A Vision of Healthcare
New York City’s reputation as an innovator in public health can be traced back to 1736 when political leaders started a six-bed infirmary on a site now occupied by City Hall (De Blasio Admin, 2016). Today, the primary trustee of that legacy is Health + Hospitals (H+H), which serves more than 1.2 million New Yorkers each year and is the largest public health system in the country (De Blasio Admin, 2016). As of 2016, Health + Hospitals has more than 40,000 employees, 11 hospital centers, five long-term care facilities, six diagnostic & treatment centers, 70+ ambulatory care centers and extension clinics, and 500,000 members in their MetroPlus health plan (De Blasio Admin, 2016). It handles nearly one-third of all emergency department visits within the five boroughs, making Health + Hospitals unmatched in its scope. It’s the foundation of New York’s healthcare system. Even though many New Yorkers may not be immediately familiar with the name Martin S. Begun, his work in New York City healthcare has touched your life (Paid Notice, 2016; Begun, 2002).
Martin S. Begun was a leading thinker and architect of the vast structure that so many New Yorkers depend on today. From 1974 to 1994, he served as the Chairman and a member of the New York Community Services Board, Department of Mental Health, Mental Retardation and Alcoholism Services before it merged with the Department of Health and was renamed the Department of Health and Mental Hygiene in 2002 (Cooper, 2002; Begun, 2002). He was a member of Mayor Abraham Beame’s 1970s BEAME task-force which dismantled the inefficient, cost-cutting health planning superagency created under Mayor John Lindsay’s tenure and completely reorganized health services in NYC (Begun, 2002). He also served on Governor Pataki's task force dedicated to improving healthcare facilities in the 21st Century. His 1996 paper, "The True Need for Public Hospitals in New York City,'' was published by the American Public Health Association, which informed his service on the New York State Hospital Review & Planning Council in 2000.
Begun grew up in New York City, which remained as the center of his life and career. He was considered a balancing force among policymakers as a result of his ability to influence. For example, Begun had a hand in NYU Medical School’s affiliation with Health + Hospitals' Bellevue Hospital. Through coalition building, he shed light on the value of symbiotic public-private affiliations in New York’s municipal health system (Stan Brezenoff Interview, 2017). Perhaps, one of the most powerful moments of his career was his resignation as Chairman of the New York Community Services Board, Department of Mental Health, Mental Retardation and Alcoholism Services at the start of the Giuliani administration. In his resignation letter, he summarized all that had been accomplished during his tenure, such as the Reinvestment Act of 1993, the Outpatient Civil Commitment Legislation of 1994, and the Mobile/Crisis Substance Abuse Alcoholism Emergency Retention Law of 1994. These accomplishments would be undercut by the changes Giuliani was making to NYC’s mental health treatment system, such as consolidating separate mental health agencies within one health department (Stan Brezenoff Interview, 2017). He worked until the day he died in 2016, trying to convince the De Blasio administration to separate back into two different agencies (Stan Brezenoff Interview, 2017).
In many ways, Begun’s career and service to New York City is a discussion on healthcare in and of itself. He believed that access to quality healthcare was a right for all New Yorkers, especially those who are sick, low-income, homeless, or mentally ill. His model was that healthcare is not a market commodity, but a public resource and social necessity similar to electricity and heat (Begun, 1996; Begun 1985; Begun 1990). He believed it should be a fundamental requirement for any civil society. Furthermore, its delivery should be efficient, affordable, and inclusive to all New Yorkers. Although there have been some considerable strides in healthcare for New Yorkers, there have also been consequential decisions made that pick at the strength of this system.
At the center of Begun’s model for healthcare was the importance of the public hospital system. The New York City Health and Hospitals Corporation (H+H) is a public benefit corporation created in 1969 to more efficiently manage public hospitals and health facilities in the city (CBC, 2014). Currently, more than one million patients receive care at H+H yearly, and more than 500,000 are enrolled in MetroPlus, the health insurance plan H+H launched in 1985 (CBC, 2014; Caress & Parrot, 2017). H+H is an indispensable structure that provides essential healthcare services to the most vulnerable New Yorkers. In 2011, H+H hospitals discharged over 200,000 patients, over a quarter of the citywide total, and the number has risen each year since (CBC, 2014). In 2014, discharges from H+H hospitals of uninsured patients consisted of 45%, and Medicaid patients consisted of 26% of the citywide total (CBC, 2014; Caress & Parrot, 2017). H+H hospitals also provide vital mental health services, operating over 45% of all certified psychiatric beds in New York City (CBC, 2014; Mueller, 2017). Despite its crucial nature, the H+H system is facing one of the most profound challenges in its 40+ year history. In 2020, it is projected that there will be a $1.8 billion deficit hanging over the corporation (Caress, Parrot, 2017; Hennelly, 2016).
Much of H+H’s fiscal problems can be set at the door of Albany and the private hospital system in New York City. For example, Governor Cuomo tends to undercut the budget by vetoing bills that would increase reimbursements to hospitals that provide a disproportionate share of care to Medicaid patients, as well as uninsured patients. He also withholds state funding in favor of important but admittedly more trendy efforts, like a $25 million investment in biotech innovation (Chanda, Ford, & Murphy, 2017). This stifles H+H along with the private sector off-loading its patients (Chanda, Ford, & Murphy, 2017). H+H spends more on care than it is reimbursed because of its function within the expansive health services system in the city. H+H takes on the costs and services that private hospitals avoid, including the bulk of care for the uninsured and underinsured, Level 1 trauma visits, addiction services, mental health services, and unreimbursed or underfunded medical services (Caress & Parrot, 2017). For example, mental health admissions at public city hospitals increased considerably as private hospitals discarded psychiatric patients over the same period (Mueller, 2017). The existence of H+H and its dedication to vulnerable populations enables private hospital networks to operate at a surplus, while H+H has faced escalating losses (Caress & Parrot, 2017; Hennelly, 2016).
In response to these fiscal strains, 16 hospitals have closed around New York City since 2003, for example, the shuttering of Goldwater hospital in 2013, which resulted in the overcrowding of Harlem hospital (Chanda, Ford, & Murphy, 2017). In total, it has cut its 40,000+ workforce by 10 percent, which puts pressure on the remaining hospitals to see more patients under more congested and unstable conditions (Chanda, Ford, & Murphy, 2017). H+H has also settled on the privatization of certain functions to offset the cost as well. However, privatization leads to more inadequate conditions (NYSNA, 2013; Straube 2013). For example, during Mayor Bloomberg’s tenure, the H+H Board of Directors voted to outsource outpatient dialysis to a for-profit company (NYSNA, 2013). The H+H dialysis privatization plan and proposed staffing model lead to patient-to-staff ratios doubling (NYSNA, 2013; Zhang, Cotter, & Thamer, 2011; Straune 2013). The strain on H+H mounts without much support, and it leaks into the communities it serves most, which further exacerbates the health disparities among low-income New Yorkers.
As Begun stated in his essay, “The True Need for Public Hospitals in New York City,” public hospitals are the foundations for healthy communities. Public hospital ERs act as the equalizer; it’s where anyone and everyone can go to have their basic healthcare needs met, whether it’s for a check-up or a crisis. You don’t need to have a phone, access to the internet, or a primary care physician. You just need to walk in, which is why the closure of 16 hospitals, four in Brooklyn alone, since 2003 has created such a dire situation for underserved communities and exacerbates health disparities. These closures and funding cuts put more and more pressure on the remaining hospitals to see more patients under more crowded and unstable conditions.
Furthermore, these funding cuts limit the scope of what healthcare could be in these communities and create a cycle of disinvestment. Health systems in New York City can go beyond merely ensuring inclusive, affordable, and efficient access to healthcare (which they barely do). They also can address “unemployment, incarceration, housing issues, joblessness, lack of public safety, lack of educational opportunities, limited access to healthy food, and other social determinants of health” (Chandra, Ford, & Murphy, 2016). Creating programs and spaces that recognize the broader health story without funding is extremely difficult. For low-income families living in poor neighborhoods, hospital closings and funding cuts have put a burden on the surviving facilities, and they have also stretched the distances people have to travel to receive care. As a result, many opt out of care entirely because it is physically and financially out of reach for them.
The population which has suffered and continues to suffer the most from the disinvestment in public healthcare is New York City’s homeless. In “Crossroads,” an essay Begun published in 1985, he acknowledges the plight of the homeless, especially the homeless and mentally ill, in New York and the city’s failure to care for them (Begun, 1985). This failure has only worsened since then, and in 1990, Begun accurately predicted that budget cuts would swell New York’s homeless population. Now, almost 30 years later, the situation has hit a boiling point (Begun, 1990). Today, New York City has the largest homeless population in the United States, with over 60,000 homeless people a night in shelters and countless more in the streets (Coalition For Homeless, 2018).
In 2013, the number of people sleeping in city shelters each night reached a historical high since the Great Depression, with shelters reaching capacity forcing The City to rent out hotels to house homeless individuals (Shan & Sandler, 2018; Markee, 2013; Coalition for Homeless, 2018). It is important to note that city surveys significantly underestimates the number of unsheltered homeless New Yorkers because they are a vulnerable population that is ever visible but also largely anonymous (Coalition For Homeless, 2018). Nearly 33% of all homeless individuals suffer from severe mental illnesses, and over half of the homeless mentally ill New Yorkers also suffer from concurrent substance use disorders (Groton, 2013). Care for The City’s homeless is projected to cost New York City over $3 billion, a 72% increase in the last eight years (CBC, 2018). Today New York’s homeless population faces a health services crisis that is made worse by the state of public hospitals and housing in the city. Homeless people are the most likely population to use and need ER services in public hospitals because their housing situations are extremely unstable ( Sun, Karaca, & Wong, 2014; Kerker, Branbridge, et al., 2005; Baggett, O’Connell, et al., 2010 ). However, New York’s public hospital system isn’t given the funding or infrastructure to support its needs.
Although there have been significant health service failings, such as the state of homelessness and H+H funding, over the past few years, the De Blasio administration has been taking steps to address these issues. In 2016, he acknowledged the strain H+H has undergone and unveiled a comprehensive plan to restructure and stabilize the cooperation. The plan included a recurring $140 million addition to the budget for four years and advocating for fairer reimbursement from the state and federal government for care provided to the uninsured and low-income populations enrolled in Medicaid (De Blasio Admin, 2016). It also seeks to “embed more health centers in New York communities in need, build on existing efforts with targeted, community-based outreach to enroll people who are eligible for coverage but remain uninsured, and secure more of a fair New York State funding formula for safety-net hospitals” (De Blasio Admin, 2016).
The city has also committed to enhancing green space in underserved areas and awarded $30 million each to five different parks in low-income areas for significant renovations (Chandra, Ford, & Murphy, 2017). Studies have shown that the presence of well cared for green space in low-income areas is a critical and long-overlooked weapon against poor neighborhood health (Chandra, Ford, & Murphy, 2017). To address infant mortality rates as a result of health disparities the city has invested in “maternal and infant health by expanding maternal depression screenings at hospitals, Safe Sleep campaigns with the Administration for Children’s Services, and Family Wellness suites in Neighborhood Health Action Centers” (Press Release, 2018). As of 2016, there has been a 24% decline in infant mortality from 2007 (Press Release, 2018).
To address the homelessness crisis, the De Blasio administration rolled out the $22 million initiative Safe NYC, under which mental health experts will aggressively canvass the city in search of mentally ill citizens who require treatment. Safe NYC “will unite various city agencies including the Department of Homeless Services, New York City Police Department, and the Department of Health and Mental Hygiene in strengthening the security at homeless shelters, connecting mentally ill returning citizens with care via “intensive mobile treatment teams,” and sharing information about treatment regimen” (Coalition for Homeless, 2018). He also promised 300,000 units of income-targeted housing for the homeless, which is a step in the right direction but remains insufficient in the face of the 60,000+ individuals sleeping in shelters on a daily basis (Coalition of Homeless, 2018). Perhaps, one of the most exciting announcements to come out of the De Blasio administration was the comprehensive affordable healthcare plan that would guarantee healthcare for every resident in New York City, including homeless, uninsured, low-income, and undocumented in 2019 (NYC City Hall Press Office).
Time will tell if De Blasio’s efforts will bring the health services crisis in NYC to a simmer. However, Martin S. Begun would agree that having a mission to help the people in need is better than no mission at all. For Begun, healthcare was not a market commodity, but a public resource and social necessity, in his model, healthcare is a fundamental requirement of a civil society, and its delivery should be efficient, affordable, and inclusive to all New Yorkers, but especially accessible to New York’s most vulnerable populations (Begun, 1996; Begun 1985; Begun 1990). The current state of health services in New York City is failing his model. Public hospitals, which are the institutions at the center of his model, are suffering financially. New York has a governor that has repeatedly undercut the budget of the city’s municipal hospitals in favor of vanity projects and a Mayor whose response to Albany’s financial decisions is to simply advocate for fairer insurance reimbursements for H+H ( De Blasio Admin, 2016; Chanda, Ford, & Murphy, 2017).
The failure to protect, uphold, and improve H+H, the foundation of health services in New York, bleeds into its communities and exacerbates suffering among the neediest of New Yorkers. These are the populations that depend on public health services to survive, and Begun’s model and life’s work was built with them in mind. Hundreds of thousands of New Yorkers are still underinsured (Chandra, Ford, & Murphy, 2017). In 2018, 60,000+ individuals were sleeping in shelters on a daily basis, and countless homeless and mentally ill New Yorkers are still spread across the city in the streets this winter (Coalition of the Homeless, 2018). Much of De Blasio’s health policy announcements seem like bandaids being put on a bursting dam, however, his healthcare for all initiative is something that is finally grasping at Begun’s model (Begun, 1996; Begun 1985; Begun 1990; NYC City Hall Press Office, 2019). As Begun stated in his resignation letter, his mission as a citizen was to set goals that help the people in need and then, most importantly, build the road to achieve those goals. Time will tell if the path towards affordable, efficient, and inclusive healthcare for all New Yorkers will be constructed. The need has been there for years, and New Yorkers will die waiting.
By Stephanie Jones
llustrations done in collaboration with the New Media Artspace at Baruch College. The New Media Artspace is a teaching exhibition space in the Department of Fine and Performing Arts at Baruch College, CUNY. Housed in the Newman Library, the New Media Artspace showcases curated experimental media and interdisciplinary artworks by international artists, students, alumni, and faculty. Special thanks to Stephanie Jones for also creating artwork for this piece.
Check the New Media Artspace out at http://www.newmediartspace.info/