As the legislative session came to its end in June -- the Capitol shaking with the chanting of protestors for and against same-sex marriage -- numerous pieces of controversial legislation also were settled and voted on. But when the emotional vote on gay marriage ended, Senate Majority Leader Dean Skelos called an end to the 2011 legislative session, leaving some lobbyists and lawmakers shocked.
Observers weren't surprised that the Senate failed to take action on controversial bills such as independent redistricting, but one piece of legislation remained that had been agreed to by the Assembly, governor and Senate -- legislation that would see the creation of a federally mandated health insurance exchange.
Under federal health care reform law, every state must set up a one or more health insurance exchanges to help provide heath coverage to residents who are not insured through their jobs. When the Senate left town without acting on the insurance exchange legislation that was passed by the Assembly, it missed the first deadline. Even though New York lacks a plan, Washington still provided the state with funding to set up an exchange.
Health care experts, though, question how long Washington will maintain its generosity. And they caution that, funding issues aside, the state needs to get to work on the very complicated task of laying the groundwork for its exchanges or risk being forced to accept a federal plan that may not be to its liking.
The legislature and governor reportedly agreed on a bill in June. While there were numerous versions of the bill, the one they concurred on was a slightly altered version of a bill put forward by Senate Republican health committee chair Sen. Kemp Hannon. S.5849, the New York Health Benefit Exchange Act, would create the exchange as a public benefit corporation with nine unpaid directors, seven of them gubernatorial appointees and two legislative. The bill left several technical issues unresolved such as how to finance certain benefits, but set an April 1, 2012 deadline to resolve them.
Some Republicans felt reluctant to go on record in support of "Obamacare." The decision to bring same-sex marriage to a vote was enough of a strain on some members that they refused to vote on the legislation -- despite the deal with Cuomo and the Assembly.
On a policy level, some members have distinct concerns about the effect a health care exchange will have on small business. Consumer groups want to maintain strict controls on what kind of plans can be offered, while small business groups want to make sure there is a wealth of options because of cost concerns.
Advocates of the legislation assumed that the Senate would return this summer or fall to approve labor contracts and vote on health care exchange legislation, but as the summer wore on more Republicans made it clear they felt no pressure to vote on the legislation.
Now it remains unclear what the Senate will do.
"The basic answer is I don't know," Hannon told the Gazette this week. A spokesman for Skelos said that there are no plans to return to Albany. "We do not currently have any plans to return," said the spokesman.
Hannon said that he thinks the agreed-on bill could be renegotiated and points out that he and his colleagues don't feel much pressure to move on the legislation when the federal government is sending the state money even though it missed the June 30 deadline to pass legislation.
In fact, New York has received three grants from the federal government specifically for the construction of an exchange: a $1 million grant for exchange planning to the Insurance Department, a $27,431,432 Early Innovator grant to the Health Department and a Level 1 Exchange Planning Grant worth $10,774,898.
And Hannon said that a great number of otherwise uninsured New Yorkers are, "already on Medicaid."
Elisabeth Benjamin, vice president of health initiatives for the Community Service Society, was fairly upbeat about the prospects of legislators to returning this fall to vote on the exchange legislation. But when told about Hannon's comments she seemed a bit exasperated.
"Applying for federal funding is not as simple as sitting down at your computer terminal one morning," she said. “You have to set up an agency, have to have a director, a plan, a staff before you apply for level 2."
Benjamin further explained that the agency would have to decide what kind of coverage it would offer, how it will offer the plans, if the plans will be standardized, what roles brokers would have and a whole other list of specifics.
Once the election year begins, the prospects of getting a bill through would grow dimmer. "If you think you can pass the bill in 2012 ... that is just insane," said Benjamin.
New York is supposed to have an exchange up and running and certified by the federal government by Jan. 1, 2013, or face intervention by federal authorities.
If it fails to set up its own exchange, Benjamin said, New York will leave itself at the mercy of the federal government. "The people who are so afraid of 'Obamacare' -- that is exactly what they will get if they don't get the exchange in place. The feds will come in and do what they want. They will set something up that doesn’t use our agencies and doesn’t have our consumer protections."
But New York is not alone in being behind schedule in setting up an exchange, and federal officials have acknowledged that. Fewer than a dozen states have implemented exchange laws, and the lawsuit against health care reform has kept some Republican states from acting.


Steve Larsen, deputy administrator and director of the Center for Consumer Information and Insurance Oversight which is an arm of the federal Centers For Medicare and Medicaid Services, announced rules in late July that would make the deadline flexible. The rules would allow states to have part of an exchange active by 2014 with the federal government filling in the what the state was not prepared to provide. States that missed the deadline all together could apply to create an exchange later on. The Center for Consumer Information and Insurance did not return calls for comment.


Despite possible changes at the federal level, Sen. Neil Breslin, the ranking Democrat on the Senate insurance committee, said he is concerned that, if New York does not act, it will miss out on funding. "Federal money is available on a first come first serve basis. There are two monies available -- to create an exchange and to sustain it," he said.
While New York has received phase 1 grants without meeting phase 1 requirements, Breslin does not think that will continue through phase 2. And if New York misses the deadline all together, Breslin said, "Then we don’t determine what we want to do, the federal government implements something and charges us for it. The insurance department is very concerned."
Benjamin agrees the state will lose money if the Senate does not act. "Yes, they are getting some money, but they can miss out on so much more. We could get enough money to run the entire exchange," she said. But for that to happen, she said, "We have to have a certified functional exchange by 2013 ... . You can't just pass something in 2012 -- there won't be enough time. This isn’t a simple thing."
So what could change things? What could get Senate Republicans back to Albany to vote on the agreed-upon exchange legislation?
The same thing that makes everything else happen in Albany these days: Gov. Andrew Cuomo.
"The governor has to be the ultimate advocate for New York to step up and have a functional health insurance exchange. The governor did a good job negotiating a three way bill, now he has to get them to pass it," says Benjamin.
Benjamin said she is certain legislators are well aware of the bill and the time constraints. "This is not off their radar. They are getting memorandums of support and letters in their mailboxes everyday. Unless they don't check their mail."
Cuomo has remained silent on the topic. His office did not respond to calls for comment. Some Democrats think Republicans are avoiding a return to Albany so as not to face pressure on independent redistricting and that the governor has decided the exchange is not a priority.
That could change if members of the Public Employee Federation vote to ratify their new contract. Then the legislature would likely have to return to approve the pact. Once the members are in Albany anyway, the Assembly could ask Cuomo why he is not pressing the Senate to vote on a bill that has already been agreed upon.
Hannon does not seem to be in any hurry. "It's not certain their will be a special session," he said. "The governor may like us, but I don't know if he wants us back that badly. This could be addressed next year. The important thing is we get the right system."
The area around 12th Street and Seventh Avenue in the heart of Greenwich Village is remarkably quite these days -- so quiet that Yetta Kurland, an activist, goes so far as to say that "it almost looks like a bomb went off."
The block was home to St. Vincent's Hospital Manhattan, which closed in April 2010 after years of financial troubles. St. Vincent's, which cared for victims of the Titanic, the AIDS epidemic and the 9/11 attacks, was New York City's last Catholic general hospital, and its absence has been felt throughout the community.
In addition, St. Vincent's was one of New York City's most prominent safety-net hospitals, serving mostly those either on Medicaid or Medicare or without insurance. It was also known as a refuge for the homeless. It has principally been these patients, then, who have been hit the hardest by St. Vincent's closing and by the shutting of other hospitals elsewhere in the city.
Regardless of income, most residents of the Lower West Side who used to go to St. Vincent's now end up either at Beth Israel or Bellevue on the East Side. Shortly after St. Vincent's closed, Timothy Lunsford, a survivor of two heart attacks and two bouts of cancer, experienced a medical emergency in which his blood pressure dropped to a dangerously low level.
"It took me 33 minutes to get from Canal Street and Varick to Beth Israel hospital," he said.
Both hospitals have had to adapt to a rapidly growing patient volume, which Lewis Goldfrank, Bellevue's chief of emergency medicine, has called "a significant disaster."
"Those 60,000 people [treated each year at St. Vincent's] now have to find another place to go, so the nearest emergency rooms are overwhelmed. … And it's not because the hospitals aren’t trying, but they're unable to cope with what is a disaster," said David Kaufman, a member of St. Vincent's medical staff for 30 years and a part of the Coalition for a New Village Hospital.
With no access to local care, overcrowded emergency rooms in neighboring hospitals, the loss of a medical safety net and longer waits, the health situation in Greenwich Village is a "crisis," according to Kurland, also a member of the coalition. To remedy the problem, the coalition wants to see nothing less than a full-service hospital at the former St. Vincent's site.
The plan reached by Rudin Management, a development firm, and North Shore-Long Island Jewish Health System does not align with that vision. (Disclosure: My father is a doctor at Lenox Hill Hospital, a member of the North Shore network). Instead, it would create 300 luxury apartments and townhouses on the eastern side of the medical campus and refurnish the historic O'Toole buildinginto a freestanding emergency department to be operated by North Shore.
The ability of the care center to serve the 385,000 New Yorkers living in the Lower West Side remains hotly contested. According to Terry Lynam, a spokesperson for North Shore, the care center will be able to treat 90 percent of patients. "[It] would be the same kind of emergency department you would see in most hospitals with the exception that it doesn't have inpatient beds," Lynam said.
The facility would provide around-the-clock diagnosis and treatment services. It should also be open to those on Medicare or Medicaid.
However, since it would not have the resources of a full-service hospital, including operating rooms and an intensive care unit, patients suffering from heart attack, stroke or major trauma would "need to be transferred elsewhere," Lynam said. She emphasized that agreements will be in place with local ambulance providers so they do not bring these patients to the care center in the first place.
Kaufman, however, argued that these restrictions will "create a life-threatening sense of confusion for patients and ambulance drivers."
If an emergency patient does enter the care center, the amount of time it would take to transfer him or her could prove significant, according to a recent study by the Journal of the American Medical Association. It found that it takes nine out of ten transferred heart attack victims more than 30 minutes to reach their second facility, above the recommended medical guidelines. These patients consequently suffer higher mortality rates.
Despite this proviso for emergency cases, Lynam said the care center "is returning health care to the Village" and "will save lives."
But coalition members remain unconvinced. Kaufman in particular worries that the care center will be unable to manage the large number of patients who used to enter St. Vincent’s doors.
"Can their comprehensive care center … treat 61,394 people a year?" Kaufman asked at a rally on April 30. "Can it house 19,388 patients sick enough to require inpatient care, can it deliver the lifesaving, critical care that 13,572 poor souls required in the emergency room in 2009?"
Others, though, look to the closing of St. Vincent's and see a lesson for anyone thinking about opening a new full-service hospital in the area. St. Vincent's failed after a decade of mismanagement, including a hospital merger in 2000 and the hiring of consulting firm Speltz & Weis in 2005.
St. Vincent's failure, though, also speaks to a troublesome citywide trend for charity hospitals -- a trend that has severe implications for low-income communities. Following the tradition of the Sisters of Charity, St. Vincent's was dedicated to "compassionate care": serving the poor and disenfranchised. Like many other struggling safety-net hospitals, St. Vincent’s charitable mission, ill-suited for today’s high-tech, costly health care, led to its end.
Over the last ten years, the state's Medicaid reimbursements, a significant portion of St. Vincent’s revenue, have been cut. Moreover, while St. Vincent's saw an increase in emergency room visits, which are costly and in many cases go unreimbursed, its inpatient volume decreased as wealthy residents left for more prestigious institutions.
In general, New York City hospitals are struggling. Over the past decade, hospitals nationwide have seen average profits of 4 percent, whereas in 2008, hospitals in New York City faced an average 6 percent loss.
Since deregulation in the 1990s, safety-net hospitals have struggled with less government support. What was once a highly regulated industry became a free-for-all, as "suddenly hospitals were put in the position of competing with each other," North Shore's Lynman said. This took a toll in New York City where hospitals are located close to one another, the most noticeable example being New York Presbyterian-Cornell Weill, Mount Sinai and Lenox Hill all on the Upper East Side. Without state regulation, this competition allows insurers to drive down reimbursement rates, fueling hospital debt.
To stay economically viable, hospitals vie for privately insured patients, setting off what has been called a medical technology "arms race" that raises the price of health care. They are far less eager to take in publically insured -- or worse yet, uninsured -- patients. In New York, reimbursements by the public insurers Medicare and Medicaid are notoriously low. This means that those on public insurance or not insured at all—the majority of St. Vincent's patients— place a financial burden on struggling institutions.
Evidence of the strain abounds. In 2009, in the wake of the H1N1, or swine flu, outbreak, Mary Immaculate and St. Johns – both safety net hospitals in Queens -- closed. According to a 2009 report from former City Comptroller William Thompson Jr., this led to "overcrowded emergency rooms, longer wait times for patients, and longer ambulance turnaround times."
Jamaica Hospital has picked up a flood of Mary Immaculate's and St. Johns' patients. Its emergency room, built to accommodate 60,000 patients annually, now sees 131,000. Emergency care is costly to provide, and in 2009 Jamaica Hospital lost $13.5 million. If Jamaica, one of the borough’s most prominent safety-net hospitals, goes the way of Mary Immaculate and St. Johns, the health implications, particularly for poorer residents, could be devastating.
This is a familiar pattern. When safety net hospitals close, low-income, already underserved communities bear the brunt of the impact. Patients spill over to surrounding hospitals, overcrowding their waiting rooms and increasing their financial pressures, setting off what could become a chain of hospital failures.
In the case of St. Vincent’s, Bellevue has absorbed much of the excess patient volume both because of its relative proximity and the fact that it is now the only Level One Trauma Center in lower Manhattan. Bellevue now serves an additional 2,000 people each month in its emergency room, a 25 percent increase. Beth Israel has also seen a 25 percent traffic increase with slightly higher numbers these past two months.
"What happened last year was not a tsunami that came and went, but the increase has been sustained," said Gregg Husk, chairman of the Department of Emergency Medicine at Beth Israel. Beth Israel has increased its emergency room personnel, nursing staff and physicians and recruited former St. Vincent's programs, such as the Comprehensive Cancer Center.
Beth Israel is still "tweaking" some of its health care practices to adapt to the increased patient volume, but overall, Husk said, "we were very fortunate" and "the environment is not chaotic."
Despite this, a June 2011 study on St. Vincent's closing wrote that the surge of patients to neighboring hospitals "was characterized as 'crushing' to staff morale as hours and workload increased dramatically." The study also reported patient crowding and increased waiting room violence.
The trend toward deregulation leaves little hope low-income New Yorkers will regain their safety net care in the future. "The changing landscape of healthcare is such that no one in the New York City area is building new hospitals," said Lynam.
After St. Vincent's closed, Rudin Management proposed to donate the O’Toole building and $10 million in funds for an urgent care center run by North Shore. In April 2011, a bankruptcy court judge approved the transaction.
"This is the only deal that is doable in today's environment," said John Gilbert, executive vice president and chief operating officer for Rudin Management.
Mount Sinai had been prepared to take over and run a full-service hospital in the neighborhood but suddenly withdrew in April 2010. Coalition members blame this on a lack of support from the state Department of Health which, following the recommendations of the 2006 Berger Commission, is trying to limit "the state's unacceptably high excess capacity of hospital beds."
The North Shore care center will not create any new impatient beds and so aligns with the state's goal. A new full-service hospital on the other hand would work directly against it.
The coalition argues the focus on overall number of beds is short-sighted. "They give no thought to the distribution of beds -- all they care about is shutting them down. Community needs, bed per person ratios, socio-economic issues are all irrelevant," said Kaufman at a rally in April.
Kaufman has pointed out that in the Upper East Side and East Harlem there is one bed for every 82 residents. In contrast, after St. Vincent’s closing, there are now no hospital beds for the West Side’s 385,000 residents.
Judy Wessler, director of the Commission on the Public's Health System, noted that hospitals in New York City have "always been mal-distributed," but with the closing of many charity hospitals in underserved communities, "it's getting worse."
"The East Side is wealthier, and that's where institutions tend to settle," she said. "Studies have [shown] over and over … that there is an absolute correlation between income and access to health care and even race … and access to care."
The coalition continues to fight the Rudin/North Shore plan. Yet, while it has galvanized support among community members, it has failed to win backing from some key politicians and other community leaders. Councilmember Christine Quinn, former Mayor Ed Koch and Greenwich-Chelsea Chamber of Commerce president Tony Juliano have all spoken out in favor of the comprehensive care center.
"Our health care needs are significantly underserved. This will go a long way to bring this service back to the community,” said Juliano, warning that if the community does not support the North Shore plan "we'll be looking a year from now … at a horrible situation where a whole city block is vacant."
Since St. Vincent's declared bankruptcy in 2010, 3,500 former employees are jobless and around 40 local businesses have closed. Juliano hopes the development will "bring economic life back" to the neighborhood.
Proponents for the Rudin/North Shore plan argue that, while it may not be ideal, it represent a pragmatic solution to an admittedly bad situation.
"We recognize that, listen, you had a full-service hospital in your community for over 100 years and suddenly it's gone. We certainly understand why people are frustrated by that," said Lynam. "But the reality is that there are no other providers stepping forward. We've put forward what we think is a realistic plan that will fill that void."
For the thousands of former St. Vincent's patients – particularly those without a lot of resources -- this offers little comfort. "I think it's a health crisis like a silent time bomb," said Kaufman. "It's just sitting there, brewing. It’s happening every day but it's hidden from the public eyes. … And I think it’ll get worse."
Smoking in New York City parks, beaches, and pedestrian malls became illegal last week. At a public hearing when the ban was proposed last fall, the city's health commissioner, Thomas Farley, predicted, "In the future we will look back on this time and say, 'How could we have ever tolerated smoking in a park?'"
Farley is almost certainly right. Public attitudes toward smoking have changed so thoroughly in the last 40 years that the smoke-filled offices depicted in "Mad Men" are barely recognizable. It’s likely that a few decades from now, if not sooner, the idea of smoking in a park will seem as outlandish as lighting up in an elevator or a supermarket -- the first public spaces in New York City where smoking was prohibited, 37 years ago.
It was in the spring of 1974 that New York City's health commissioner tried to ban smoking in "places of public gathering," such as restaurants, theaters, museums, libraries and hospitals. It was a radical proposal. Almost 40 percent of U.S. adults smoked, around double the rate today.
The resistance to the proposal was so intense that the law was dramatically weakened on the way to passage; the ban was whittled down to cover only elevators and supermarkets "There will be no more ashes flicked on raw meat in the meat departments," the commissioner, Lowell Bellin, said.
Over the following decades, however, public tolerance for smoking eroded, and most public spaces became smoke-free. Opinion polls have shown overwhelming support for the increasing limitations, even among smokers themselves.
Extending bans from enclosed spaces to outdoor areas represents a new phase. Yet a common thread connects the first restrictions on indoor spaces passed in the 1970s to the new laws on parks and beaches that have become increasingly common across the country: All these bans have dual rationales, but only one is usually acknowledged.
The first and most prominent rationale is to protect non-smoking bystanders from secondhand smoke. At first, this reasons was based more on suspicion than fact -- the scientific evidence of the dangers of secondhand smoke was scant in the early years of tobacco control -- but eventually studies demonstrated that exposure to the smoke of others was associated with elevated risk of cancer, heart disease and other illnesses.
The second purpose behind smoking bans, then and now, is less often acknowledged but almost equally important from the standpoint of public health: changing public attitudes. To reduce the toll of illness and death from cigarettes, tobacco foes sought to transform smoking from a glamorous, desirable behavior to a stigmatized, unacceptable one. In political debates over bans, this rationale was often soft-pedaled, although a few public health officials were blunt about their goal. Said Bellin when he was New York's health commissioner in 1974, "We hope to create a climate in which the smoker is uneasy."
Bans on smoking in indoor spaces are unquestionably justified on health grounds. Outdoors, however, air-monitoring studies have shown that cigarette smoke dissipates and poses little risk to anyone more than a few feet away.
So it's clear that, whatever health claims proponents may make, the intent of banning smoking in parks is a social one: to "de-normalize" smoking. Testifying last fall on New York's law, health commissioner Farley made this clear when he said, "Parents should be able to bring their children to parks and beaches knowing that they won't see others smoking."
Some critics see this use of the law as unjustified, even sinister. But it's important to remember that the social climate decades ago when smoking seemed natural didn’t come about naturally -- it, too, was engineered. Throughout the 20th century, tobacco companies with vast resources at their disposal used aggressive marketing and advertising to portray smoking as a symbol of glamour and sophistication.
Public health advocates seeking to halt the epidemic of tobacco-related illness don't have anywhere near the financial clout that the tobacco industry does, but they can shape public opinion through laws and regulations. Banning smoking in public places such as parks and beaches sends a powerful symbolic message that smoking is unacceptable, even in situations where it poses no direct health risks to others.
James Colgrove is associate professor in the Center for the History and Ethics of Public Health at Columbia University's Mailman School of Public Health and author of Epidemic City: The Politics of Public Health in New York (Russell Sage Foundation, May 2011).
Ten years ago Jeremiah Taylor walked into a New York City hospital thinking he was going to undergo routine surgery on his lower back. Things did not go as planned.
Hospital staff didn't monitor his blood pressure while he was under anesthesia, and as a result it dipped to dangerously low levels -- so low that his optic nerves died. When he was wheeled out the back door of the hospital and given a month’s prescription for sleeping pills, he was totally blind. His life irreversibly changed. Gone was his privacy; now he would require help to do the things that used to seem so simple.
"I have to ask people I don't know for help getting to the bathroom," he said. "Can anyone really tell me my pain and suffering is worth only $250,000?" asked Taylor.
Taylor finished the legal wrangling over his own incident years ago, but now he has come to Albany to lobby against the recommendation that that non-economic damages in malpractice suits be capped at $250,000.
The caps represent one small part of the package assembled by Gov. Andrew Cuomo's Medicaid design team. The team's recommendations would trim $2.3 billion from Medicaid for the upcoming fiscal year. All these proposals made their way to Cuomo's budget, as well as the Senate's, and are now being debated in the capital. The caps, though, have met staunch opposition from the Assembly, and many expect them to emerge as a deal breaker in this year's budget negotiations.
Hospital organizations like the Medical Society of New York, the Greater Hospital Association of New York and the Healthcare Association of New York State support the cap. These groups say the cost of malpractice insurance is skyrocketing, thanks to multi-million dollar malpractice awards, and make doctors leery of taking on high-risk patients. Further, the increases, they say, will force doctors to leave the state or even their profession. Hospital associations estimate that the caps will save them $700 million a year. They charge that trial lawyers oppose the cap because it would limit what they could earn from a malpractice suit.
Vehemently opposed to the measure in New York are lawyers groups such as the State Bar Association, as well as advocacy groups such as the AARP, Citizen Action and the New York Public Interest Group. They say the cap was proposed largely as a way to get hospital groups to support the rest of Cuomo's Medicaid plan.
"When doctors and hospitals were presented with the question, 'What do you want to sign onto this Medicaid program?’ their holy grail is to be unique from all other members of society -- to be immunized from their mistakes and consequences. When the genie pops out of the bottle and says, 'You get one wish -- not three,' this is exactly what they wished for," said Assemblymember Rory Lancman.
Assemblymember Deborah Glick said the proposal will limit the tools the public has to punish physicians for their negligence. "The way we punish people, the way we correct incorrect behavior in our society is by either sending someone to jail or by financial punishment,"said Glick. "If you take away the financial punishment, the system has no reason to correct itself. Doctors have no reason to be more careful,"she said.
Advocates on both side point to California, which has had a similar cap on non-economic damages in malpractice cases since 1975. The same figure was used: $250,000. Critics point out that by now the number should have been adjusted for inflation and would stand somewhere around $900,000. The number has not been adjusted for inflation in California, and the New York proposal also does not take it into account.
Proponents of the measure say that California's malpractice insurance rates have only risen by half the national average since the law took effect. Yet the number of malpractice cases per doctor in California has remained the same, and in almost half of malpractice cases judges have had to reduce non-economic awards suggested by juries that have wanted to to give plaintiffs greater awards.
Lancman says the stakeholders negotiating the Medicaid agreement did not seriously consider other routes of reducing malpractice costs. This, he said, would include working to reduce incidences of malpractice so that there are fewer lawsuits.
Lancman has sponsored a bill called the Medical Malpractice Savings Act to require that the health commissioner establish a set of rules for every hospital to ensure that each one has a comprehensive obstetrics program to reduce malpractice. The Lancman bill was inspired by a "recent report by an obstetrics team at New York Presbyterian Hospital that detailed how it reduced the department’s malpractice payouts by 99 percent.
Bill Ferris of the AARP agrees and blames the omission on the lack of "consumer representation" on the Medicaid redesign team. “There should have been more discussion on how to reduce medical mistakes, not on capping the damages," he said.
Ferris' organization is lobbying against the caps because, according to Ferris, seniors rely on non-economic rewards-- damages for pain and suffering-- to get compensation in malpractice suits. "Seniors are generally unemployed and rely on Medicaid and social security. This would limit rewards for pain and suffering, and economic rewards are generally based on future salary -- seniors don't have that. This does away with how they can be compensated for a medical mistake.
Glick has introduced legislation that would limit hospital administrators' pay to $250,000 a year. Glick said she is trying to make people understand that if $250,000 is enough to cover a life of pain and suffering caused by a hospital error than it should be more than enough for a hospital CEO to make in a year.
"I did this to raise the point that there is another side of the balance sheet -- one that is quite costly," said Glick. "I don't think it will pass, necessarily. ... There are a lot of people who have supported the bill, but hospital administrators are not so happy. I've stepped on some toes there."
Glick said she thinks Cuomo is picking and choosing which “special interests” to back and uses different standards.
"Gov. Cuomo says he doesn’t believe that school districts can't weather these cuts. He doesn't believe that there isn’t waste and corruption in these school districts. Well I don’t believe insurance companies will reduce their rates if this cap goes through. I think they will just take the money and run and find another excuse for why premiums are so high," she said.
With the three major legislative leaders currently in heated negotiations, it is unclear whether the caps will make it through as part of the budget. Cuomo has made it clear that he isn't keen on giving up anything in his budget and has told lawmakers that if a deal is not reached he will push through his budget in extenders.
If a deal is a reached, the caps could be a critical part of making it happen. Majority Leader Dean Skelos has told reporters that he could not support a budget deal that included with a millionaires tax or rent regulations; both of those things are near and dear to Assembly Speaker Sheldon Silver's heart. Silver is a lawyer and tends to be friendly toward trial lawyers. However unions that represent hospital workers also are close to Silver, and the hospital associations warn that if the caps don;t go through they could be forced into layoffs. It may be possible that the caps will be done away with as a concession to the powerful Silver.
At this point it is unclear. But things are much simpler to Taylor, who plans to come to lobby on the issue until there is no more hope. He says he wants others to have the right to sue for an amount that compensates them for having their lives altered by negligence.
"Right now, if I hit you with my car you can sue me, but I can't sue a doctor for more than $250,000? I will fight for other people’s rights to compensation. Why not look at reducing malpractice? Why aren’t doctors subject to tests? I think they sat in a back room and made this deal to take away people’s rights to compensation. It is just un-American."
In an emotionally charged moment, the City Council approved legislation Wednesday to force pro-life crisis pregnancy clinics that do not perform abortions to disclose what services they do and do not provide.
Supporters of the legislation allege these facilities deliberately deceive pregnant women who visit clinics to get medical services. These clinics do not disclose in advertising that they refuse to perform abortions, and staff members wear scrubs even though they have no medical training, the bill's backers say.
"Be proud of what you are and what you do," said Council Speaker Christine Quinn at a rally celebrating the legislation's approval. "I don't understand why anyone would oppose this legislation."
But many do. Opponents of the measure claim forcing clinics to immediately list the services they provide violates their First Amendment rights. Opponents promised to sue the city after the mayor signs the bill, which he is expected to do.
"No city or government agency has ever fined us, sued us or cited us for any violations of law," said Christopher Slattery, the founder and president of EMC Frontline Pregnancy Centers, which has 12 locations in the five boroughs. "The city transit system has accepted our advertising for years. If it is deceptive, why is it accepted?"
The council approved the bill by a vote of 39 to 9 with one abstention.
Both sides dueled in opposing rallies and protests Wednesday. Supporters of the bill, which include Planned Parenthood and NARAL Pro-Choice New York, carried signs reading, "I love pro choice New York." Opponents of the bill, who led a sing along outside of the council's meeting, thrust up posters emblazoned with, "#1 Enemies of the First Amendment." Below the sign had photos of the bill's sponsors.
First introduced in 2010, the bill has attracted an unusual amount of attention despite its small impact. According to council officials, the legislation would only impact about a dozen clinics.
It also comes at a time when Planned Parenthood has come under fire in Washington and could lose hundreds of millions of dollars in federal funding.
Council officials say they are attempting to target clinics that do not provide any medical services, and are not attacking pro-life counseling centers.
Under the legislation, these clinics would have to post a sign disclosing whether they have a licensed medical professional on staff and whether they provide or refer to prenatal care, abortions and emergency contraceptive.
This information would also have to be included in advertising.
Opponents are confident they will never have to post those signs. The courts struck down similar legislation in Baltimore earlier this year, determining it was against the First Amendment. Council officials say their proposal would hold up in court, because it targets a very narrow group of crisis pregnancy clinics.
At the Emigrant Savings Bank Wednesday, the council's temporary home, council members traded barbs and tears -- an exchange that pit the First Amendment against a woman's right to choose.
"Contrary to the speaker's comment this bill is in fact more restrictive than the speech requirements in [the Baltimore bill], and I say that as someone who practiced constitutional law and who is actually admitted to the Supreme Court," said Councilmember Dan Halloran, a Republican of Queens. "This is an unconstitutional infringement. It will be struck down."
Councilmember Melissa Mark-Viverito fired back.
"Our country is continuously being faced with controversial issues, and it is important that we embrace measures that promote choice and democracy versus exclusion and degradation," said Mark-Viverito.
Some council members attempted to change the tone of the debate altogether -- pointing to the city's more than 40 percent abortion rate. They urged the council to focus on education as opposed to a debate on pro-life versus pro-choice.
The City Council also approved legislation Wednesday, which would provide homeowners who are eligible for tax exemptions assistance with liens.
The measure strikes an appropriate balance between getting scofflaws to pay up and assisting homeowners who can't keep up with their bills, said the legislation's sponsor Al Vann. Under the proposal, homeowners will be given the option to pay off tax liens in installments for eight years with no down payment.
The bill could affect any homeowner in default for property taxes as well as sewer or water payments.
The bill also gives the council the authority to sell liens based on an emergency housing repair program, which targets deadbeat landlords.
With the Federal Patient Protection and Affordable Care Act -- the full name for "Obamacare" -- set to require that all Americans have health insurance, more people will seek medical care more frequently, health experts predict. The healthcare system is already overburdened, so a key question in New York, as elsewhere, is how can the system take in and treat the people who currently do see medical providers because they don't have the resources?
The Manhattan Institute, a conservative think tank, believes it has the answer. And it could be right in your local Duane-Reade.
The care would come from retail health clinics, for-profit health centers probably located in chain drug stores. These centers would treat people complaining of minor aches and pains, the type of things uninsured people or people who do not have access to primary care now bring to a hospital emergency room. The clinics also would refer patients to specialists if their problems turned out to be serious. The clinics build on some of the services drug stores already provide, such as flu shots and blood pressure testing, and their number has been growing in states such as California, Texas and Georgia.
Manhattan Institute scholar Paul Howard, who once bashed the Obama administration's healthcare overhaul on the pages of conservative websites, has now accepted its existence. The author of the Manhattan Institute report on the clinics, Howard thinks expanding them would help provide care for the 1.2 million New York state residents who will get health insurance under the federal legislation.
"They can offer a terrific access point for busy people," Howard said in an interview. "They often partner to make referrals to a primary care.
The Manhattan Institute study said that when Massachusetts instituted its healthcare law, which is similar in some respects to the federal measure, "expanded coverage led to longer waiting times for physician appointments and a 10 percent increase in emergency room use." Noting that "New York could experience similar problems," the report says an "expansion of retail-clinic utilization in New York could reduce healthcare costs by $350 million between 2011 and 2020 by reducing the number of unnecessary emergency room visits."
Manhattan Institute is not alone in singing the praises of these types of retail clinics. A study commissioned by the Rand Corp. in 2009 showed "no difference in the quality offered to patients visiting retail clinics, physician offices and urgent care centers."
The study's lead doctor, Ateev Mehrotra, a professor at the University of Pittsburgh School of Medicine, told MSNBC at the time: "These findings provide more evidence that retail clinics are an innovative new way of delivering health care. … Retail clinics are more convenient for patients, less costly and provide care that is of equal quality as received in other medical settings."
The push to bring these retailers into the state -- there are about 15 so far, according to Howard -- could spark some dissent from health groups. It would require removing the state's legal barrier that prevents for-profit corporations from getting medical licenses. The Manhattan Institute report also calls for getting rid of what it describes as "a costly certificate intended to prove that the health-care provider service will fill a need." This approval, it says, can "take time and often deters new clinics from opening in retail stores in New York."
The report notes that current state law "prohibits retail clinic operators from employing even nurse practitioners and other mid-level practitioners upon whom the cost-savings of the model depends." Currently, these practitioners, nurses who can diagnose ailments and prescribe treatments, need to be under a doctor's supervision. If the state ditches this requirement, retail health clinics could hire nurse practitioners to oversee operations. The institute advocates such a change.
But some groups have questions. The New York State Nurses Association, for example, supports the retail centers in theory, but opposes the current state legislation meant to bring more of them into the state.
"There isn't enough information known about how this would operate," said Deborah Elliott, the association's deputy executive director. "It would have to be clearly indicated who would be managing the primary care on these sites."
"It is not a substitute for primary care; it is an adjunct to primary care," Elliot said. "In the long run there could be some very valuable benefits from this."
Judy Wessler, the executive director of the Commission on the Public's Health System, was less than enthused about what Howard is proposing.
"It's as bad going to the emergency room," she said of the clinics. "There's no continuity of care. The person taking care of you doesn't know who you are. It's a very inadequate way of providing care, but it's cheaper than an emergency room."
Politics might be bad for your health. As the state confronts huge budget deficits, Gov.-elect Andrew Cuomo will almost certainly face enormous pressure to slash spending on health care, particularly the Medicaid program for low-income people.
So it may come as a surprise that one expert and key player in state health care policy, Richard Gottfried, who chairs the State Assembly's Health Committee, wants to spend additional money to beef up the state's brain trust.
Gottfried has other goals as well. They include, in his words, "promoting alternatives to nursing home beds and strengthening home care and strengthening primary care to help avoid unnecessary hospitalization," as well as "better integration of health care so that the health-care system can profit by people keeping healthy instead of profiting by increasing volume of procedures." He believes that the federal health-care reform bill, if it survives Republican attempts to repeal it next year, will help the state implement some of these programs.
"You get no political support for putting money into central administration. That's about as exciting as a Crisco sandwich, but it is absolutely necessary if we're going to make any kind of progress," Gottfried said. "Has anyone ever marched on Albany saying, 'We need more bureaucrats'? They don't arrive in an ambulance when you're having a heart attack; they're at a desk in Albany, hopefully trying to remake the system."
Medicaid -- not bureaucrats -- will almost certainly get the attention when the new governor and legislature take office in January. Medicaid expenditures in the state exceed $50 billion per year, making it tempting target for cuts.
In fact, Cuomo, as the state attorney general, won high-marks for investigating Medicaid abuse; last year the U.S. Health and Human Services Department named his Medicaid fraud unit the best in the country. Although McKnight's Long Term Care News reported that Cuomo has vowed a "fundamental restructuring of Medicaid," details of how he plans handle costs when he takes office remain a mystery. Whatever cuts or reforms he might pursue will likely spark opposition in the Assembly and from unions.
Outgoing Lt. Gov. Richard Ravitch suggested, for example, limiting eligibility, such as denying Medicaid to childless adults. And Albany Republicans earlier this year called for a variety of measures that they say will rein in costs. According to a statement from State Sen. Betty Little's office, a March report recommended, "requiring recipients to choose a primary doctor and a primary pharmacist, similar to managed care plans; allowing elected comptrollers, treasurers or other appointed officials to audit Medicaid claims; and preventing individuals from being forced to go to other counties or states for long-term care."
Gottfried warned that such moves would hamper the overall health-care apparatus in the state.
"You are not just cutting the care for people who are on Medicaid," Gottfried said. "If a nursing home or a hospital has to lay off staff because of Medicaid cuts that affects everyone at the institution, rich and poor alike."
Gottfried supports funding Medicaid through higher taxes on the wealthiest 1 and 2 percent of the state’s population.
Shaun Flynn, the director for governmental affairs at the New York State Nurses Association, agreed that Medicaid cuts hurt across the board.
"You don't see cuts in CEO salaries," he said. "It comes out of direct-care staff, which has a huge impact on how patients receive care in these facilities."
To counter that, the nurses association advocates a mandate on all hospitals to maintain a set patient-to-nurse ratio, similar to the one in California.
"It's something that's been pending in our legislature for some time," Flynn said. "We're hopeful that Cuomo will ask the tough questions that no one else has. What New York hospitals say is, 'We can't do it,' but they can't explain why California can."
To help fund this, the nurses association, which is both a union and a professional organization, supports a tax on sugary beverages along with the Doctor's Council (a Service Employees International Union affiliate), on grounds that it would provide needed revenue for health care and reduce obesity. But some unions like United Food and Commercial Workers Local 1500, whose members work in grocery stores, argue that such a levy is a regressive tax, and the bottling industry managed to scuttle a similar proposal earlier this year.
The transition team that Cuomo has appointed to advise him on these issues consists largely of hospital management representatives. Other than nurses association President Karen Ballard, there are "no voices representing the physician community or community health centers," and "few voices from the health-care policy or academic world, or labor," Gottfried said.
Cuomo broke Democratic Party tradition in his campaign this year by heaping blame for the state’s budget mess on state-worker pensions and pay, resulting in few unions backing the nominee and a half-hearted -- and some say short-sighted -- endorsement from the Working Families Party.
So it wasn’t too much of a surprise when Cuomo failed to initially place a representative of 1199/SEIU, the state's strongest health-care union, on his transition team, although he later brought aboard its president, George Gresham, to smooth relations.
But Flynn believes the inclusion of the nurses association indicates that health-care advocates could get their point across. And that's good news to anyone concerned about the other big health issues in the state, whether it is an infant mortality rate one group has called "disgraceful" or the fact that three major hospitals in New York City have shutteredin the last few years.
"It shows a willingness to listen to people," Flynn said of the Cuomo transition team. "From NYSNA's perspective that's all we're really looking for. We believe the strength of our arguments are enough to win on their own."
The day before Thanksgiving, many New York foodies hustle to pick up heritage turkeys and heirloom vegetables at their local Greenmarket. Meanwhile, food rescue agencies like City Harvest try to persuade the shoppers to donate a bag of produce such as apples, onions or broccoli to food pantries and soup kitchens.
The food pantries trying to help the more than 1 million New Yorkers who cannot afford an adequate supply of food must look to a variety of sources for the food they provide, and much of it originates far from the city. But that could change. A number of programs already try to give poor New Yorkers access to locally grown produce, and several local officials have proposed sweeping efforts that could bring the locavore ethos to low-income homes.
Both Gov.-elect Andrew Cuomo and City Council Speaker Christine Quinn have recently presented plans to get more locally grown food into the city and then to institutions and poor neighborhoods. If implemented, the proposals would bolster grassroots programs that make local food available to people who often have little access to fresh, healthy food, let alone locally produced fruits and vegetables.
Several well-established programs already provide poor New Yorkers with Empire apples and root vegetables. The Food Bank for New York City spends up to $500,000 annually on local produce for over 1,000 citywide emergency food programs. The Food Bank's Community Kitchen and Food Pantry of West Harlem runs a Community Supported Agriculture program, where produce comes directly from local farms to consumers, and offers members several plans to pay for it.
In addition, the U.S. Department of Agriculture's Farmers' Market Nutrition Program, established in 1988, gives people enrolled in the Nutrition Program for Women, Infants and Children or in Senior Nutrition Programs coupons that they can use to buy locally produced fruits, vegetables and herbs at participating farmers' markets. All recipients get $20 a year and those in the Women, Infants and Children program get an additional small monthly allotment.
This program encourages people to visit the markets and discover the benefits of eating fresh produce, according to Bob Lewis, who assists the state Department of Agriculture and Markets in farmers’ market development.
Lewis, who co-founded New York's Greenmarket program, said that the city has always worried whether people introduced to farmers' markets by the program could afford to continue to shop there once their coupons ran out. That led Greenmarket to install Electronic Benefits Transfer machines to allow shoppers to use food stamps at the markets.
Cuomo and Quinn want to take government farm-to-fork initiatives further. In his farm agenda released last month, Cuomo outlined plans to build food-processing facilities and expand urban farmers’ markets. These measures would provide a boost to the state's farmers while providing healthier food to lower-income New Yorkers.
On Monday, Quinn announced the City Council’s own ambitious food policy agenda, called Food Works that addresses all aspects of New York’s food industry, from farming to composting. The plan looks at the way food reaches and then is distributed around the city for solutions to an array of problems.
"For far too long, we’ve ignored a growing crisis in our city and across the nation," Quinn said in her speech. "We’re a city of more than 20,000 restaurants, yet 1.4 million New Yorkers struggle to put food on the table. One out of every four children in New York City is overweight or obese. New York State farmers ... only make half as much per acre as farmers in other parts of the country. Meanwhile, the food system is responsible for nearly 80 percent. of our increased energy use in recent years. "
Both Cuomo and Quinn have stressed the need to update the Hunts Point Terminal Produce Market in the Bronx. The State Department of Agriculture and Markets supports rebuilding the market, constructed in the 1960s, to improve efficiency and food safety and reduce air pollution created by trucks. In particular, the City Council would like to see a large permanent wholesale market at Hunts Points to make it easier for businesses to purchase fruits and vegetables from local producers. The department estimates that rebuilding the market will cost between $300 million and $500 million.
"If we only get one thing in Food Works right, it has to be this,” Quinn said Monday. “How are we going to get healthy food to our neighborhoods if we can’t even get it into our city?” Quinn would like to see train service expanded throughout the state to allow more food to reach the market.
Quinn said that, with more local food in the city, New Yorkers, especially those living in poor neighborhoods, would be better able to buy more local produce. “If we want to have New Yorkers make better choices, we need to give them better options,” she said.
For people living in public housing and using food pantries, those options would include enrolling in a Community Supported Agriculture program. Cuomo said he would ensure that people could pay for their membership in installments and with government assistance benefits. In these programs people pay a set fee for a weekly or monthly basket of fresh seasonable produce direct from a local farm.
Cuomo and Quinn have urged schools, hospitals, nursing homes and corporations to buy more local produce and enroll in a Community Supported Agriculture program. In the past, state farmers have struggled to sell produce to the city’s SchoolFood program because it demands year-round, cheap and easy-to-handle food. Although the department has begin to purchase some locally produced fruits, vegetables and milk, the council report said, "This procurement has, thus far, occurred on an ad hoc basis." The council has said that Councilmember Gale Brewer will introduce a bill to require the city to develop new purchasing guidelines that would encourage it to buy from local farmers.
Whatever its shortcomings, though, Quinn used the Department of Education as an example of an institution that has increased its purchase of regional food without increasing procurement costs. "Why can’t every other city agency do the same thing?" she asked.
The speaker wants to keep food production in the city and have producers buy produce from local farmers. She acknowledged that a lot of low-income entrepreneurs who cannot afford to prepare their food in an approved commercial kitchen that complies with the city health department’s regulations. Quinn said the council had helped remedy that issue by building a shared kitchen in East Harlem within La Marqueta.
Finally, Quinn urged producers to minimize packaging and New Yorkers to compost. "We need to stop thinking of food scraps as garbage," she said. The council plans to expand the compost program at Union Square to other farmers markets so that more people will have a place to take their food scraps.
While New York politicians drum up support for their initiatives, local leaders have already reshaped their community’s food systems, making seniors in particular not only the recipients, but also the sources of local food.
Through the Healthy Communities Through Healthy Food initiative, seniors work on urban farms, sell food at local farmers' markets and grow food at public housing sites. The program directors said that a large number of older people have been involved in urban agriculture and food for years. Many started gardens in their backyards during the Great Depression or after World War II.
United Community Centers sponsors the East New York Farms! project, which runs two farmers markets that serve East New York, a food desert with one of the city’s highest obesity rates. Project members design gardens with raised beds so that seniors can grow food without straining themselves. They also train seniors to increase the yield of their gardens and to sell more of what they grow at farmers' markets.
Isabella Geriatric Center in Upper Manhattan has organized a senior-run fresh food buyers' club called YUM Food Box that offers regional produce to residents of Inwood and Washington Heights. Only a quarter of food retailers in those neighborhoods sell fresh food, and almost half of residents receive public assistance. Every month the buyer's club distributes about 300 bags of produce, which cost members $20 per share or $10 for a half-share. The club differs from Community Supported Agriculture in that members don't pay upfront for a share, which typically costs several hundred dollars.
Myrtle Avenue in Fort Green and Clinton Hill separates brownstones from the projects and those likely to eat fresh food from those who are less likely to do so. The Myrtle Eats Fresh initiative, led by seniors, tries to level that class disparity by creating farmers' markets, small urban farms on public housing land and fresh-food advocates.
Lee Gary is an intimidating man, towering over most -- if not all -- the people he meets. Sitting in the offices of CASES -- a nonprofit group in Lower Manhattan that assists the formerly incarcerated -- Gary, built like the largest of linebackers, spilled over his black rolling chair, obviously uncomfortable.
He fidgeted. He seemed nervous.
But this was not the most compromising situation he has ever been in.
According to his estimate, Gary has been arrested 30 times in the last eight years, spending a total of a year and a half on Rikers Island -- the 400-acre facility yards from LaGuardia Airport that houses many of the city's accused and convicted criminals. Gary, a 49-year-old Bronx resident who is diagnosed with bipolar disorder, spent half of his time in a mental observation unit there. The rest was clocked in at the prison ward of Bellevue Hospital Center.
"It's horrible," Gary said of Rikers, anxiously rubbing the sides of his legs with his large palms. "You get guys hoarding food. You get guys that want to fight."
"The officers are not there to help you," said Gary. "You'll just sit there to rot."
But Gary had company -- lots of it.
The percentage of Rikers inmates with mental illness has reached its highest level in eight years. While the number of people sent to Rikers Island every year continues to fall -- bucking a national trend-- those that remain, like Gary, keep coming -- often.
In what one expert refers to as a "population distillation," the number of people classified as mentally ill on the island has gone from 25 percent in 2004 to 32 percent today, according to the city Department of Correction. If the trend continues, Rikers Island could resemble the shuttered mental institutions of the 1970s instead of the correctional facility there now.
"Mentally ill inmates are less likely to be released. They are perhaps not as well equipped to manipulate the system. Their cases are more complex," said Martin Horn, the former commissioner of the Department of Correction. "All of those things, make them harder. They are the ones most likely to be there."
Advocates and experts acknowledge the city has taken steps to address the challenges this population presents. But following a decade-long court case over the quality of mental health care, they claim inmates with mental illness continue to fall through the cracks. They say more needs to be done to tackle the treatment, the recidivism rate and the overall number of mentally ill on Rikers -- long term.
These are Rikers' regulars and, for now, they don't appear to be going anywhere.
Circa 1999, it could be 2 a.m. Neon signs might penetrate the pitch-black sky in the middle of Queens Plaza -- a former hotbed of liquor stores, strip clubs and homelessness. Imagine the Rikers Island shuttle bus roaring up, opening its doors and inmates pouring out. Those with mental illness would be among them.
They would have subway fare, but many had nowhere to go.
More than a decade ago, the Urban Justice Center filed a lawsuit, commonly referred to as "Brad H," against the city claiming it failed to provide adequate discharge planning for inmates with mental illness. Advocates and experts contend proper planning for inmates outside of the jail's cement walls will successfully halt the revolving door of incarceration for Rikers' regulars.
Under a settlement reached in 2003, any inmate who stays on the island for more than 24 hours and sees a mental health staffer more than twice must receive a "discharge plan" -- a roadmap to services, housing and hopefully a normal life. When released, inmates must have medication for seven days, leave the island during daylight, be referred to a treatment provider and start the application process for supportive housing or reactivating Medicaid benefits. Inmates are also free to deny these services.
In 2003, the court appointed monitors -- who declined to be interviewed for this story -- to oversee the transition for the next five years.
Because of counter suits, that five-year period was extended until the summer of 2009. The center, which claims the city has not met its discharge planning goals, then asked the court to extend the monitoring for another two years.
In August, the city successfully convinced the courts on appeal that the monitoring period had expired and the Urban Justice Center had no grounds to extend it. The center has appealed to the state's highest court, which will soon decide whether to hear the case.
While the case is on appeal, the monitoring continues at Rikers.
“When people with mental illness are released from city jails today, the services they receive vary widely. Some get real discharge planning, and that’s an improvement from a decade ago -- but too many still do not,” said Jennifer J. Parish, the director of criminal justice advocacy at the Urban Justice Center’s Mental Health Project. “The city has not yet lived up to the commitment they made when they settled the case in 2003.”
Part of the so-called failures at Rikers is communication. There are four city agencies that have some hand in the delivery of health care -- from start to finish -- in addition to a for-profit, private corporation, PHS Correctional Healthcare.
Some say the correctional system itself is the problem -- a jail is not conducive to treatment and its confines aggravate the mentally ill.
Or maybe it's staffing. The department of health, in particular, critics say, has been plagued by high turnover rates. (The department did not provide Gotham Gazette with turnover figures for this story.)
All of this leaves advocates wondering whether inmates with severe mental illness are leaving the island without the proper preparation, reentering society just as unstable as when they left it and destined to return to Rikers.
Marcelene J., according to an affidavit filed with the state Supreme Court, could not get any treatment after leaving Rikers in October 2008. Marcelene, a 23-year-old homeless woman who is diagnosed with bipolar and schizoaffective disorder, was referred to Interfaith Medical Center in Brooklyn upon her release by a Department of Health and Mental Hygiene discharge planner.
When she got to the hospital, she was told she didn't have an appointment. No one knew who she was or that she was coming.
So she left, according to the court filing.
"I was not able to continue my medication because I did not have any place to get ongoing mental health treatment," Marcelene wrote. "I would like to receive psychiatric medication and therapy because I continue to have mood swings and the voices I hear never seem to go away."
Darryl C, according to the court filing, has been bouncing between hospitals, prison and Rikers almost his whole life. A heroin user diagnosed with depression and generalized anxiety disorder, he first received treatment at Rikers in 1990.
During his recent stint there in late January 2009, following an arrest for petit larceny and possession of stolen property, doctors on Rikers refused to treat Darryl, despite his previous medical history, according to the court filing.
He was removed from mental health status the next month.
"I do not want to use heroin again," Darryl wrote. "I want to get help for my mental illness."
According to the most recent monitoring report released in July, many "pivotal monitoring, programmatic and legal issues remain unresolved" in the delivery of discharge planning services. Inmates are misclassified, the report states. Computer files put them in a less severe category of mental illness, while the inmate's physical medical chart may say otherwise. Inmates were not referred to programs that address more serious mental health problems, the report states, and some are still leaving Rikers at night.
The monitors criticize inmates' refusal of treatment, questioning whether discharge planners make an honest effort to convince this difficult and untrusting population to get help.
In response, a spokesperson for the health department said it has been working to increase the accuracy of its electronic records. According to the department, a patient must be "motivated" to receive proper follow-up care. The agency said it is training staff to help engage inmates to get the assistance they need.
Of the 33 areas the monitors evaluate, the city was found "noncompliant" in 10, according to the latest report, which examines a sample of inmates' records. Of those, the city made the appropriate appointment referral only 57 percent of the time. Just 22 percent of the eligible cases received the appropriate referral for supportive housing, according to the report, and 82 percent were sent to the right place for case management. In five areas, results were inconclusive.
Some of the city's figures dispute the monitor's findings and in many cases show it meeting and surpassing its goals. But the reliability of those figures has been repeatedly questioned by the court appointed monitors.
In the areas the health department did acknowledge it failed to meet the court's requirements, staff did perform the relevant tasks, but not within the required timeline, according to the department.
"While it's in appeal, we are complying with the requirements," said Deputy Commissioner Louise Cohen of the Department of Health and Mental Hygiene in response to questions about the lawsuit. "The city is committed and we are certainly committed as an agency to do discharge planning in the best way that we can for the mentally ill."
Should the state Court of Appeals refuse to hear the latest iteration of the litigation or side in favor of the city, Cohen said the city would likely modify its discharge planning process.
The settlement focuses on time restrictions, such as ensuring an inmate referred to the Rikers mental health staff is seen within 72 hours. Cohen said the department would prefer to focus on results. She declined to give specifics on the proposals the department is considering.
"The city would continue to hold itself accountable for discharge planning for those that are mentally ill," said Cohen. "I think it’s a question of what that looks like."
"Single file, ladies," called Deputy Warden Antonio Cuin down the halls of the Rose M. Singer Center, the women's facility on Rikers Island. Two women in jumpsuits several yards ahead followed the order.
Red and yellow stripes line the floor of the fluorescent-lit corridor. Inmates on either side. Staff in the center.
Asked why the inmates had to walk in a straight line, military-style, Cuin explained: "It's just control. That's what it is."
Later on, Corrections Commissioner Dora Schriro explained further.
"Our primary mandate to focus on is 'Safety Now,'" said Schriro, detailing her new department philosophy. "The statute, at a minimum, expects the Department of Correction to prevent bad things from happening."
Schriro just celebrated a full year on the job. She was previously the head of corrections in Arizona and Missouri and had a brief stint as an advisor on immigration in the Department of Homeland Security.
So, her personal philosophy is still being teased out here on Rikers. Nonetheless, inmates aren't in rehab, although Cuin said they hold daily Alcoholics Anonymous and Narcotics Anonymous meetings and regular group therapy sessions at the women's facility. It's a jail.
Balancing safety with required mental health care can be precarious -- especially when two thirds of the violent incidents that occur at Rikers involve someone classified as mentally ill, said Schriro.
Health care comes second.
"It's only after they have symptoms or behaviors that by the Department of Corrections standards are dangerous," said Dwayne Mayes, executive director of the Howie the Harp program, a peer advocacy group for the mentally ill that contracts with the health department at Rikers. "They are subjective to punitive measures as opposed to health measures."
And some results are mixed.
James, whose first and last name are being withheld due to safety and privacy concerns, has battled schizoaffective and bipolar disorders since 2003, said his mother, Elizabeth, whose middle name only is being used.
But James early this year had been taken off of his medication by a therapist in the Bronx, Elizabeth said. On Mother's Day he was riding the bus when he felt threatened by a female passenger. James found a stray piece of glass, slashed her face and ran away.
He ended up in Rikers' mental health facility -- the Anna M. Kross Center -- in a group dormitory setting, said Elizabeth. Nervous and agitated, he refused to shower, and he was punished for it. When another inmate punched him unprovoked, he ended up in the hole (or solitary confinement), said Elizabeth.
"People who don’t understand people with mental illness, they don’t get it," Elizabeth, who has been communicating with her son and advocates on a daily basis. "We get up and bathe every day. People don’t understand that."
On other occasions, Elizabeth said, her son was so overmedicated he was to the point of drooling. As of Friday, Elizabeth was able to get James his own cell back at the mental health facility and on the right medication. But she and advocates wonder what happens to inmates who don't have someone pushing from the outside.
No one questions that since 1999 the city has made improvements in how they handle the mentally ill on and off of Rikers Island.
For the past year, Schriro, has been ruminating over population statistics and procedure. In August, she unveiled her first major policy shift as the head of the country's second largest jail system (the first is Los Angeles County).
She is going to build a new jail and tear down the dilapidated temporary facilities erected during the crack epidemic of the 1980s (facilities that resemble small white spacecraft instead of jails). Hailed by criminal justice advocates, the commissioner is also centralizing the intake procedure, making sure inmates are classified up front. She plans on consolidating staff and some of the mental observation units, streamlining the process. There are now seven separate units spread out throughout the island.
Starting this month, Schriro launched a pilot program to provide corrections officers with additional training on mental health issues. The commissioner says she is approaching correction and health department staff "as a team who together can create a continuum of custody and care that can be carried out not only in the hours and days that our clinical staff is there."
Advocates have called for additional training for a very long time.
The department of health also has almost completed its electronic patient records system on Rikers (now active in several jails). The new system will make sure there is an ongoing record of those with mental health issues on the island.
Should an inmate come back, officials don't have to start off at square one. They can pick up where they left off, said Schriro.
Advocates commend the effort.
"Commissioner Schriro is making really valiant attempts to do something about this," said Joel Copperman, the chief executive officer and president of CASES. "She recognizes the reality that people are coming back to Rikers Island, so what she wants is to understand it, to develop treatment plans."
These represent steps in the right direction, advocates said. But a more seamless transition to society is still necessary to make sure those without advocates or parents by their side can get help too, they add. That means better communication between the agencies overseeing health care and the service providers on the outside. It means getting the proper diagnosis and classification as soon as one enters the system.
Back at CASES, Derrick Neptune, a 36-year-old diagnosed with schizoaffective disorder who has been to Rikers four times, called his treatment off and on the island "helpful."
After spending five years in the shelter system, Neptune now lives in Flatbush in Brooklyn. He attends barber school. He is taking medication and quit smoking marijuana -- the so-called cause of many of his psychotic episodes.
"You learn a lot from being in jail," said Neptune.
So much that he hopes he won't have to go back.
Timothy Chuang has been in the restaurant business in Flushing for more than 20 years. He said it is hard to do business these days and the city's new sanitation inspection letter grade system is not helping.
The system, approved by the food and community health board in March and effective on July 1, will require food establishments to post letter grades on front windows or entrances easily seen by the public.
This week restaurants that got A's began posting the grades in their windows, and the city launched a website that will present the grades and other information on an establishment's inspection as it becomes available.
Chuang is among the many restaurants owners in Flushing who publicly support the new letter grade system but fear they are at a disadvantage because of preconceptions or misunderstanding about Chinese restaurants. Many are afraid they will get a bad grade, which might deter customers.
Faced with such concerns, the health department said it has made concerted efforts to educate and reach out to restaurant owners in all five boroughs. The agency has held workshops in Chinese, Cantonese, Korean, and Spanish.
"Our inspectors go through extensive training. They are all professionals," said Erin Brady, deputy press secretary at the health department. "They follow very specific protocols, and all restaurants are treated equally."
It is still too early to know how the letter grades will affect the city's 24,000 restaurants and their patrons since it will take more than a year for all the restaurants to get their first report card, according to the health department.
The schedule "depends on each restaurant’s inspection cycle," Brady said. "For example, the ones that were inspected last July are being inspected now."
The letter grade system, similar to the one in Los Angeles, aims to promote sounds sanitary standards for preparing and serving food. According to the health department, the proportion of restaurants in Los Angeles meeting the highest food-safety standards rose from 40 percent to more than 80 percent in seven years, and hospitalizations for food-borne illnesses declined.
"The health department is issuing restaurant letter grades to help consumers make informed choices about where to eat out," said Brady. "Consumer awareness creates a powerful new incentive for restaurants to maintain the highest food safety standards."
At a press conference this week, Mayor Michael Bloomberg said he does not expect to see many low-scoring restaurants. "The best thing that could happen is for everyone to get an A," he said. "That's what we're trying to do and get everyone to that level."
The grades, A, B or C, will correspond to the business's sanitary inspection scores based on a point system, which has been in effect since 2005 and can be viewed on the health department's website. A restaurant will get an A if it receives no more than 13 points for violations, and a B if it gets between 14 and 27 points. A C, the lowest grade given, is assigned if the restaurant gets 28 points or more for violations. The system does not specify how many points will result in the closing of a restaurant. Instead the department will determine that on a case-by-case basis, depending on the severity of the violations.
Some food establishments are not regulated by this new system, including mobile lunch trucks, school cafeterias, soup kitchens and restaurants owned by nonprofit organizations that only serve food to their membership.
Although restaurants getting As, Bs and Cs all are deemed sanitary enough to serve food, the grade determines the frequency of inspection. An A restaurant gets inspected once a year, and a B restaurant gets it every five to seven months. The health department will visit a C restaurant every three to five months.
Some restaurant owners see they system as adding to one the many regulations set by the health department. To Ricky Nacipucha, who owns El Pollito Mexicano restaurant in Park Slope, every inspection means a minimum fine of $200.
"They will look for everything," said Nacipucha, a native of Ecuador. "They give violations for no reason."
If a restaurant is not satisfied with its grade, it can appeal to the health department's administrative tribunal and post a sign that says "Grade Pending."
"I always take pictures when inspectors come so I can fight them in court," said Nacipucha. "At first, I didn't know. But my restaurant friends told me I could appeal. Last time I had seven violations but four were dismissed." He added that he once managed to reduce his fine from $3,800 down to $1,000.
Mario Suvia, a manager at El Pollito Mexicano, added that some inspectors are on a mission to find fault.
"They really want to take points," said Suvia. "They have to find something."
Marilyn Reid, owner of The Islands, a Caribbean restaurant on Washington Avenue in Prospects Heights, said she is confident that her restaurant is clean and her customers are loyal.
"We'll never get a C," said Reid, who came to New York from Jamaica 35 years ago. "Whatever the grade is, it does not reflect the quality of our food."
A search on the health department’s website shows that her restaurant received 20 points of violation when it was inspected in March, which can be converted to a B.
"They are killing me with regulations," added Reid, showing the latest posters on food allergies she said she must post on the wall, which is already covered with various notices from the health department. "I am sure a lot of small business owners will agree with me."
Local community organizations and elected officials have worked with the health department to educate business owners on the new rules. City Councilmember Peter Koo of Flushing, said that business owners must understand and comply with the regulations if they want to conduct business successfully.
"It's not hard to follow the rules," said Koo. "But there are a lot of insensitivities among the inspectors, especially if you don't speak English."
Koo is pushing to form an Asian restaurant alliance and will send his staff members to courses held by the health department so they in turn can help train local restaurant owners and their employees.
In New York City, all restaurant managers must be certified in food protection. A course is available in Chinese, Korean, Spanish and English at the department's health academy. The course lasts 15 hours (three hours a day, Monday through Friday) and costs $114. It also is available online in English, Chinese and Spanish with free access to course material and a $24 fee for the certification exam.
Andrew Rigie, director of operations of New York State Restaurant Association's Greater New York City chapters, said the letter grade is not the most responsible system because the health code is too complex and nuanced for the public to understand what the grades mean.
"A restaurant should either pass or fail the health inspection. You are either sanitary enough to serve the public or you are not," Rigie said.
When asked by reporters, Bloomberg said he would not eat at a favorite restaurant if it got a C. As to one that received a B, he said, "It depends on the food."
Charlie Hauber, a public school teacher from Jackson Heights who frequents Flushing Mall's food court with his family, said the letter grades might influence his decisions only when it comes to a restaurant that he has never visited.
"But if it is a place that I often go to and I see a lot of locals there," said Hauber. "I would still go."
Chris Enright, a tour guide from Park Slope who was enjoying a chicken burrito at El Pollito Mexicano, agreed with Hauber.
"For unfamiliar places, if I have to choose between an A and a B restaurants, I would probably choose the A," said Enright, who had lived in Los Angeles.
"It is hard to run a restaurant. This just adds another stress to them," he said. "But they need to be held to standards."
Larry Tung is a Brooklyn-based journalist and media artist.