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Internet resources for what you need to know about NYC Health
Five Favorite Sites For Beginners

The Topic
"Health" refers to the health issues facing the city, touching on everything from the mayor to Medicaid to managed care to mosquitoes.
The Context
New York City is one of the biggest public health challenges in the world. With 7 million residents--over 1 million of whom are uninsured--the city has the largest number of HIV cases and the largest number of intravenous drug users in the U.S. Efforts to contain a tuberculosis outbreak that threatened the city in the 1990's have been a major success--between 1992 and 1998, the deadly multi-drug resistant cases of TB declined by over 90 percent.

New York City has 20 public hospitals which served 1.5 million people in 1998 alone. Run by New York City's public Health and Hospitals Corporation, the hospital system now has a surplus of $21 million, following years of deficits and cutbacks.

The Reporter
Maia Szalavitz is author, with Dr. Joseph Volpicelli, of "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems." She writes frequently on health, science and public policy for the New York Times, New York Magazine, the Village Voice, and other publications.

by Maia Szalavitz

Mandatory Medicaid Managed Health Care

(Sept '01) New York City is in the middle of a transition aimed at creating the country's largest mandatory Medicaid managed care program -- and few can say whether the result will be real improvements or simply a different set of problems than those that plague the fee-for-service system.

This system will ultimately serve more than one million people and will intimately affect the fates of the city's doctors and hospitals. The next mayor will have to look carefully at the effects of increased use of managed care and determine whether the complex system is working in practice the way it was supposed to in theory. If not, he will have to negotiate with the governor and the federal government to change direction.

Most experts thought that New York would be far closer to relying completely on managed care to treat all but the sickest populations of poor people by now. Instead, delays caused by the federal government, problems with enrollment fraud and other difficulties have meant that only 20 percenr of the Medicaid population has either voluntarily or through mandate begun to participate in managed health plans in the city.

The nature of the health plans providing care in the program has also shifted completely from what was originally envisioned. According to David Sandman, Senior Program Officer for the Commonwealth Fund who has been following the transition, "there has been virtually a complete pull-out," of for-profit HMO's and other commercial plans.

As managed care in the general population has become less profitable, it has become even less likely that companies will make money trying to serve poor populations. "Across the country," says Jim Verdier, Senior Fellow at Mathematica Policy Research, who studies Medicaid and state health policies, "commercial providers now account for about half of managed care in Medicaid, and this is down from 60 to 65 percent." He notes that the same pull-out is being seen in Medicare, the program for the elderly.

In New York, the primary managed care providers are now hospitals and clinics themselves -- which means that there might be less incentive to deny needed care to save money, but also therefore less likelihood of cutting costs.

"The low hanging fruit has been picked," says Verdier, "Or if it hasn't been picked, there are political and market reasons not to pick it. There is not a lot of [money] to squeeze out through managed care [now.]"

Both Sandman and Verdier agree that increased use of managed care for Medicaid patients is not likely to save money. Verdier believes that in the short run, good managed care may even cause costs to rise as people who have previously not had access to appropriate care for all their problems begin to get help.

What managed care can offer if done well, say the experts, is co-ordination of care, accountability for outcomes and a reduction in the use of emergency rooms as a source of primary health care.

Sandman adds, "Managed care can offer policy makers greater predictability," which means that they can budget for health expenses properly. "New York's expenditures on Medicaid are vast," he says. "It's a matter of using that money efficiently."

Continuing challenges for the system include "churning," which occurs as people move in and out of the welfare system. "It's hard to co-ordinate care when plans lose more than half their participants in 12 months," says Sandman, using the example of someone with asthma who might wind up having to see a completely different set of doctors who are not familiar with her history after changing plans.

While Mayor Rudy Giuliani has worked to correct the problem of people losing health benefits when they lose welfare eligibility, the numbers suggest that many people still either believe that their health benefits end when their welfare checks do -- or are somehow falling through the cracks by other means.

Another problem is that when people move from welfare to low income jobs and become eligible for Family Health Plus and Child Health Plus as opposed to Medicaid, different provider networks serve these programs so they might again have to change doctors. "There needs to be a way to ensure that the same plans participate in all three programs," says Sandman.

There are some good signs, however. While there is still a serious shortage of primary care physicians for low income people, a study by the Community Service Society found that there has been some improvement.

And, where people have been moved into mandatory Medicaid managed care, the percent of people who didn't make a choice and were just assigned to a program by the system is, according to Sandman, "roughly 20 to 25 percent." Since some experts had predicted that this number would be 40 to 50 percent -- and since high numbers of people avoiding making a health care plan choice means that the system isn't properly reaching them, the lower numbers are also a positive sign.

Unfortunately, says Sandman, because only 20 percent of Medicaid patients have moved to managed care, "it is difficult to even make a mid-course assessment," of the success of the program.

Given this, and given that the roll-out is continuing to proceed slowly because it requires additional permission from the federal government to apply to each geographical area covered, the new mayor should carefully consider the options. If managed care isn't saving money, is it worth it to proceed with mandating it? What should the goals for managed care be? What systems can best work for patients and keep hospitals and clinics serving them?

All of these questions must be considered if access and quality of health care for the poor (and the elderly in Medicare) are to be improved.

Maia's Favorite Five Sites For Beginners:

  • New York City Department of Health - Includes health alerts (including West Nile info), information on restaurant sanitary conditions and information on various health-promotion programs.
  • New York State Department of Health - More health data for New Yorkers including information on how to sign up for Child Health Plus and Family Health Plus-- the insurance programs for those who are presently not covered by other plans.
  • Medscape - This site, aimed at doctors, allows you to search Medline, the database of medical journals, for free. Abstracts of most journal articles are available for free as well. Once you have some basic knowledge about a condition you are researching, you can look here to get a sense of what is going on in terms of study in the area. There is a companion consumer-focused site, CBSHealthWatch, which is linked.
  • American Cancer Society - Half of all Americans will face cancer at some point in their lives-- and the New York and Washington-based American Cancer Society web site provides a wealth of information for those dealing with the disease. Includes links to other major cancer sites and resources.
  • AIDS Information - A sort of "AIDS central" for New York city with links to major HIV/AIDS organizations and information sites.

Other Recommendations:

  • Quackwatch - Debunks medical scams and inflated claims made by "alternative" medical practitioners.
  • - A consumer health information site, affiliated with CNN.
  • Citizen Action - Healthcare is one of the primary focuses of this New York advocacy group. Includes information on New York's health plans for low income people lacking insurance.
  • Oncolink - An incredible research resource for cancer patients and others concerned about this disease.
  • National Alliance for the Mentally Ill - An organization of advocates for people with mental illness which includes information on treatment and support for various disorders like depression, bipolar disease and schizophrenia.
  • Insure Kids Now - Information on New York state's insurance program for poor kids and information on other state's policies, from the federal government and the governors' association.

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Gotham Gazette is published by Citizens Union Foundation and is made possible by support from the Robert Sterling Clark Foundation, the John S. and James L. Knight Foundation, the Altman Foundation,the Fund for the City of New York and donors to Citizens Union Foundation. Please consider supporting Citizens Union Foundation's public education programs. Critical early support to Gotham Gazette was provided by the Charles H. Revson Foundation, Rockefeller Brothers Fund and the Alfred P. Sloan Foundation.

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