As a private citizen, Michael Bloomberg showed a keen interest in health care. He sat on the boards of health care organizations, including a local foundation that provided services and sponsored research on the immunity disorder lupus; helped sponsor the Children’s Health Fund’s mobile medical units for the children of homeless families in New York; and donated so much money to Baltimore’s Johns Hopkins School of Public Health that the board eventually decided to name it after him.

Bloomberg’s enthusiasm for public health has continued since he became mayor four years ago. His administration has developed Take Care New York, an guide for healthy living that has been described as the most comprehensive public health plan that the city has ever had. Most people now see his aggressive anti-smoking policies, which provoked controversy when introduced, as a success – with the notable exception of Audrey Silk, who is running for mayor on a pro-smoking platform. The city has recently turned its focus towards trans fats. Many health care advocates appreciate the mayor’s energy and acknowledge his accomplishments.

Still, 1.8 million New Yorkers don't have health insurance, including almost a million who work full time. Medicaid is straining the city and state budgets, even though hundreds of thousands of people who are eligible receive nothing from the program. Many hospitals are struggling financially, and a new state commission has begun discussing which ones could be closed.

When the Community Service Society recently asked low income New Yorkers what they thought of the city's approach to health care, 70 percent said New York is on the wrong track. It's not hard to see why. While the average New Yorker lives longer than the average American, white city residents live an average of six years longer than those who are black. High rates of chronic diseases, from AIDS to diabetes to obesity, are clustered in low income and minority neighborhoods. Language barriers at local hospitals continue to cause problems (report in .pdf format). For those who can’t access basic health care, the city’s tips on healthy living provide little help. And while many hospitals are struggling, the only one where closure is imminent is St. Mary’s in Central Brooklyn, an area whose residents are hospitalized at 30 percent higher rate than the city as a whole, and where 30,000 people went without necessary health care as of 2003.

“The biggest issue we face as New Yorkers is access to affordable health care,” says Mayor Bloomberg. His rivals in the mayoral race agree. When they talk about health care, it is to stress the importance of providing New Yorkers with health insurance through public or private plans, and to break down other barriers to receiving health care.

GETTING TO HEALTH PROBLEMS EARLY

Financial hardship, language barriers and other cultural problems combine to keep many New Yorkers from getting regular checkups or treatment for minor health problems. This is both bad for the health of the individual and expensive for the city. When someone puts off minor treatment they often miss signs of major problems that could have been averted. By the time someone arrives at the emergency room, it is often too late to avoid drastic, expensive measures.

Under Mayor Bloomberg, the city’s department of health has worked on several programs to make it easier to access preventive health care by letting people know what is available to them. It has opened district offices in underserved areas, which also serve as places for people to receive direct medical services. The administration boasts of increased number of breast cancer screenings and the widespread distribution of nicotine patches. But critics say that the health department neglected to use such district offices to identify and address local health problems, and has centralized its approach when it could have expanded relationships with community-based organizations.

Other parts of city government have focused on breaking down barriers that keep immigrants and minorities from accessing health care. The City Council passed a law requiring city agencies that handle Medicaid to have translation services for six languages – Arabic, Chinese, Haitain Creole, Korean, Russian, and Spanish. As Manhattan borough president, Virginia Fields spent time studying the disparities in health among communities of color (report in .pdf format). Her recommendations included programs to steer people from underserved populations towards health care professions, which she believes would increase cultural sensitivity.

Even before preventive care, though, comes improving environmental conditions that lead to health problems. Bloomberg described his proposed garbage plan largely in terms of taking the burden off neighborhoods where heavy truck traffic leads to high asthma rates. As speaker of the City Council, Gifford Miller forced a tough lead paint law through a mayoral veto, and passed bills that required the city to buy energy efficient appliances, improved the emissions standards of its trucks, and supported green buildings.

Of course, the major way to expand access to preventive health care is by enrolling as many of the nearly two million uninsured New Yorkers in some kind of health care plan.

MEDICAID AND PUBLIC INSURANCE PROGRAMS

New York has the most expensive Medicaid program in the country, and Albany is unique among state governments in passing along a significant portion of the cost to local governments. Last fiscal year, the city spent $4.9 billion on Medicaid, about 10 percent of its total budget. City officials and budget watchdogs (report in .pdf format) believe Albany should pay a greater share of Medicaid costs, but it looks unlikely that this will happen soon. Mayor Bloomberg now describes the program as one of the major budget items over which the city has no control.

Because the city does not control Medicaid, a major part of the mayor’s role is to put pressure on the state and federal governments. In addition, the city can actively seek to enroll more people in the program. Currently there are about 500,000 city residents who are eligible for Medicaid but not enrolled. Signing them up has the obvious benefit of giving them access to health care coverage. Moving uninsured New Yorkers onto Medicaid also makes financial sense; the city splits Medicaid costs with the state and federal governments, but foots the entire bill when an uninsured patient shows up in the emergency room of a public hospital.

Mayor Rudolph Giuliani did not make it easy to access Medicaid. The Bloomberg administration, by contrast, boasts that there are 900,000 more people enrolled in public health plans than there were three years ago. Democratic mayoral hopefuls hope to expand this: Anthony Weiner says that as mayor he would focus on improving the technology used to administer public health plans, simplifying the enrollment process; he believes that by doing so the city could sign up two-thirds of eligible uninsured New Yorkers for Medicaid. Fernando Ferrer says he would enroll every child in some type of public health insurance program (all children are eligible for public insurance regardless of immigration status) while also adding 200,000 adults in public health care programs.

PRIVATE HEALTH INSURANCE

Many of the 1.8 million city residents without insurance are not eligible for public health insurance. Since most Americans get their health insurance through their employers, the best thing the city can do is explore ways to expand the number of employers who give their workers health coverage.

This summer, the City Council passed a bill that would require grocery stores and other food retailers to contribute $2.50 towards health care for each hour an employee works, or $5,000 a year for a full-time employee. Mayor Bloomberg said that the city doesn't have the authority to pass such a law, and that this specific bill unfairly singles out one industry. He has promised a veto, but as of the end of August the council seemed to have the votes to override it. The law’s supporters – including Fernando Ferrer – have said that the law is only a pilot program, and hope to extend it to other industries.

Another approach the city can take is to make it cheaper for employers to provide health coverage by encouraging them to band together to bargain with insurers. Anthony Weiner recently pointed to Brooklyn Healthworks, such a program run by the Brooklyn Chamber of Commerce, as a model for the city. By developing a similar plan citywide, Weiner hopes to provide coverage to about a third of the 969,000 uninsured New Yorkers who work full time.

HOSPITALS

Because they do accept patients regardless of whether they have insurance, New York City’s public hospitals, run by the Health and Hospital Corporation, suffer financially from serving the city’s uninsured population. In 2004, the Corporation ran a deficit of $200 million.

The Bloomberg administration has invested in new equipment and other upgrades for the system, which advocates say contrasts sharply to the approach of his predecessor. Still, both Virginia Fields and Fernando Ferrer say public hospitals need more attention: Fields says she will put more money into the system, and Ferrer calls for “full funding” of the Health and Hospital Corporation.

But it is not just the city’s public hospitals that are facing tough financial times. Due to a myriad of factors – overcapacity, rising health care costs, the strain of serving uninsured populations, diminishing federal aid for teaching hospitals, tough state regulations – some private hospitals are doing badly as well. These are mostly smaller hospitals serving poorer areas, where fewer people have insurance. Seven hospitals in New York City have closed since 2003, one is planning to close soon, and several more are reportedly at risk.

This will likely be an issue that the next mayor will have to deal with, but the city’s role in all this is unclear. Local governments have no representation on the state’s hospital closing committee. If that committee decides that some hospitals in the city should close, there is little the mayor can do.