 2015 Census, 4.7 percent of the city’s population lives in public housing. No new public housing buildings are being constructed and New York is one of few places in the country that has committed to keeping its public housing stock. At the same time, federal funding for NYCHA has shrunk considerably, with the federal government moving more toward housing vouchers, which are used at some NYCHA facilities. 

The de Blasio administration has invested considerable additional funds into NYCHA, but the authority is also in serious financial trouble. The mayor launched a 10-year plan titled NextGeneration NYCHA, which includes a variety of initiatives, one of which is a program that leases underutilized land to developers to build both affordable and market-rate housing.

This plan hopes to combat the decline in federal funds dedicated to public housing, especially after NYCHA’s expected deficit jumped from $25 million to $60 million in 2016. NYCHA has struggled to meet basic maintenance and operation costs, though it has instituted several new reforms to improve the situation. Bowles, of Center for an Urban Future, said that Congress has not increased funding for housing projects in New York and other major cities for decades.

“Public housing has been starved at the federal level for years,” Bowles said. “It’s been decades since we’ve seen a real appetite in Washington to support the public housing infrastructure.”

Public housing is one piece of the overall affordable housing picture. Despite being a major issue for most cities nationwide, tackling affordable housing and the cycle of poverty never became a major focus during this presidential election. In September, Clinton wrote an op-ed in the New York Times addressing housing.

“If we want to get serious about poverty, we also need a national commitment to create more affordable housing,” Clinton wrote. “Too many people are putting off saving for their children or retirement just to keep a roof over their families’ heads.”

Clinton calls for expanding Low Income Housing Tax Credits in areas of high-cost to create more affordable housing in viable neighborhoods.

Trump, a real-estate mogul, has released no specific plan to address affordable housing and nothing on his campaign website mentions it. However, the Republican Party’s platform calls for “responsible homeownership” and giving more control over zoning procedures to local authorities, rather than from the federal government.

Congress, the President and Mayor de Blasio
The relationship between the Mayor of New York City and the next president is important, as is the next president’s commitment to urban issues. Additionally, the makeup of Congress and the major funding decisions regarding aid sent to cities remains of utmost importance. If Democrats are able to retake control of the Senate, New York Senator Charles Schumer is likely to be Majority Leader, which could be a boon for New York.

Despite a long relationship with Clinton, including managing her 2000 campaign for U.S. Senate, de Blasio waited months after Clinton announced her presidential candidacy to endorse her, wanting to push her more to the left on issues. In recently hacked emails, the Clinton campaign expressed annoyance with de Blasio, jokingly calling him a “terrorist.” Donald Trump has called de Blasio “incompetent” and the “single worst mayor in the history of New York City,” but has praised the mayor after he was elected.

In part due to obstruction by congressional Republicans who want to see less government, President Obama has issued over 250 executive actions to get around legislative gridlock. Bruce Berg of Fordham University says if Clinton wins the presidency, she may face similar barriers to getting laws passed in Congress, which would affect federal aid granted to New York City and elsewhere. 

“I think the most likely scenario, looking at the election right now, is a Clinton victory, where she comes in as a rather crippled president and we get very little major initiative in the next four years,” Berg said. “I think what that means is that routine federal aid to New York continues to decline slowly as it has for the last several decades.”

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by Devin Gannon for Gotham Gazette

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On Election Day, Federal Policy & Funding Stakes High for New York City Sun, 06 Nov 2016 04:00:00 +0000