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How the 2004 Budget Is Shaking Out for Health Care


The 2004 state and city budgets look significantly less dire than they did only a few short weeks ago in terms of their impact on New York City's health care. But they are far from ideal, with several important public-health programs slated to be cut or even eliminated.

One much-needed break came courtesy of the state legislature, which in mid-May, simply defied Governor George Pataki's draconian proposed budget and passed its own, which featured an extra $2 billion (for a total of $92.8 billion). In particular, the legislature restored more than $750 million from roughly $1.4 billion Pataki had wanted to strip from the health care industry.

Hints of the legislature's intent had emerged before the actual voting. Kevin S. Parker, the State Senator from the 21st District in Brooklyn, speaking at a May 9 conference on discrimination in health care, called Pataki's budget "the worst I've ever seen." He added, "I've got two theories about the governor's budget: Either he fell down and suffered a severe head injury and has just been kind of wandering around in a daze, or he's been kidnapped by aliens and replaced by a pod person."

As reported here earlier, Pataki had proposed changing the state's Medicaid program so that the state would absorb all of the local costs for Medicaid prescription drug coverage, while the localities would increase their share of hospital and clinic costs from 25 percent to 37.5 percent. Although this swap would have benefited every other county in the state, New York City stood to lose some $140 million, according to the Independent Budget Office, because 35 percent of Medicaid payments here go to cover inpatient hospital costs and only 15 percent go for drugs (in-hospital care in New York is particularly expensive).

But the legislature rejected this "swap," meaning that the city will avoid the extra cost.

Governor Pataki had also proposed a variety of measures to contain the cost of Medicaid by lowering reimbursement rates, "taxing" providers, and limiting eligibility for Family Health Plus and children's Medicaid. These changes would have had a major impact on the city's Health and Hospitals Corporation, which, as a Medicaid provider, was projected to lose $200 million through lower reimbursements and increased assessments.

But the legislature rejected these changes as well. James R. Tallon, president of the United Hospital Fund, says, "Because the legislature largely rejected the proposed cuts, the outcome is that New York City hospitals have sidestepped -- for now -- the greatest level of negative impact of the governor's plans for Medicaid."

Handily, New York will also receive a Medicaid boon from Washington under the recent federal changes in the tax law. The city could receive as much as $290 million in new Medicaid funding over 15 months.

Yet another set of health care changes proposed by the governor would have reduced state matching funds for local public-health programs. The city's Department of Health and Mental Hygiene had estimated that this proposal would have reduced support for these programs in the city by $50 million. The legislature rejected most of the changes sought by the governor, although the city will still see an estimated reduction of $20 million in public-health matching funds. Because these are matching funds, however, this change will only affect the city's budget gap if the city chooses to replace the lost state funds.

Bloomberg Adds Back $90.2 Million in Services

The city's new fiscal year begins on July 1, and for the last few months, Mayor Michael R. Bloomberg and the City Council have been haggling back and forth, trying to close a $3.8 billion budget gap.

But on June 4 -- the day before Mayor Bloomberg's and the City Council's initial budget deadline -- Bloomberg unexpectedly restored $90.2 million for services that his executive budget plan had proposed cutting; including, according to the Associated Press, $5 million worth of health department funding. He gave as a reason the fact that the state will now be giving much more budget relief to New York City than the city had previously believed. According to the city's Independent Budget Office, Albany is now offering the city a total gap-closing package worth roughly $2.3 billion: $1.3 billion in new tax revenue that the city will be allowed to raise, and $1.0 billion in other assistance. This, the Independent Budget Office says, may be as much as $210 million more help in closing the 2004 budget gap than the mayor's initial executive budget had taken into account.

Among the health care restorations the mayor has promised are continued funding for an asthma control initiative (a recent study showed that an astonishing 25 percent of children in Harlem suffer from asthma) and a program to combat lead poisoning. He also backed off from an earlier budget proposal to outsource case management jobs at the city's HIV/AIDS Services Administration and to seek other changes to the 1997 legislation governing this agency -- moves that AIDS advocacy groups protested vigorously as ploys to weaken the agency.

As of this writing, the mayor and the Council continue to haggle over its details. According to the New York Times, the Council has a "wish list" of another $260 million in services it wants to preserve. Among health care measures, City Council Speaker Gifford Miller has vowed, the Council will fight to keep open 12 child health clinics still slated to be closed. (There are 31 child health clinics in the city, but the dozen targeted for closing are disproportionately located in disadvantaged neighborhoods -- four in Harlem, four in Brooklyn, and two in the Bronx -- according to Judy Wessler, director of The Commission on the Public's Health System, a local public-health advocacy group.)

Miller and the Council's Deputy Majority Leader, Bill Perkins, are also calling for the restoration of $5 million to continue funding an initiative to combat infant mortality, particularly among infants of color, whose mortality rate, Perkins says, is 70 percent higher than the city average. "Five million dollars is not that much money," Perkins says. "But it's a statement of a commitment."

Other important public-health programs in the city have also had their funding yanked or slashed in the mayor's budget, and not yet restored. The Commission on the Public's Health System cites four such:

- five school-based health clinics, one in each borough, which could close for lack of $419,000 in funding
- waivers of medication fees for uninsured and poor patients who lack money to fill their prescriptions at public health and hospitals facilities; their funding has been slashed.
- mental health and substance abuse programs in six Health and Hospitals Corporation, to be cutback; and
- a hepatitis-B school immunization program that will be eliminated, and 100 public health assistants terminated, because its $1.6 million in funds were cut.

Says Judy Wessler, "We believe that the public health infrastructure is critical, and the loss of these programs would be a very bad thing. Remember, public health is a 'first responder' for public safety, too, just like firemen or the police. It prevents epidemics, it can prevent people from getting very sick."

It doesn't necessarily look good for these programs. City Council leaders have told the press that high among its remaining priorities are reopening the six firehouses Bloomberg closed at the beginning of the month, and saving zoos in Brooklyn and Queens. Meanwhile, a poll of city residents taken by the New York Times on June 6-10 indicated that their top priority among services is also preserving firehouses, followed by maintaining classroom aides in public schools.

Whether anyone will champion the public health programs still on the chopping block hard enough to save them remains an open question. The Council has re-scheduled its budget vote, though the process could drag on for the rest of the month. Stay tuned.

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School Buses Can Be Dangerous to Kids' Health


The children are there on West 26th Street every morning, waiting to board the yellow school bus. They say their quick good-byes to parents and caregivers, and the adults rush off to jobs or daily chores, completely unsuspecting of any danger. And why should they worry? A Transportation Research Board report (in pdf format) found that kids are much safer traveling on school buses than by foot, on bicycle, or in private vehicles. But in fact, there is danger awaiting these children that perhaps their parents and caregivers, and even the Transportation Board, overlooked.

A majority of the school buses serving New York City children use diesel fuel, and while the dangerous effects from exposure to diesel exhaust are fairly well known -- cancer, for example, and respiratory ailments, including asthma, which is on the increase in alarming proportions among children -- who knew that diesel emissions were actually greater ON the school bus than in the outside air?

According to "No Breathing in the Aisles," a report (in pdf format) conducted by the Natural Resources Defense Council, the Clean Air Coalition, and the University of California at Berkeley, the average child riding a school bus is exposed to levels of diesel pollution that are up to four times greater than those measured in a passenger car directly in front of the bus, and up to eight times greater than the average diesel exhaust levels in outside air.

The combustion of diesel fuel creates particulate matter, the majority of which are fine particles, less than one micron in diameter. "The fine particles are particularly harmful, especially to children," explained Craig Wilson, associate director of environmental health at the American Lung Association of New York State. "They penetrate deep into the lungs and interfere with the development of lung tissue. They also contribute to asthma, exacerbate allergies, decrease lung function, and have been linked to lung cancer and premature mortality."

The New York Power Authority agreed to pick up the tab to retrofit 1000 city school buses with diesel particulate filters which would reduce emissions significantly. The initiative focuses on school buses in all boroughs except Manhattan. After a year and a half, however, not one school bus company has taken advantage of the deal.

Diesel particulate filters trap exhaust particles and, combined with an engine adjustment and the switch to using ultra-low sulfur diesel fuel (with all related costs covered by the power authority), emissions on the school buses are reduced by 90 percent.

Bus engines built before 1995 are not able to accept this particular retrofit (and 3200 buses in the fleet of 5000 that serve New York City school children presently have pre-1995 engines), but the New York Power Authority also agreed to cover installation costs for diesel oxidation catalysts that would reduce pollution on the older school buses by approximately 20 percent to 30 percent. To date, 10 buses have had oxidation catalysts installed, and 30 more will be completed in July. An additional 200 older buses are in the pipeline, according to the authority, awaiting completion of the agency’s bidding and selection process for vendors to service the installations. All 10 of the older buses that have been equipped with oxidation catalysts, and those in line to receive them, are from one company, Atlantic Express in the Bronx. None of the other 64 bus companies serving the school system have requested installation of the catalysts on their older buses.

Even more disturbing, not one bus company has agreed to install diesel particulate filters on their newer buses and switch to using ultra-low sulfur diesel fuel, the combination that achieves the greatest reduction in emissions. "Our goal is not a 20 percent reduction," said Wilson of the American Lung Association. "It is to get in excess of a 90 percent reduction."

In a recent article in the New York Times, bus company officials blamed the technology for the delay, and expressed fears regarding engine damage or manufacturer warranties not being honored, as well as the suspicion that switching to low sulfur diesel fuel -- a necessity with the diesel particulate filters -- would eventually mean higher costs.

The New York Power Authority has done everything it can to allay these fears, according to New York Power Authority spokesperson, Connie Cullen. "We’ve been talking with the bus operators, answering their questions and concerns. We independently contacted every school bus engine manufacturer and were able to get letters of verification that the warranties on the engines will remain intact when this equipment is installed. This is in addition to already existing warranties that come with the filters and catalysts. We’ve shared all these letters with the bus operators.

"Initially we offered to pay the difference in cost between the regular onroad diesel and the ultra-low sulfur diesel (a differential that fluctuates between 10 and 18 cents a gallon in New York), and then we decided not only to pay the differential, but the whole cost. None have agreed to use the ultra-low sulfur diesel."

In 2006, all bus and truck operators will be required by federal Environmental Protection Agency regulations to use ultra-low sulfur diesel fuel (15 parts per million sulfur as opposed to 500 parts per million sulfur in onroad diesel). The New York Power Authority initiative covers the cost of purchasing the cleaner fuel for the three years prior to the mandate.

"All New York City transit buses and sanitation trucks are already using ultra-low sulfur diesel fuel," added Ms. Cullen.

It takes the same amount of time to install the diesel particulate filter (or the diesel oxidation catalyst) as it does to replace a muffler on the vehicle, between two to eight hours. The New York Power Authority also offered to accommodate the schedule of the bus operators, to do the work on weekends or school holidays, and to pay overtime for the maintenance workers involved.

Apparently, these efforts have not swayed NYC school bus operators. And it is a voluntary program. The Department of Education has yet to require the retrofits as a condition for doing business with the city.

Some school bus associations, citing other public health studies, dismiss the Natural Resources Defense Council report as unscientific and even play down the danger to children outlined in it.

"People call anything ‘unscientific’ when what they really mean is that they didn’t like the results," said Gina Solomon, Senior Scientist at NRDC, and one of the authors of the report. "The study was scientifically designed in collaboration with well-respected researchers from the University of California at Berkeley, and was peer-reviewed. In addition, scientists from Yale University repeated our study in Connecticut and found the same results."

In the Yale study, released last year by Environment and Human Health, Inc., measurements of fine particulate matter were five to 15 times higher on the school buses than in the average outside air. Monitoring equipment was not only located on the bus, as in the NRDC study, but on the children themselves as they went through their school day. Levels spiked every time the children were on the buses, or even when they approached them. A moving bus once again produced the highest levels in the back of the bus and with the windows closed. But levels were even higher inside an idling bus that was loading and unloading students, and highest when idling with the windows open, particularly if more than one school bus was lined up, allowing exhaust from one bus to enter another.

In both studies, emission levels varied by bus, and none of the buses tested had any pollution control devices and/or used ultra-low sulfur (or "green") diesel.

Advocates of the retrofit program in New York City are frustrated by the delay. "We know other school districts have done it, one in Connecticut, and one in Boston," said Craig Wilson of the American Lung Association. "There are some technical challenges, but there is no reason why it can’t be done."

"They will be legally required to use low sulfur diesel fuel in three years anyway," noted Ms. Solomon of NRDC, "so it’s hard to argue against it now. Some people are just resistant to anything new."

Do parents need to take their children off school buses? According to Natural Resources Defense Council recommendations, if a child has asthma, the parent should observe whether the condition worsens as a result of riding on the bus and, if so, consult a pediatrician and consider alternate transportation. All other school children should be instructed not to sit in the back of the bus, particularly for long trips. Harmful effects accumulate over years, so it is important to contact school districts and local politicians, appealing to them to reduce diesel emissions on school buses immediately through retrofits and the use of ultra-low sulfur diesel, prohibiting bus idling, and the purchase of alternatively fueled buses.

Amid news of an unprecedented rise in asthma for New York City children, a new grassroots group, the Asthma Free School Zone, is gearing up for community action in the next school year. Director and founder, Rebecca Kalin, has a 6-point agenda for the Asthma Free School Zone, and the first two items on the list involve diesel emissions: prohibiting idling within a school zone, and insisting on clean fuel technology on school buses.

Kalin related a story about a public school on East 12th Street where the yellow school bus is no longer a welcome sight. "One teacher I know runs to the windows and slams them shut every day when the school bus appears," she said. "He doesn’t want his kids to have to breathe the smelly fumes." Kalin hopes the community will come together on this issue so that teachers can keep their classroom windows open, and students can breath safely.

Various funding options exist for school bus operators in New York, in addition to the $6 million available through the New York Power Authority initiative. The New York State Clean Air School Bus Program has allocated $5 million for awards up to 100 percent of school bus retrofits or replacement costs. Another $5 million is available for upgrading buses built before 1990, as well as other funding incentives for retrofits, through EPA’s Clean School Bus Program. And $20 million is available from the EPA to retrofit school bus diesel engines, as part of a consent decree with Toyota stemming from emission violations.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Survey of Emotional Distress


More than six percent of New Yorkers report suffering from "severe emotional distress," with Hispanics and the poor among the most likely to suffer such distress, according to a citywide survey released on April 30.

The city's Department of Health and Mental Hygiene surveyed 10,000 residents from 33 New York City communities in 2002. This Community Health Survey asked New Yorkers about the extent to which they had recently experienced conditions such as feelings of sadness and anxiety. Those who reported high levels of these feelings were classified as experiencing significant emotional distress: 6.4 percent of New Yorkers overall reported such distress.

According to Lloyd I. Sederer, M.D., Executive Deputy Commissioner of the Department's Division of Mental Hygiene, this is the first time the survey has been done, so it is not clear if the reported rates of severe distress have increased (for example, in response to the economic doldrums or threats of terrorism), decreased, or stayed the same over time. Sederer said the agency plans to repeat the survey in June in order to see if there have been any changes.

Sederer said the New York survey was unusual in its "snapshot" approach, asking how respondents had been feeling over the past 30 days. "That does make it hard to say how the rates would compare to the rest of the country," he said. A large national study done by the U.S. government in 1991, the National Comorbidity Survey, asked about feelings of depression and anxiety in the past year and over the respondents' lifetimes; it found that 10 percent of Americans had suffered from major depression and 17 percent from an anxiety disorder in the past year, and 17 percent from depression and 25 percent from an anxiety disorder over the course of their life to date.

One finding of the survey was a strong correlation between poor emotional health and poor physical health. Those who said they suffered significant emotional distress also reported being in poor physical health three times more often than New Yorkers who said they were not significantly distressed. Among those with significant distress, 54 percent said they were also in poor or merely fair physical health, versus 17 percent of those who felt better emotionally. Those who reported significant emotional distress generally had higher rates of chronic health conditions such as high cholesterol, high blood pressure, obesity, asthma, and diabetes.

Sederer acknowledged that it is not always clear whether emotional distress was leading to poor health or vice-versa, but he did note that those who reported more emotional distress tended to follow less healthy lifestyles, including less exercise, more binge drinking, greater likelihood of tobacco use, and poor diet. "If you're depressed or anxious, the likelihood is that you'll be at a much greater risk for so-called habit-related disorders -- those that result from drinking too much, smoking, and not taking care of yourself," he said. "But poor physical health can also definitely lead to emotional distress. In the elderly, for example, those who have chronic physical illnesses have much higher rates of depression than those who are physically healthy. It's important to be aware of that in order to screen for depression those who are at the higher risk."

Other survey findings included:

" Hispanics reported nearly twice the rate of severe distress as other New Yorkers (11.9 percent, versus 4 percent for Asians, 4.6 percent for blacks, and 4.9 percent for non-Hispanic whites). Sederer said that the reasons for this were not clear. "Is it a cultural issue, a greater willingness to talk about the problem, a problem with access to or seeking of care? The reasons haven't yet been well studied," he said.

" Neighborhoods with the lowest incomes tended to report the highest rates of significant emotional distress.

" Only 36 percent of New Yorkers who reported significant emotional distress were employed, compared with 60 percent of other New Yorkers.

" 55 percent of New Yorkers who reported significant emotional distress had annual household incomes of less than $25,000.

" Significant emotional distress was more frequently reported among people 45 and older.

" Significant emotional distress was more frequently reported among those who are divorced, separated, or widowed (9.6 percent) than those who are married or partnered (5.5 percent) or never married (6.6 percent).

"As with all of these studies, these are correlations, not analyses of which causes which," Sederer said. "But with the next survey, in June, we hope to refine the questions to tease out some of those issues."

The report noted that effective treatments exist for emotional problems, and it recommended that New Yorkers experiencing persistent symptoms of emotional distress seek help from their physician or a mental health counselor. 1-800-LIFENET, the city's free information and referral hotline for mental health and alcohol/substance abuse services, is available 24 hours a day, seven days a week. LIFENET can be reached at the following numbers:

English: 1-800-LIFENET (1-800-543-3638) OR 311
Spanish: 1-877-AYĂšDESE (1-877-298-3373)
Chinese: Asian Lifenet (1-877-990-8585)
Other languages: 1-800-LIFENET
TTY (hearing impaired): 212-982-5284

The study also recommended some simple steps for better mental health that New Yorkers could take on their own: exercise regularly, eat a healthy diet, and refrain from abusing alcohol or drugs or smoking.

Meanwhile, the state legislature continues to battle to pass a state budget that would restore huge sums of money that Governor Pataki has proposed cutting from health care, including mental health care. The legislature passed an appropriation bill for health and mental hygiene that would restore $1.1 billion of $1.25 billion Pataki had proposed cutting, The New York Times reported on May 2. The Times quoted Richard N. Gottfried, a Democratic assemblyman from Manhattan and the chairman of the Health Committee, as saying that several hundred million dollars in federal Medicaid money would also return to New York under the legislative proposal.

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF.



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