Gotham Gazette

The Place for New York Policy and politics

Topics

9/11 Health Care Bill Could Get Boost in Congress


Photo (cc) viewmaker

There’s a type of wind that blows in off the North Shore of Long Island that is not only so sharp and cold it burns your face but also has enough force that if it hits you at the right angle, it can knock the air away from your mouth as you try to inhale. Just after Christmas, as firefighters gathered outside a Suffolk County church for the funeral of retired firefighter James Ryan -- who died from cancer doctors believe was caused by toxins he was exposed to while doing recovery work at Ground Zero -- the burning wind augmented another chilly reality for New York’s Bravest: Ryan was not the first front-line responder to die from a 9/11-related illness, and he will certainly not be the last.

Exactly a week later, many of those same responders gathered by the World Trade Center site to read the names of 9/11 responders and Ground Zero recovery workers who have died from illnesses related to their duty. It was the fourth anniversary of the death a another notable responder, New York Police Department Detective James Zadroga, whose name is attached to a bill in Congress that would establish permanent funding for health treatment and monitoring programs for 9/11 response workers and lower Manhattan residents, students and workers.

The medical centers treating the thousands of 9/11 responders as well as lower Manhattan residents and workers suffering from respiratory ailments and mental illness such as post-traumatic stress disorder survive on annual appropriations funding from Congress. Already a precarious situation, the financial crisis makes things shaker, which is why advocates are intensifying their push for a more reliable funding source.

Show Us the Money

The hold-up -- legislatively speaking -- is in the House Energy Committee. The bill has two parts. The compensation and health component was approved with bipartisan support in the Judiciary Committee on the former aspects terms, but the health subcommittee of the Energy Committee hasn’t voted on it, as its chair, New Jersey Democrat Frank Pallone, is not sure there is enough support for it.

The bill’s supporters -- among them New York Reps. Carolyn Maloney and Jerrold Nadler, both Democrats, and Peter King, a Republican -- say the votes are there.

However, it has been difficult for lawmakers outside the tri-state area to commit to it, since the measure carries an undetermined price tag. "I am more confident than I have ever been, but like anything it's never done until it’s done," Maloney said, noting that the Zadroga Act has the support of House Speaker Nancy Pelosi.

The bill has had a complicated history among the various groups who support long-term federal funding. The main city police union -- the Patrolmen’s Benevolent Association -- has opposed the bill’s current language because it does not specifically mention certain cancers. They have feared this means that members who develop those cancers would not be covered. Other police and first-response unions believed it is more important to pass the bill now and tweak conditions -- such as adding the cancers -- later.

Resident and worker groups such as Beyond Ground Zero have had similar reservations and also noted that the bill covered residents, students and workers only from Houston street to South Ferry in Manhattan. They believe that the coverage area should extend at least to 14th Street, of not higher.

Even if the activists can push the measure through the House, the Senate will be another story. If the health-care reform bill is any indication, the Senate is far more averse to government funding for health-care than the House. And the senator who had been credited with pushing for much of the current temporary funding, Hillary Clinton, is now secretary of state.

At the ceremony on the anniversary of Zadroga’s death, John Feal -- who heads a 9/11 responders group called the Feal Good Foundation-- showed his technique for passing the bill as soon as possible by displaying his chief weapon: a piece of Whole Foods pork.

"That’s how we get votes right? We give someone in Washington some pork," he said, citing the recent drive to pass the health-care reform bill by offering funding provisions geared to specific states. "So what I’m going to do is mail every member of Congress one these pieces of pork, and I'm going to put a 9/11 responder’s name on it."

Death and Glory

Meanwhile, the 9/11 first responders, their families and supporters face other issues as well.

Ryan’s funeral, at first glance, looked like the typically ornate send-off the city's fire department is famous for: the Emerald Society’s rendition of "Amazing Grace" and a salute by columns of uniformed members. But it wasn’t an official Fire Department event with eulogies from the mayor and commissioner. Those events are reserved for firefighters who die on or as a result of injuries sustained on their shift. Those who die years later don’t count, and 9/11 responder families take this as a snub.

Fire Department officials responded that while members who die long after 9/11 don’t get the official "line of duty" funeral, Ryan and many others did retire with a disability pension, meaning they get three fourths of their average annual salary for their last three years on the job, as opposed to half the salary, which is the standard benefit. In addition, they said, Ryan's family was virtually guaranteed a full death benefit.

But for many first responder advocates, including the heads of unions and fraternal groups, the pomp and circumstance matters. They have voiced their protests for people, such Paramedic Deborah Reeve, a dead Ground Zero worker whose death was designated an "administrative line of duty death." One activist joked that this sounded like she died from a paper cut.

There is a split between how the police and fire departments handle this kind of death in terms of memorials. Police officers like Zadroga, have their names displayed on the police department's memorial wall in lower Manhattan, along with cops who died on their shift, such as officers shot and killed by assailants. Ryan’s name, though, will not be affixed to the Fire Department's memorial wall at its downtown Brooklyn headquarters, along with the 343 FDNY members perished as the towers collapsed.

Mayor Michael Bloomberg has the power to set a single standard for honoring uniformed responders who die in the line of duty. But he has said he won’t. "I think each agency has to make its own policies," he said at a recent press conference. "There are great traditions that go back a long ways in both these departments."

Uniformed Firefighters Association president Steve Cassidy said that after Ryan’s funeral, much of the media coverage treated his as a line-of-duty death -- more than had been the case for another responder who had died before him. This, Cassidy said, gives him hope that pressure has increased not only on Washington to enact the Zadroga bill but also for the city to give further honors to responders like Ryan.

"A sense of change is in the air," he said.

Ari Paul is a reporter for The Chief-Leader, a weekly newspaper covering city government and the civil service, and a correspondent for Free Speech Radio News. Due to a computer error that deleted key words, this article originally incorrectly identified Rep. Pallone and Rep. Maloney. The error has been fixed.

Ban on HIV Positive Immigrants Lifted


Photo (cc) ttfnrob

Enrique Chavez, a native of Lima, Peru, was excited about the prospect of joining his father and sister in the United States in 1991 when his father, a Green Card holder at the time, sponsored him for immigration. However, that dream quickly vanished when he was tested positive for HIV during the medical exam required for prospective Green Card applicants. The officers at the U.S. embassy told him that result made him ineligible for immigration to the United States.

"The doctor told me I had one year to live," said Chavez, calling the diagnosis a social as well as a medical one. "I went into depression." His job at a trading company was not renewed because his boss found out he was HIV positive, and a neighbor threw rocks at his house. His family was extremely supportive, but it took him another 12 years before he finally immigrated to the United States.

On Oct. 30, President Barack Obama made a major announcement that should help prevent similar stories in the future. He removed a 22-year-old ban on travel and immigration to the United States by individuals with HIV or AIDS. Calling the ban "a decision rooted in fear rather than fact," Obama also reauthorized the Ryan White Comprehensive AIDS Resources Emergency Act, which funds the largest program in the country to provide care and support for people living with HIV or AIDS.

"We lead the world when it comes to helping stem the AIDS pandemic -- yet we are one of only a dozen countries that still bar people from HIV from entering our own country," the president said. "If we want to be the global leader in combating HIV/AIDS, we need to act like it.”

Many applauded the announcement, saying it finally ends the discrimination.

"HIV or AIDS is just another disease like diabetes," said Chavez. "It transmits, but it is not contagious."

Shut Out

After the diagnosis and the loss of his job, Chavez, still in Peru, started volunteering at the local AIDS organization, Via Libre, which eventually offered him a staff position. Miraculously, he continued to live without any HIV medication because it was not available. But seeing many people suffering helplessly, his dedication to HIV/AIDS advocacy work grew stronger.

"I watched my friends die," he said. "Sometimes three or four died in one night. I need to work hard to make sure they have medicine and better quality of life."

In 1996, Chavez started to take medication through a program run by Aid for AIDS, a New York-based organization that provides services to people living with HIV or AIDS in Latin America and the Caribbean as well as immigrants from the region. It is called the HIV Medicine Recycling Program, which provides unused medication to patients in Latin America. The organization also runs other programs, including AIDS treatment access, immigrant program, children’s program, and prevention program among other things.

In 1998, Aid for AIDS established a branch office in Lima and hired Chavez. As he gained prominence in the HIV advocacy world in Latin America, his missed his father and sisters in the United States. In 2003, after a one-month trip to the United States on a one-year double-entry visa with a special HIV waiver, Aid for AIDS asked him to relocate to New York to serve as its director of advocacy. But his HIV status came up again as a problem. This time, he sought political asylum.

No Easy Asylum

"In my case, I had to prove I was persecuted because of my sexual orientation and my activism," said Chavez. "In addition, I had to prove that there was no medication available to treat HIV in my country."

Chavez is one of the few lucky ones. Obtaining legal status through seeking asylum is not an easy task and it requires a lot of supportive material, according to Vishal Trivedi, project manager of the Immigration Project at Gay Men’s Health Crisis, which provides direct legal representation as well as consultation.

"You have to submit the application within a year of your entry," Trivedi said. "The basis of asylum is either past persecution or a well-founded fear of future persecution. You can argue that because I am HIV positive, I was a target of persecution or it is likely I will become a target. … I would be beaten, tortured or killed and there is no government protection."

"The burden of proof is on the applicant," said Trivedi, adding that proof can include documents such as State Department reports, reports by Human Rights Watch, newspaper articles, scholarly study and eyewitness testimonies.

For Eric Wong the obstacles proved too great. A native of Hong Kong, he came to New York in 1998 as an international student and tested HIV positive in 2000.

"I cannot seek asylum because I am not persecuted in Hong Kong, and there is medicine available," said Wong, who used a false name to protect his privacy. "But everybody has preferences in terms of where to live. This is where I feel most comfortable."

After graduation, Wong worked for a company on a H-1B work visa for six years until the visa expired. When the company offered to sponsor him for a Green Card, he declined, fearing that the medical exam required for the application would reveal his HIV status. He later switched to a different employer and obtained another temporary work visa under a different classification.

Obama’s announcement brought him hope.

"It was huge," said Wong. "I was in tears. Who would’ve thought? It is like part of my dream came true. Now I realized that I actually have an opportunity, even though it is very slim."

To Wong, immigration is a race with time. His current job is not permanent and will most likely end next year. So the Obama announcement could provide a reprieve. Now that his HIV status is no longer a roadblock, he can try to obtain a work visa other than H-1B.

Wong wants to get an O Visa, which is granted to people with extraordinary abilities. His lawyer said this would be difficult. Another alternative is to get married. But being gay, he cannot marry his longtime partner in New York and does not want a paper marriage. Wong does plan to enter the diversity visa lottery, which allows citizens from countries with low immigration to the United States to enter to win a Green Card.

Chilling Effect

The entry ban, introduced during the peak of the AIDS pandemic, was written into immigration law in 1993. It included mandatory HIV-testing as part of the medical exam.

The rule has had a long-lasting effect on Wong, who is paranoid about traveling. "Every time I left the country, I had to flush all my pills down the toilet on the way back before I got off the plane," said Wong. "What happens if they check my luggage and find all those pills? I was afraid to travel. Everything was in limbo."

In addition to the stress and anxiety, the cost of HIV medicine is also prohibitive. Wong pays $1,000 a month for his health maintenance organization because his employer does not provide health benefits.

"But I am lucky to have a job and could afford the medicine," said Wong, who prefers to pay for his own treatment rather than to seek help from HIV organizations. "My insurance is expensive but it doesn’t have many restrictions. My immigration problem is stressing me out already, so I just want to make sure I have a good health insurance."

Syphilis Rate Rises Despite Public Health Efforts


Image: syphilis bacteria
Image from the cdc.gov
Syphilis is caused by the spirochetal bacterium Treponema pallidum.

The solution is not simple, and the cause is even more complex. That's what experts and advocates say about the reemergence of syphilis in New York City and across the country. The number of cases among both men and woman and in all ethnic groups has risen, but the disease hits some parts of the population more severely than others.

In an effort to combat syphilis and other sexually transmitted diseases, the city health department handed out a record number of free condoms this year. Government and private groups have launched public education campaigns, and free testing clinics exist around the city. Still, as the numbers continue to rise, advocates think the city and health organization must design campaigns more closely tailored to the group hardest hit by the increase in the infection: men of color who have sex with men.

The Disease's Targets

In 2000, the national syphilis rate fell to its lowest point since 1941. But it has increased annually since then; New York City cases nearly doubled to 282 in 2001, according to the Centers for Disease Control and Prevention. This year 1,079 cases were reported, up 12 percent from last year. City health department data shows that the highest concentration of syphilis is in Chelsea.

Men who have sex with men account for 87 percent of cases, with the disease most prevalent among African-Americans. Well over half the victims are HIV positive.

"The connection between HIV and syphilis is really disturbing," said Sean Cahill, managing director of public policy, research and community health at Gay Men’s Health Crisis in Manhattan.

Syphilitic sores facilitate transmission and contraction of HIV/AIDS. And the same is true the other way around -- anything that weakens the immune system makes people more vulnerable to other infections.

This bacterial infection spreads through skin-to-skin contact. Congenital syphilis is passed from a mother to her child during childbirth. According to the website of the New York City Department of Health and Mental Hygiene, antibiotics can cure syphilis, but the chances of curing the infection becomes more difficult the longer someone waits to get treated. The most infectious stages of the disease are primary and secondary syphilis. These stages are also the easiest to treat.

A Web of Risks

Experts point to a number of factors that have contributed to the resurgence in syphilis. One is what health experts call "risky sexual behavior," including having unprotected sex and having multiple partners. The 2009 Mayor's Management Report, for example, attributes the rise in the disease "primarily to increases in risky behavior among men who have sex with men." One factor here is substance abuse.

Jose Gonzalez is the founder and president of TRI Center, which offers rehabilitation services in Manhattan, Brooklyn and the Bronx. Gonzalez said there was a "high correlation between sexually acting out and the drug use." He added that education about how to avoid HIV and sexually transmitted diseases can be part of some people's treatment plans. Engaging in high-risk sexual behavior and other compulsive behavior is "just one of the medical aspects of the disease" of addiction, Gonzalez said. He said health clinics should ensure that clients who test positive for STDs are asked about their substance habits to see if they need more comprehensive care.

At the Lesbian, Gay, Bisexual and Transgender Community Center, substance abuse treatment focuses on the clients' particular vulnerabilities. "We’re looking at the areas we would call 'disconnections,'" said Carrie Davis, the director of adult services who also directs the center's CARE Wellness and Recovery programs for substance abuse treatment and prevention.

Social stigmatization can cause these "disconnections" or "isolations," as can particularly difficult transitions in people's lives, like coming out to family members. Hard times can lead to substance abuse and other risky behavior, which could play a factor in the spread of sexually transmitted diseases.

"From an overall prevention standpoint, I think it's really critical that we de-stigmatize LGBT identities," said Davis.

Unprotected sex also has to do with inadequate or absent sex education for young people, said Cahill from Gay Men’s Health Crisis.

While condom use has increased around the city, Cahill said not everyone uses them properly. For example, some people may use lotions that render the condom ineffective. Susan Blank, assistant commission for the city's Bureau of STD Control, said people reported not using a condom during oral sex, when syphilis also can be transmitted.

But risky behavior cannot explain the racial disparity incidence in sexually transmitted diseases. In 2006, non-Hispanic blacks of all ages had the highest rates of chlamydia, gonorrhea and syphilis of any group nationwide, according to the Centers for Disease Control. But national and New York City studies show that gay and bisexual African-American men do not participate in behaviors deemed "risky" at a higher rate than white men who have sex with men.

A New York City report produced as part of the National HIV Behavioral Surveillance Study found that white men who have sex with men "had the lowest HIV prevalence, yet higher rates of many HIV risk factors." For example, binge drinking and alcohol use during sex were more common among whites.

New York City is one of 25 sites participating in the national study, which began in 2004 and focuses on at-risk populations.

Patrick Wilson, an assistant professor and researcher at the Mailman School of Public Health at Columbia, is among those studying why African-American men have higher rates of syphilis than white men. He says a key factor is an individual's "sexual network," such as the number and profile of partners.

In addition, Wilson has found, there is a kind of vicious circle at work here: The prevalence of syphilis and other sexually transmitted diseases among African-Americans produces high rates of HIV and vice versa. Also, Wilson has looked at the characteristics of the sex partners and has found evidence that young African-American men tend to have older partners. Older partners, by virtue of their age, are more likely to have syphilis themselves and more likely to have sex with men of the same race/ethnicity, said Wilson.

Getting Treatment

And then there is access to health care.

"Access to treatment and health care is a huge issue," said Wilson, Dealing with that, he said, is "not an easy step to take but it is a step that we can take."

A 2007 report by the city health department in 2007 found that " Hispanics, men, younger adults, people with low income, and residents of the South Bronx, South Brooklyn, and West Queens are more likely than others to lack insurance and a regular provider." It determined that 25 percent of Hispanics, 21 percent of Asians/Pacific Islanders, 16 percent of blacks and 11 percent of whites in New York City were uninsured in 2005.

The study also compared data on testing for HIV, finding that "among those with two or more sex partners in the past year, those without a regular provider are less likely to have been tested recently." Delaying treatment increases the severity of the virus and likelihood that the infected person will pass it on, whether it's HIV or syphilis.

The Latino Commission on AIDS, based in Manhattan, has tried to create a space geared specifically toward Latinos. The commission’s director of health policy, Oscar LĂłpez, pointed to their MPowerment Project as particularly successful and effective.

"The focus is building community and addressing the feelings of isolation that many experience,” said LĂłpez, who explained that many of the members only speak Spanish and are separated from their families. While the commission only offers HIV testing, the experiences of its members indicate many avoid other types of testing or care. LĂłpez said many of the men he works with have a "mistrust of the system" or worry about deportation, so they either do not seek medical attention.

The city tries to encourage these men to overcome their fears. Its Bureau of STD Control operates 10 free and confidential testing clinics: three in Manhattan (although one in Central Harlem is closed for renovations), three in Brooklyn, two in Queens, and one each in the Bronx and Staten Island.

Blank said that staff doesn't ask for immigration papers before testing a patient. LĂłpez agreed that he had never heard of such a case in New York City, but that undocumented immigrants had been picked up in other states and these stories can act as a deterrent.

Fighting the Disease

The current resurgence in syphilis is surprising but not completely unexpected due to the many factors working together to spread the disease, said Wilson. He believes the trend will reverse but only with a lot of work.

"It really depends on our prevention and our treatment efforts and how robust those efforts end up being," Wilson said. And those efforts have to correspond with the actual trends and the reasons for those trends. According to Wilson, doing that also requires support from all levels of government and funding to bolster efforts already in existence.

On a state level, the New York State Department of Health, AIDS Institute and Center for Community Health, and Health Research, Inc. accepted grant applications last month for organizations working with gay men and men of color who have sex with men.

The city also has made efforts to collaborate with community-based organizations to combat the spread of syphilis. The Syphilis Advisory Group, formed as a direct response to the flare up in 2002, according to an email from the health department press office, is a coalition of the health department, the New York State AIDS Institute and community-based organizations that work with gays and lesbians. The group aims "to improve the quality of internet-based HIV and STD prevention, as well as partner notification services."

The Internet could play an increasing role in this, according to Wilson. Companies have created anonymous online notification systems to allow people to inform past sex partners if they are at risk of infection and encourage them to get tested.

Davis also would like to see advocacy and information at commercial sex venues, where adults to pay to engage in sexual activity on site. This, he said, could keep the parties from going "underground."

The advisory group is looking into this too with the Commercial Sex Venues Workgroup. With the help of the health department, the group plans to "establish new community partners (e.g., owners of sex clubs) to raise syphilis awareness in these venues, increase condom usage, and encourage regular STD screening."

Gay Men’s Health Crisis currently provides testing at three commercial sex locations in the city, said Cahill.

In the past, the city had tried to shut down such establishments. Cahill said he did not see a push for closures recently. But these are fights that date back to the early years of the AIDS epidemic and government closures of bathhouses in an effort to stem the rising crisis.

With the AIDS crisis, there was a tendency to blame the victims. With syphilis, Wilson and others said it is important not to do that.

"There’s not a sound bite that can really explain how this happens," he said. Dwelling on that, he said, could only end up “maligning” affected communities.

Instead, Wilson said, efforts should remain focused on targeting the numerous facets of the disease: "We’ve still got a firefight going on. It’s not at all over."

Plan's Move to Senate Presents Challenges for New York


Photo (cc) uberzombie
Ambulances wait outside Columbia University Medical Center

The financial stakes of federal health care reform are high. I am a strong believer that we need to rethink the way we provide health insurance for all Americans. However, I also feel strongly that the health care reform legislation currently under consideration in the United States Senate can and must be made better for the residents of New York State.

As New Yorkers, we should be proud of our state’s trailblazing leadership in developing important public programs like Medicaid, Family Health Plus and Child Health Plus. By broadening eligibility for these programs, we have dramatically reduced the ranks of uninsured. Unfortunately, under the bill approved by the Senate Finance Committee last month, New York and nearly 10 other so-called leader states will be fiscally punished for their efforts.

The Senate bill would provide new federal money only for states whose eligibility for public coverage programs currently falls below the new federal minimum -- an outcome that the New York state health department estimates will result in an additional $900 million in annual costs for New York State. In this area, the House bill is better and rewards all states -- regardless of previous coverage levels -- for expanding public insurance coverage.

Penalizing High-Cost States

The Senate Finance bill also could better address the needs of high cost of living states, like New York. This bill provides insurance premium subsidies based on the federal poverty level, which does not recognize the high cost of living -- and of health insurance -- in New York State. The value of the proposed insurance premium subsidies will not go very far in New York’s high-cost health insurance market.

A new affordability exemption, included in recognition of the unfair burden that high health insurance premiums might place on lower-income families, would allow many New Yorkers to opt out of the insurance mandate. Some estimates indicate that as many as 500,000 New Yorkers might accept this exemption and remain uninsured. While nearly 2 million would still get coverage, I believe that we can, and must, offer better subsidies to reflect the realities of high cost states such as New York.

Protecting New York's Protections

New York has some of the strongest consumer protections in the nation. Our state has guaranteed open enrollment and renewal and significant limitations are placed on insurers regarding exclusions for pre-existing conditions. We are the only state in the country that has a pure community rating model, meaning that health insurance rates are the same for everyone, regardless of age or health status. This protects our most vulnerable residents and ensures that the cost of illness and disability is shared fairly across our state.

New York also has strong external review and appeals protections, which encourage expeditious resolution of claims disputes. The Senate Finance bill would curb the worst insurance abuses and provide new national protections that would act as a national floor, but not a ceiling for insurance regulation. But insurers still will be able to charge higher prices for older people and people who smoke. New York will maintain its superior rules, though some are concerned that the existence of a federal floor will create pressure on New York to loosen its laws.

Several other provisions of the Senate Finance bill raise red flags for New York State. Its version of health care reform would change one of the ways that we reimburse hospitals that care for people who do not have insurance. This would devastate New York City’s public hospital system, the Health and Hospitals Corp., for which these payments are a critical source of funding.

A new small business tax credit, meant to help small businesses because their cost of insurance is higher than for larger companies, is pegged to wage rates. Hence, New York’s high cost of living and relatively high wages would leave many small businesses ineligible for federal help.

Finally, a tax on high-cost insurance plans, intended to discourage people from buying more health insurance than they need, will harm many New Yorkers more than people in other states. The high cost of health care in the state has led to insurance premiums that are correspondingly high and the relatively high rate of unionization in our state has led to more generous benefits packages for New York workers. As a result, New Yorkers will likely pay considerably higher taxes on their health care.

Looking Out for Our Interests

So where does this leave New York? The good news is that there is still time to improve the Senate bill -- first in the melding with the Senate Health, Education, Labor and Pensions bill, and second when the House bill and the Senate bill are crafted together in conference. In addition, none of the provisions of health care reform begin immediately, which provides New York State an opportunity to think through our plans.

It would be wise for our state to put together a team that includes representation from the executive and legislative branches, as well as relevant stakeholders, to generate, discuss and vet ideas and plans. Bringing providers, consumers, health plans providers and insurers together increases the likelihood of getting it right, and of being sure that key issues are not overlooked. National health reform presents a huge challenge for New York State. It will take all our best efforts to get it right at the federal level and make it right for New York.

Thomas K. Duane, a Democrat, represents 29th Senate District on Manhattan's West Side and parts of the East Side and chairs the Standing Committee on Health.

Fixing a Broken System


The national discussion of health care reform has huge implications for our state, and I believe it is critical that Congress and the president reach an agreement that moves us down the road to real reform. The heated rhetoric and spurious charges that opponents of any reform were making in August seem now to have quieted down a bit, and both houses of Congress are moving toward their own versions of a reform package. Speaker of the House Nancy Pelosi released the new House leadership bill (the Affordable Healthcare for America Act, H.R. 3962), and Senate Majority Leader Harry Reid is expected to release a new Senate leadership bill some time in early November. While I have strong preferences as to what needs to be in the final legislation, the good news is that some fundamental reforms that will address the most serious problems of our health care system are now under serious discussion.

It is important to remember why we are undertaking this exercise: The current system is not working. In New York, 2.5 million people, or 13 percent of the state’s population, do not have health insurance. The uninsured are overwhelmingly represented by groups like the poor (47 percent of uninsured adults in New York State have incomes under 200 percent of the federal poverty level), minorities (while 13 percent of whites are uninsured, 21 percent of African Americans, 23 percent of Asian/Pacific Islanders, and 31 percent of Latinos are uninsured), and immigrants (30 percent of the uninsured are non-citizens).

An Unacceptable System

Health care costs continue to skyrocket while millions go without any health coverage at all. To the extent that these millions receive care, it is through emergency rooms – after they are already far more ill than necessary – which is a horribly ineffective way to deliver services, both in terms of the health of the individual and of the cost to the system.

Critics of reform claim health care will be rationed under the new system while they fail to acknowledge that we have more rationing of healthcare in the United States now than anywhere else in the developed world. But since that rationing occurs under the guise of inability to afford to treatment, or by the denial of coverage by insurance companies, some seem to see that as acceptable. It is not.

The costs of continuing our current system are simply unsustainable. Over the last decade, employer-sponsored health insurance premiums have increased 119 percent – four times the rate of inflation. A study of bankruptcy filings in 2007 found that 62 percent of them were related to medical expenses, and that it was not just the uninsured who were affected. In 80 percent of those bankruptcies, the filers had insurance that failed to adequately cover their costs. Without national health care reform, by 2018, national health care expenditures are expected to reach $4.4 trillion – more than double 2007 spending.

What Reform Must Do

Fundamental reform must meet the following basic criteria:

  • Access to insurance for all Americans, regardless of income;
  • Cost containment through increased competition and improved efficiencies;
  • Preservation and strengthening of Medicare and Medicaid as a foundation for expanded coverage;
  • Shared responsibility: Government, individuals, the industry, taxpayers and businesses must all equitably participate in reform; there need to be targeted incentives and penalties to encourage full participation by employers and individuals;
  • Ensure reform is sustainable during all economic conditions: The federal government must create a system of counter-cyclical funding so that states have the necessary financial resources to ensure health care for al even during economic downturns. States like New York, which are ahead of other states in providing public health options, need to maintain our existing federal matches and must not be penalized for having been in front of the curve.

Obstacles to Change

The plans proposed by the House and the Senate all attempt to balance these goals with greater or lesser degrees of success. I believe the reluctance of some in the Senate to support a public option undermines the ability to achieve the appropriate balance of these goals because it leaves private insurers with little incentive to change their long-standing practices and huge profit margins, which have led to the skyrocketing costs we now see. A robust public option will provide more choice for consumers and businesses and create greater competition in the insurance market.

The arguments against a public option are also often blatantly self-contradictory -- arguing that we can't let government into the insurance business because government is inefficient, at the same time suggesting government would drive private insurers out of business by offering better benefits at a lower cost. And these critics seem to forget that government has run Medicare and Medicaid with much enrollee satisfaction for years.

The health care industry is a huge part of our economy, directly employing the equivalent of more than 357,780 full-time workers in New York, including 72,000 registered nurses. Nationally healthcare makes up more than 17 percent of our gross domestic product.

Reforming health care is not an easy thing, and we have certainly seen past presidents who took on this issue fail. But this time around there seems to be a greater recognition that we must address this crisis now, both for the well being of our citizens and for the economic health of the country. We can and should fight over the details of the final plan, and hopefully do so in a civil and constructive manner, but in the end we must recognize that the worst possible outcome is the status quo -- a broken health care system, with out-of-control costs, which leaves millions of Americans unprotected.

Liz Krueger, a Democrat, is the New York state senator from District 26 on Manhattan's East Side.

New York: Model or Warning?


What does health care reform mean for New York?

The better question might be what New York’s strict insurance regulations and high spending on Medicaid means for the nation. If Congress follows in our footsteps -- as key bills in the House and Senate seem to do -- New York's situation might not get any worse, but certainly won’t get any better.

And the status quo is simply unsustainable in the long run.

New York’s world class hospitals and physicians offer cutting edge health care -- at least if you have good health insurance. Currently, there are about 2 million uninsured in the state, about 14 percent of the non-elderly population (residents over 65 are covered by the federal Medicare program).

Regulating and Spending

But Albany has not ignored the problem of the uninsured. New York’s private, individual health insurance market is among the most heavily regulated in the nation. New York state laws mandates "guaranteed issue" of private health insurance, meaning that insurers cannot deny coverage because of health status, such as pre-existing conditions. The law also mandates community rating, which requires insurance companies to charge policyholders the same premium, regardless of age, gender or health.

These policies were intended to make insurance more affordable for New Yorkers who are older or who have chronic health conditions. Instead, prices have shot up, as young, healthy people were charged higher premiums and decided they were better off without expensive coverage they would probably never use.

In fact, the market for individual, unsubsidized health insurance has nearly disappeared, plummeting by 96 percent since 1994, after the reforms were implemented. New York City residents can expect to pay at least $9,036 a year for individual coverage, or $26,460 for family coverage -- hardly the "affordable" premiums reformers expected.

As the private market atrophied, Albany responded by expanding coverage through public programs like Medicaid. But New York’s Medicaid spending (projected to be over $49 billion in 2010) is breaking the state budget. We spend far more on Medicaid than any other state in the nation, in part because the program has become heavily politicized in Albany by powerful union lobbyists. Gov. George Pataki, for instance, cost tax-payers billions when he cut a backroom deal giving raises to workers in the powerful Service Employees health care union in return for their support for his 2002 re-election bid.

To their credit, Gov. Eliot Spitzer and then Gov. David Paterson recognized that Medicaid spending was out of control and the state wasn’t getting above average health outcomes for our much higher levels of spending. But fixes to date have been largely cosmetic -- in fact, Albany has used federal stimulus funds to expand Medicaid coverage. Paterson projects that nearly one out of every four New Yorkers may be on the Medicaid rolls by 2013.

In New York's Footsteps

The reform plans being considered in Washington, D.C. closely follow New York’s flawed strategy, including guaranteed issue and community rating requirements, increasing Medicaid coverage (to cover people with incomes of up to 150 percent of the federal poverty level) and billions in new taxes on health insurance companies along with heavy subsidies to help the uninsured buy government-mandated coverage. The only twist is a requirement that the uninsured must buy coverage, and employers must offer coverage or pay a penalty, moves that advocates hope will help keep young and healthy residents in insurance pools and so lower costs.

The problem is that this approach has already been tried in Massachusetts, which added an individual mandate in 2006. Since then, state spending has skyrocketed, and the Bay State has the most expensive insurance premiums in the country -- projecting double-digit increases again next year.

If Congress continues on its current trajectory, we’ll see more of the same: higher insurance costs, higher health care costs, more taxes and more deficit spending. That’s bad news for New York, which is already grappling with a severe fiscal crisis.

Looking at the Alternatives

If we’re going to get control of our health care costs, lower the number of uninsured and reform safety-net programs like Medicaid, we need to get beyond the screaming matches and finger-pointing that characterizes so much of the health care debate.

Here’s how:

-- Let markets do what markets can do well: set prices and allocate resources. In a recent report from the Manhattan Institute’s Empire Center for New York State Policy, researchers Stephen Parente and Tarren Bragdon advocate for a handful of market-based reforms that could make private health insurance much more affordable.

They found that repealing the community rating and guaranteed issue laws would reduce the number of uninsured by 18 percent and 19 percent respectively, and lower premiums by 42 percent. Letting New Yorkers buy health insurance plans licensed in Connecticut and Pennsylvania, where policies can cost 25 percent less than in New York, could allow as many as 26 percent of the uninsured to buy their own policies. Overall, these market reforms would lead up to 780,000 New Yorkers back into the private market.

-- Set up a safety net for New Yorkers with high-cost, chronic illness. Parente and Bragdon advocate creation of a pool for high-risk New Yorkers who would otherwise have to pay high premiums. Today, 35 states have such pools.

-- Tell Congress to focus on real, bipartisan reforms that gradually bend the cost curve of health care. The president promised not to sign any health-care bills that cost more than $900 billion or increased the deficit by one dime. The current bills meet that pledge -- but only through fiscal gimmicks, such as assuming that Medicare will slash physician reimbursements by more than 20 percent starting in just two years. That will never happen, pushing the House and Senate versions of reform well north of $1 trillion. New Yorkers will pay for those costs through higher taxes, lower wages, and higher insurance premiums.

A better approach is to start with basic, fundamental reforms -- like fixing the tax treatment of health insurance. Economists generally agree that excluding employer-provided health insurance from income taxes is unfair (the rich get more of a benefit than the poor), arbitrary (why link insurance to employment?) and expensive (by making health insurance seem free, workers ask for generous plans that drive up health-care spending).

Replacing that exclusion with a universal tax credit or standardized tax deduction for all Americans would help millions of the uninsured afford coverage, put money back in people’s pockets through higher wages, and slow the growth in health care costs that is crippling private and public budgets.

The basic idea has been embraced by everyone from Sen. John McCain to one of Obama’s health care advisors, Jason Furman. By mixing a safety net for those with chronic illness to market incentives that put patients and families in control of their own portable health insurance, we can help slow the rise in health-care costs and cover the uninsured.

We have tried time and again to fix health care by relying on top-down solutions cobbled out behind closed doors in Albany and D.C. They have failed every time. We need a different approach.

Mr. President, do you still have that reset button?

Paul Howard is the director of the Center for Medical Progress at the Manhattan Institute and managing editor of MedicalProgressToday.com.

A Floor Not a Ceiling for Health Reform


All eyes are now on Washington’s health care reform efforts. But since the 1980s, health care reform in this country has largely been generated at the state level. There is a critical danger that the health care legislation being developed in Washington will legally block state initiatives. The power of interest groups limits what we can realistically expect from Congress, so it is important that the legislation protect and promote the ability of states to do more.

Here’s some of what states have done -- with New York in the forefront. Programs for prenatal care for low-income pregnant women began at the state level in the early 1980s and later led to national legislation to provide federal support. Senior citizen prescription drug programs were created in many states long before Medicare Part D was enacted, and many would agree that the state programs are better designed. The Child Health Insurance Program, or CHIP, began with state programs in a few states and then was supported by federal matching funds. The recent change to let CHIP cover children in more moderate-income families was a response to state efforts to expand the highly successful program. Several states expanded publicly-funded health coverage for low- and moderate-income adults.

State governments have led the way in protecting consumers in the private insurance market. Laws limiting restrictions on pre-existing conditions, rules protecting consumers and health care providers from being unfairly denied payment for medically necessary services, and other reforms have come from our state capitols, not Washington.

In some states, giant multinational drug companies have been reined in by state legislation restricting marketing and pricing abuses.

Letting States Do More

Each state is different. Some will want to do more than Washington does, and some won't. This is America, after all. The federal legislation should be a floor, not a ceiling.

"Pre-emption" is the legal term for one level of government taking over a field of law and barring other levels of government from acting in that area. Sometimes federal law explicitly pre-empts state or local laws. Even when there is no specific pre-emption language, the courts often rule that a federal law has pre-empted the field.

Major corporate interest groups often push for language in federal legislation to pre-empt state or local government action. They don't want state laws to give consumers more protection than a federal law provides. On the other hand, federal law can also specifically allow state or local governments to enact additional legislation.

In this instance, health insurance companies and big employers will argue that allowing state initiatives will make it impossible for them to operate across the country. That doesn’t hold water. Multi-state companies have always worked with different state laws on insurance or consumer protection, different labor markets, and even different zoning or environmental laws. Anyone smart enough to run a multi-state company can handle that complexity.

We should be more concerned about families who will need help from their state government in dealing with gaps in coverage and consumer protection that will likely be left when Congress is done.

Some lobbyists say they want to "let" people buy health insurance from out-of-state companies. But insurance companies can already sell policies to people in other states -- as long as they obey the state’s insurance laws. What the lobbyists want is a clause in the federal legislation to make it easy for out-of-state insurance companies to sell without complying with state laws.

I hope Congress will enact strong legislation to give all of us access to quality affordable health care. But no matter how optimistic one might be, let's also be realistic. With special interest lobbyists sitting at the health care reform table in Washington, at the end of the day there will be a lot of room for improvement. Families and health care providers will need somewhere to turn.

If Congress pre-empts state health reform initiatives, it will shut down the engine that has done the most in recent decades to help Americans get the health care they need.

No matter what Washington does, we will continue to need the new ideas and improvements that can come from the 50 states – whether it is expanding access to affordable coverage or protecting consumers and health care providers. Congress must guarantee that state reform efforts can go forward.

Richard N. Gottfried is the state assembly member from the 75th district on Manhattan's West Side and chairs the Assembly's Committee on Health.

An Option the Public Needs


We can no longer view public health care as an option, it is a necessity. While Congress is bogged down in political lobbying, New Yorkers confront the "choice" between their pension or health care coverage, rent or medication. Millions of New Yorkers face these choices today, with over 1.3 million New Yorkers uninsured and even more underinsured. We must take this opportunity to allow those who have no other options a chance to live a healthy and productive life and receive the type of medical care we all deserve.

According to the New York Urban League's State of Black New York, diabetes in New York City has doubled in the past eight years, and it is estimated that one third of these people do not know they have diabetes. In this city, black New Yorkers have a higher prevalence of cardiovascular disease, strokes, heart attacks and hypertension than the general population, and nearly 15,000 New Yorkers die every year from cancer according to the city health department. With all these diseases, the long-term prognosis greatly improves if they are detected early through prescreening and preventative care.

The public option, now being proposed, calls for a government insurance plan as well as private insurance. While the exact proposals vary, some kind of public option would create more choice for the public, spur increased competition in the market and allow those who are shut out of the current system to enter. Access to government-issued health care will provide competition for private health providers, lower costs and help to close the healthcare gap between lower-income and more affluent Americans.

The model already exists for the federal government to provide a cost-effective and efficient option. The best public option would be run similar to Medicare. Currently, the administrative costs of government run Medicare are lower than that of any other large health care plan. Like the current Medicare, the best public option would protect the rights of all to essential health care functions and pool the risk between the healthy and sick, thereby lowering cost.

The public option can be a cost effective, efficient form of health care. It is not simply for those who are uninsured -- we can all benefit from these necessary reforms. By opening the health care market to more options, those uninsured, underinsured or with no other choices will have the freedom to choose.

A healthier America is more productive, costs less and results in an overall higher standard of living. By injecting the market with this new option, all health care options, private and public, would be forced to become more inclusive and less expensive. Low-income families, people of color, and those most in need of health care have been shut out for far too long. It is time for change to truly come to America.

Arva Rice is president and CEO of the New York Urban League.

New York and the Health Care Debate


Photo (cc) Jess J

With the House having approved an overhaul of the nation's healthcare system Saturday, the action now moves to the Senate. The Obama administration and other observers agree the health care bill faces a tough battle there, and whatever emerges could be different in significant ways from what the House passed over the weekend. By most accounts, the United States, the only developed nation without national health insurance, is now closer to adopting health care reform than at any time since President Theodore Roosevelt endorsed the idea in 1912.

Such a sweeping change will undoubtedly touch almost all Americans. New Yorkers have a number of particular concerns. Health care is not simply a service here, it is a major industry. New York currently provides more health services to its residents -- more health coverage, better public hospitals, tighter regulation of the insurance industry -- than many other states. And health care here is expensive.

As politicians bat proposals back and forth, New York officials have worried that the health care bill could penalize states like New York that already offer relatively generous benefits under Medicaid -- the government program providing health coverage for low-income people. And hospital officials in high-cost areas, such as New York and Los Angeles, have expressed concern that they could be hurt by efforts to focus on "value" and low expenses.

As the debate heads down to the wire, we asked several New Yorkers with expertise in health policy to discuss what the health care changes might mean for New York -- and what kind of legislation would most benefit New Yorkers.

Fixing a Broken System: State Sen. Liz Krueger writes that New York and the rest of the country can't afford to let this moment pass without addressing our health care crisis.

New York -- Model or Warning?: Paul Howard, director of the Center for Medical Progress at the Manhattan Institute, warns New York's effort to provide health insurance to all of its residents should offer a cautionary tale for Congress as it crafts a health care bill.

A Floor Not a Ceiling: Richard N. Gottfried, chair of the State Assembly's health committee, urges Congress to enact a bill that will allow states to fill gaps in the national law and provide health programs that meet the needs of their citizens.

Challenge in the Senate: State Sen. Thomas Duane says the version of health care reform proposed by the Senate Finance Committee would punish states like New York that have taken the lead in health care.

An Option the Public Needs: Arva Rice, president of the New York Urban League, argues that a government insurance plan -- the public option -- is essential to help those who have been shut out of our health system for far too long.

Taking the Temperature on City Health Policies


Photo (cc) _MaO_

Public health policy under the Bloomberg administration is understood popularly as "you're going to live healthier, whether you like it or not."

Michael Bloomberg heralds a number of achievements in his eight years in office -- forcing chain restaurants to post calorie counts and instituting bans on indoor smoking and the sale of food containing trans fats. These things stand along side more positive measures, such as Bloomberg's move to grant 1,000 permits in 2008 to "green carts," mobile food vendors offering fresh fruits and vegetables.

In Bloomberg's eyes, all his efforts certainly have paid off. When the two-term mayor received the Julius Richmond Award from the Harvard School of Public Health in October 2007, he hailed his administration's accomplishments: "The result is that New Yorkers are living longer than ever and, for the first time since World War II, living longer than the average American -- and that gap has grown every year since 2001."

Bloomberg's health legacy spreads beyond the bitter smoker standing outside a bar in the rain or the Coney Island visitor thinking twice about ordering the 1,000-plus calorie cheese fries at Nathan's to a range of policies affecting New Yorkers' lives.

The Thomas Frieden Show

When it came to the Department of Heath and Mental Hygiene, like many agencies, Bloomberg chose the individual he believed was the best person to run the agency. No one could argue with Thomas Frieden's credentials to be health commissioner. He left the department this year to head the U.S. Centers for Disease Control and Prevention.

Not everyone approved of the job he did, however. The dissenters include HIV-AIDS activist groups such as Housing Works. It has accused Frieden of being secretive and uninterested in community input in policymaking, as well as focusing too much on data tracking and health monitoring and not enough on direct care.

Judith Arroyo, who as president of Local 436 of District Council 37 represents city health workers including public health nurses, said that the latter complaint reflects a general change in the field of public health over the last two decades. She said that Frieden, like many in the profession, was moving away from direct care and into tracking trends so he could shape future response methods.

"He reorganized and prioritized his money differently," she said. "A lot of it went into education and tracking, the electronic health record. That's going to help a lot."

Not many municipal labor leaders speak so highly of their former management counterpart as Arroyo does of Frieden.

"As far as I was concerned he was an excellent health commissioner," she said, noting that Frieden instituted measures to hold community health groups and city programs more accountable for their performance. "You needed a commissioner to take the department of health in hand and shake it up and send it on the road to the new public health issues that are out there."

She added, "Before then we had all sorts of programs, [but] nobody was asking for results, saying, 'Is this really working?'"

The Kids Are Not Alright

One shortfall of the administration, according to several health advocates, has been health-care for children.

During his first campaign, Bloomberg promised to centralize school-based health care under the health department rather than have it under the now-defunct and oft-maligned Board of Education. He didn't keep the pledge, Arroyo said, and instead power sharing between the health and education departments has created bureaucratic confusion in school health care.

"When you got two people in charge you got no one in charge," she said. The result, according to Arroyo, is inefficient delivery of health-care in the schools.

Funding for school healthcare has been cut due to the city's budget shortfalls. While members of Arroyo's union have not suffered layoffs, some clerical staff supporting school nurses have lost their jobs. This, Arroyo said, has made it more difficult to keep track of children's health.

"Now the nurse is in the school by him or herself trying to do everything," she said. "And when you leave someone there without assistance, especially without clerical assistance, then the nurse has to prioritize and the result is the paperwork, the statistical data goes on the bottom of the list because the nurse is going to help the child first. Then [the city is] not getting the data that they need to make decisions about schools and resources. … The program is not going to data entry itself."

The city also shut several school dental clinics this year, despite protests.

"Nothing that anybody said could convince the health commissioner not to do that," said Judy Wessler, executive director of the Commission on the Public's Health System, a two-decade old health-care advocacy group.

At the time of the closing, the Department of Health and Mental Hygiene said in a statement, "We would very much prefer not to have to make this service reduction. However, lacking other options, the agency decided to eliminate a service that is available from many other sources."

Access: Getting There

Photo (cc) Vidiot

When Bloomberg was first elected the Emergency Medical Service already had been a part of the Fire Department for several years (it was previously under the auspices of the Health and Hospitals Corp.).

Union leaders representing emergency medical workers often have complained that their members are "second-class citizens" next to the firefighters, so often lionized in the public eye. But it's more than just living in the shadow of the "Bravest." The emergency medical workers have a lower pay scale that leads to high attrition rates. Skilled responders either seek promotion to firefighter or find work elsewhere rather than move up to the Emergency Medical Services officer corps because the money isn't enticing enough.

Moreover, in the last round of budget negotiations, the City Council came up with funding to stop Bloomberg's plan to eliminate 16 fire companies but did not spare the cut of 30 ambulance tours. Patrick Bahnken, who as president of DC 37 Local 2507 represents FDNY Emergency Medical Technicians and Paramedics, said this will result in a slower response to medical emergencies. In addition, he said, it will cost the city revenue because the private ambulances that will take care of the tours may take patients who might otherwise have gone to a public facility to a private hospital.

Fire Department officials have noted that, despite the cuts, the number of ambulance tours has increased since the Fire Department and Emergency Medical Services merged. Response times continue to fall from year to year, one spokesman repeated, but union officials argue morale is falling as well.

With two hospitals recently closing in Queens, along with the emergency medical cuts, Wessler foresees problems.

"There's clearly a backing-up of emergency rooms and that's been very clearly shown," she said. "There very possibly is also an extended time for ambulances."

Access: Getting Care

For Wessler, Bloomberg has done a better job overseeing the Health and Hospitals Corp. than his predecessor, Rudolph Giuliani.

He has "shown a lot more care for HHC and the public hospitals," she said. "That's been really important."

However, Wessler expressed concern that the city has not done more to provide direct care outside of the public hospital.

"Access to care issues other than in HHC have not been a strong point in this administration," Wessler said.

But referring to Frieden's successor, Thomas Farley, she said, "Could that change under a new health commissioner? We're now in discussion with him."

Ari Paul is a reporter for The Chief-Leader, a weekly newspaper covering the New York City civil service. He is also a correspondent for Free Speech Radio News, and a columnist for the on-line publication, The Faster Times.



Print Friendly and PDF

Editor's Choice


Gotham Gazette: New York Voters Approve $4.2 Billion Environmental Bond Act
New York Voters Approve $4.2 Billion Environmental Bond Act
Gotham Gazette: 
New York City Voters Approve Racial Justice Ballot Measures
New York City Voters Approve Racial Justice Ballot Measures
Gotham Gazette: 
Housing Development in New York City Slows to a Crawl as Officials Debate Tax Incentives
Housing Development in New York City Slows to a Crawl as Officials Debate Tax Incentives
Gotham Gazette: 
City Council Examines Low Voter Turnout, Moving Local Elections to Even Years City Council Examines Low Voter Turnout, Moving Local Elections to Even Years