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A One-Two Punch To Hospitals: The Proposed Federal and State Budgets


Each day, over 250 people visit the emergency room at Woodhull Medical Center in Brooklyn. And each day the hospital loses more than $75,000 treating them -- adding up to more than $27 million a year. If Governor George Pataki and President George W. Bush have their way with the state and federal budgets, Woodhull will be losing even more -- and it and other New York hospitals might be sent over the edge.

Pataki's proposed budget for New York State, released in January, contains sharp cuts for Medicaid. New York's program is the country's largest, and Pataki argues that costs must be brought under control. His proposals to do so, however, will cost New York City hospitals $341 million next year, according to the Healthcare Association of New York State, a trade association for health care providers. The loss for Woodhull alone could be $15 million (on top of the $27 million.) The association says these costs would be devastating to a struggling industry in which eight hospitals already have been forced to close in the city since 2003.

Pataki's plans are not the only thing worrying health care advocates, though, nor is Medicaid the only concern. Decisions about New York City's public health insurance programs are made at the state and federal levels (the city, while it does foot a portion of the bill, has essentially no say over how these programs are run; its own budget will not really affect them.) So it was another blow when President George Bush laid out his budget for the forthcoming fiscal year earlier this month: he called for significantly reduced funding for Medicare, the country's other major public health insurance program.

"This year our concern is the governor's budget in relationship with the president's budget," said William Van Slyke of the Healthcare Association of New York State. "It's a one-two punch to hospitals."

THE STATE BUDGET

When he presented his budget, Governor George Pataki proclaimed his dedication to health care: "[New York] must continue to invest in a health care system that is second to none," he said. "And as part of that endeavor, we have to redouble our efforts to control the growth of Medicaid spending." At an annual cost of $44.5 billion, New York's Medicaid program is the single most expensive item in the state's budget. Unlike other states, New York's Medicaid program also affects local governments, which Albany asks to share the costs. When Mayor Bloomberg complains of uncontrollable items in the city's budget, Medicaid ranks high on the list.

The governor wants to continue a program he started last year that caps the amount local governments contribute to Medicaid. He estimates that this will save New York City $750 million this year alone.

Shifting costs from local to state government, however, does nothing to address the overall cost of Medicaid. For that, Pataki hopes to cut down on widespread fraud by setting up an independent office where 600 people will work full time investigating it. While establishing this office will cost $15 million, Pataki thinks it will end up saving the state money.

The governor's budget also includes $1.3 billion in cuts to Medicaid, and health care advocates are particularly concerned with his plan to change the way that hospitals are reimbursed for providing care to patients in the program.

For years, hospitals have argued that they are losing money each time a Medicaid patient shows up in the emergency room, because it costs more to treat him or her than the hospital is paid to do so. At Woodhull, for instance, the average cost of an emergency room visit is $411. But the maximum reimbursement the hospital can get for a Medicaid patient is only $95. The governor's budget would make the problem even worse, say health care advocates.

The Healthcare Association of New York State estimates that hospitals in the state will lose $431 million if the proposed budget is approved. New York City, which has a disproportionate amount of Medicaid patients, will be hit hardest: the city's hospitals will have to absorb 80 percent of the statewide losses.

This comes at a time when hospitals are already struggling. "Statewide, they have lost money for targeted investments in emergency room, outpatient, and long term care services," he told state lawmakers earlier this month.

A state commission is already looking at how to address the poor financial performance of the industry, and will almost surely recommend closing hospitals at the end of the year.

More cuts could cause some hospitals to cut back on services or shut down entirely.

THE FEDERAL BUDGET

President Bush seems even more concerned about the cost of public health care programs than Pataki. His budget calls Medicare and Medicaid (along with Social Security) "the greatest threat to our fiscal health over the long term."

The proposed federal budget mixes spending cuts with tax incentives that Bush hopes will help lead the country towards a more market-based health care system.

The president's budget proposes $36 billion in savings to Medicare. Joshua Bolton, his budget director, was careful to say that these savings will not be cuts but a "reduction in the rate of growth." Still, the impact on New York City hospitals is slated to be $356 million over the next five years, according to the Healthcare Association of New York State.

This budget also hints at a more fundamental shift in the way the government helps provide health insurance by including tax incentives for health savings accounts. The White House estimates that these incentives will cost the federal government $59 billion over the next five years. But by allowing people to put money away tax-free to pay for health care, the Bush administration argues, health savings accounts will eventually lower overall health spending by encouraging people to make smarter decisions about seeking health care. Critics, however, believe that these savings come by encouraging people to skip necessary health care.

NOW THE NEGOTIATIONS BEGIN

"If both these budgets were enacted as proposed," said Van Slyke of the Healthcare Association of New York State, "we would absolutely lose more hospitals. There is no doubt about it."

Of course, the chances that either budget will be enacted as proposed are slim. The governor and the president have made their opening volleys; they will now spend the next several months negotiating with lawmakers about which provisions stay and which are removed.

At both the federal and state levels, it doesn’t seem as if reductions in health care costs will be easily approved. Pataki's proposals are similar to those he has made in recent years, which the state legislature has regularly rejected. Further, many are saying that the president will also have a hard time trying to get Congress to agree to reduce spending on popular programs. It is, after all, an election year.

 

The Heroes Of 9/11 Are Getting Sick


Detective James Zadroga was inside 7 World Trade Center on the morning of September 11, 2001. He escaped –- barely –- when the building collapsed. But Zadroga could not escape the damage done to his body by the hundreds of hours he spent at Ground Zero cleaning up the rubble in the following weeks. On January 5 of this year, Zadroga died from lung disease and mercury poisoning – a condition that hasn't been a widespread occupational hazard for over a century when hatters were sickened as they dyed beaver pelts.

Working at Ground Zero seems to have been even more dangerous than initially suspected, say health researchers. At least two Ground Zero rescue workers besides Zadroga –- and maybe more than twenty -– have died from illnesses that seem to be related to working on "the pile" (rescue workers' nickname for the rubble of the twin towers). But James Zadroga's death in particular has redirected attention to a problem that, experts say, will likely continue for decades.

Efforts to confront the health effects of 9/11 have not progressed quickly. Federal attempts to determine how far dangerous chemicals spread have sputtered along, enraging many local residents and environmental activists, who suspect that the towers' collapse spread contaminants across lower Manhattan and parts of Brooklyn. A registry set up to collect data on health trends covered a more limited area, and there is currently no way of knowing how many people are sick with 9/11-related illnesses.

The approximately 40,000 rescue workers are probably the one group at greatest risk, because those who worked on the site were directly exposed to these chemicals at very close range for long periods of time. Zadroga spent 470 hours at Ground Zero. But as they get sick and even die, public officials have had little success tracking their health, much less treating them.

This month, the New York congressional delegation called on the federal government to appoint a 9/11 health czar, whose first responsibility would be to find a way to track and confront the health problems rescue workers are facing. Until that happens, private screening and treatment programs are struggling to do what they can.

 

MONITORING AND TREATING PROBLEMS

 

Vincent Forras, a volunteer firefighter from Westchester County, was dispatched to Ground Zero immediately after the attack. He ended up working on the site for three weeks, spent two hours buried alive in the rubble of the South Tower, and later received the Ground Zero Service Medal.

Rescue workers had difficulty breathing soon after arriving at Ground Zero, said Forras. So, he said, "they juiced us up with all kinds of Albuterol and various medications to keep us breathing." This allowed rescue workers to continue working on the pile, where they filled their lungs with lead, mercury, asbestos, and pulverized cement and glass.

When Forras breathes now, he feels like he is "drowning in air."

He lists his other problems: He has "World Trade Center Cough", a symptom of Reactive Airway Dysfunction Syndrome. He is producing too much phlegm, has massive headaches, sinus problems, and symptoms of heart disease. More than four years after 9/11, his wife is still picking pieces of glass out of his skin.

Forras had his problems diagnosed at Mt. Sinai's World Trade Center Medical Monitoring Program, run through its Center for Occupational and Environmental Medicine. This program has screened the health of 16,000 men and women who worked on the pile, and is the largest effort to monitor the health of rescue workers at Ground Zero. The screening program is federally funded, and is open to anyone who worked at Ground Zero, whether they show symptoms or not, with a few exceptions: New York City firefighters – who have their own monitoring program – are ineligible, as are federal workers. Federal workers currently have no options for screening or treatment.

About half of the people that have come to Mt. Sinai for diagnosis have respiratory diseases, sinus or throat problems, or post-traumatic stress disorder.

Dr. Robin Herbert, who is the director of both the screening and treatment programs, continues to be taken aback by the severity of the medical problems like those afflicting Forras. She also feels overwhelmed by the problems involved with getting treatment for those her program screens. Mt. Sinai refers people who need treatment to its own program, which is overburdened, and has managed to see only 1,800 patients. It doesn't have the resources to see any more.

Private philanthropists currently provide all the money for treatment. The Red Cross gave $20 million to fund several such programs, and the lion's share of the Mt. Sinai's program comes from this pool of money (though donations like the $100,000 it received from a church group in Ohio, or $2,000 worth of pennies raised by children in Queens also help).

Mt. Sinai estimates that 5,000 people it has diagnosed as sick are not getting necessary health care. "It's pretty consistently the case that demand has tended to exceed our capacity," said Herbert.

 

WHERE IS THE GOVERNMENT?

 

The Red Cross sees its role as a stopgap measure, operating only until a more systematic public program can be put in place. It will stop its funding next year.

But interest from government is underwhelming. In his State of the City speech this month, Mayor Michael Bloomberg mentioned major plans for Ground Zero and for health care. He did not, however, connect these two themes. New York State government has provided treatment for those who worked on the pile with access to its worker's compensation program -– even if they came from out of state -– but its resources are limited.

It is the federal government's inactivity, however, that has most angered those involved with providing health care to 9/11 rescue workers.

There were 10,000 federal employees among the rescue workers at Ground Zero. The federal government set up its own medical monitoring program for these workers, but closed it down after screening only about 400 people. Federal employees cannot seek help through other programs; instead, they must wait for this program to be restored.

If the federal government has been lackluster in screening for health problems, its treatment program is nonexistent. To date, no federal money has been dedicated to treatment for any 9/11 rescue workers.

Some lawmakers in Washington are trying to change this. In December, Congress restored $125 million for funding for 9/11-related health issues that the Bush administration had cut from the budget. New York State's workers compensation program will get $50 million, with the remaining $75 million spent on existing monitoring and treatment programs. For the first time, this money will be available to be used not only to monitor workers' health, but also to treat their problems. It is not yet clear, however, when it will reach those who need it or how it will be split among monitoring and treatment programs.

On January 25, the New York Congressional delegation sent a letter to federal Health and Human Services Secretary Michael Leavitt asking him to appoint a "9/11 health czar" (letter in pdf format). So little has happened, they argue, because there is not a single person who is directly responsible for addressing 9/11 health issues.

Representative Carolyn Maloney and Vito Fossella recently called a press conference at Ground Zero to push for the idea. A position should be created within the department of Health and Human Services whose work would start with the establishment of "an exhaustive medical screening, monitoring, and health care program for all responders exposed to the toxins," said Maloney, encircled by men and women in fire department jackets or hats from local ironworkers unions. One had lost half a foot; another had lost almost a third of his lung capacity.

After Maloney finished, Forras stepped forward to talk about his battles with daily treatments, and about his feeling that the care he needed wasn't out there. He fully expected to die, he said, "sooner than later."

"I can guarantee you than when we come back here next year, some of these people will not be standing here," he said of those surrounding him. "You will find shadows of people."

 

The Need for Healthier Schools



Most people think all asbestos was removed from New York City public schools years ago. So participants in a New York State Assembly hearing on healthy schools earlier this year were shocked to learn that last year construction workers who were replacing a gym floor at P.S. 219 in Brownsville, Brooklyn inadvertently released the flaky white substance throughout the building. The school was shut down immediately for an emergency cleanup. Student and faculty health was jeopardized, and valuable learning time was lost.

The legislators were even more shocked to learn that no one knows how many other New York City school buildings still contain asbestos; records at the Department of Education are incomplete.

At the Healthy Schools Network, our files are filled with reports from parents and teachers who are struggling to deal with unusual and unnerving illnesses affecting their children, students and coworkers. But it is not possible to do a scientific study to see if environmental conditions in their schools are at fault. The data is simply not available; neither city nor state officials keep track. But ignoring the problem will not make it go away.

ILLNESSES AND ABSENCES

Students spend nearly a quarter of their waking hours in school buildings that parents trust are safe. Unfortunately, there are real reasons for concern in many public schools. The U.S. Environmental Protection Agency has said that environmental health hazards like mold infestations, toxic chemicals, diesel fumes and contaminated renovation debris, along with other pollutants such as pesticides and toxic cleaning and maintenance products, can foul a school’s indoor air quality. In fact, the EPA estimates that about half of the nation's schools have poor indoor air, a major health hazard. In the winter, as schools shut their windows and children spend more time indoors, the problem becomes even worse.

In New York City, the state Assembly heard testimony from Avril Dannenbaum, whose seven-year-old son attended PS 111 in Manhattan. He has a chronic infection that compromises his immune system. His mother says she can manage his infection and his seasonal allergies at home. “But then,” she explained, “if you add on environmental allergens in his school, such as a dirty rug to sit on, peeling, flaking paint from the walls and window sills, along with industrial cleaning products and insecticides, you have a child who comes close to shutdown. Then he is unable to learn or function in class.”

While many problems afflict older schools, new ones are not immune. Tests found high levels of two chlorine solvents at a new high school in the Soundview section of the Bronx, hastily constructed in an old Loral Electronics factory. Both are known to cause serious ailments, including cancer. Assured by authorities that the vapors were below threat levels, parents later found out that city tests of soil and ground water at the site had revealed serious lead, mercury, cadmium, and chromium contamination.

A PROBLEM IGNORED

With parents, the press, and the political establishment all demanding tougher academic standards and higher test scores, physical conditions in the schools tend to be ignored. Proposals abound for how the city might spend the billions it is owed under the Campaign for Fiscal Equity lawsuit, but none of them includes any mention of using some of the money to make schools more environmentally healthy.

These health policies and practices have a direct impact on academic achievement and efficient allocation of education funds for every child. Poor environmental conditions in schools sicken students, teachers and staff, and inhibit academic performance. And our neediest children also need the healthiest schools. Poor school facilities contribute to a poor leaning environment that can undermine children’s health, attendance and test scores.

The American Lung Association, along with the federal Centers for Disease Control and the EPA, agree that asthma is the number one reason for school absenteeism due to chronic disease in New York’s schools. The city has some of the worst asthma rates in the nation, and the disease is epidemic in many neighborhoods, especially communities of color and among the poor. Public health officials studying urban asthma think a cleaner classroom environment could help control the crisis.

CLEARING THE AIR

There is some good news to report. Coal boilers, which remained in some New York City schools for more than 20 years after they were outlawed in other facilities, have now all been removed. In 1999, the state Education Department issued minimal standards and procedures for school indoor environmental quality and health and safety. State legislation has banned arsenic-infused pressure treated wood (commonly used in playground equipment), pesticide-laden cake toilet deodorizers and elemental mercury (a potent neurotoxin) in schools. Schools must now provide notification when they plan to apply toxic pesticides.

In August, Governor George Pataki signed legislation requiring schools to use environmentally preferable (green) cleaning products. The state Office of General Services already does this for state facilities, so the healthy products are readily available. Reducing student and staff exposure to industrial strength chemicals will help reduce school absenteeism. The program will take effect with the start of the September 2006 school year.

Both the city and state are moving toward implementing guidelines to assure that all school construction and renovations meet high standards for health. In New York City, a broad coalition of environmental, labor, health and healthy schools advocates were pleased when the City Council passed a green building standards bill earlier this year and Mayor Michael Bloomberg signed it into law in October. This significant legislation requires that all public construction, including schools, meet standards for environmentally friendly – or green – buildings by January 2007. By requiring better ventilation and barring the use of toxic paints, carpets and other materials, this measure will help improve student health and performance.

WHAT MORE CAN BE DONE

Now it is time to take further steps. Fortunately, protecting our children will not add billions to the cost of education.

At the federal level, Senator Hillary Clinton secured amendments to the 2002 No Child Left Behind law, which for the first time defined healthy and high performance school standards in federal law. This legislation required a comprehensive federal study of how school environmental quality affects student health and learning. But Washington’s follow-through has been flawed. The report, which was produced last year, has yet to be released to the public. Clinton’s initiative also established a grant program for states to spur the development of healthier schools. Unfortunately, Congress has neglected to fund this despite intensive advocacy by the National Coalition for Healthier Schools (in .pdf format), a coalition of over 300 organizations and individuals led by the Healthy Schools Network.

New York State also needs to do more. Albany offers a Green Building Tax Credit that gives incentives to commercial developers to design and construct green buildings, but the credit is not available for schools. Pataki has signed an executive order that requires all state public construction to meet the standards of the Green Building Tax Credit. But while the state recommends that schools meet those standards, it does not require them to do so. That should change.

And the state should move ahead on initiatives already in the works, such as a joint project of the New York State Energy Research and Development Authority and the State Education Department to develop healthy and high performance school design standards. The legislature should pass a bill introduced by Senator James Alesi and Assemblymember Steven Englebright that would require healthy and high performance design standards for all New York schools.

For parents, teachers and school staff, such improvements cannot come soon enough. As Avril Dannenbaum told state lawmakers about her child, “I can make his home as safe as possible, but it’s at school that he needs to be able to function well to learn optimally. I’d like you to make his school a safe place where he can study and reach his full potential.”

Stephen Boese is the New York State director of the Healthy Schools Network

Image above (photomodified) from The Texas Department of Health

 

 



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