New York Hospitals' Charity Care Isn’t So Charitable

New York State’s Indigent Care Pool (ICP) exists to offset the cost of uncompensated care for uninsured and underinsured patients. Annually, nearly $1.2 billion in Medicaid funds are allocated to 201 hospitals statewide to compensate hospitals for the cost of providing care to people that cannot or will not pay their medical bills. In 2007, the state enacted the Hospital Financial Assistance Law (HFAL) to respond to concerns that hospitals were not properly notifying patients of financial assistance and lacked transparency and accountability for how they using public funds. However, a report issued this month by the Community Service Society found that an overwhelming majority of New York hospitals violate the HFAL and continue to impose barriers to financial assistance.

Bronx Health REACH is a longstanding advocate of providing equitable access to care for uninsured and underinsured patients. Part of this effort involves providing clear financial assistance policies to patients through the hospital’s website and the physician referral line. In 2011, New York State Senator Gustavo Rivera and Assemblyman Nelson Castro introduced legislation that would require patients receive information about financial assistance in these ways, as well as prohibit hospitals from steering patients into different care settings. (To read more about this legislation and segregated care, click here.) The passage of this legislation would be a step forward in ensuring that uninsured and underinsured patients receive the financial aid that they need. However, an overarching concern is that the largest amounts of money are going to the hospitals that provide the least amount of care to needy populations, while the safety net institutions shoulder an increased burden with severely limited funds.

The Community Service Society analyzed state department of health data for all New York hospitals and found that the hospitals that approved the largest amount of financial aid applications generally received a smaller amount of funding. For example, Jacobi Medical Center, a public hospital in the Bronx that treats a large proportion of uninsured patients, received $167 in 2010 for each of the 52,702 financial aid applications it approved in 2008. In comparison, Lenox Hill Hospital, a private hospital on the Upper East Side of Manhattan, approved only 130 applications that year and received $84,469 per application. In this current system, the Indigent Care Pool does not reward safety net institutions, which provide significant financial assistance to needy New Yorkers, as they generally receive a lower amount of funding. The report concludes that the extreme variability in the amount of funding received shows that there is a serious need for change in state policy, as well as increased regulation of how these payments are distributed.

The CSS report contains no end of statistics that detail the non-compliance of New York hospitals under HFAL, as well as the inequitable distribution of resources to safety net hospitals. While these reports are critical in order to shed a light on these practices, they should also be a call to action for communities, organizations, and health care advocates. Enormous amounts of money have been paid to treat indigent patients, yet it’s not reaching the people that need it most. (The New York Times wrote an article on this issue and outlined some patient stories, which you can read here.) Without pressure from the communities that these funds are meant to assist, the hospitals may continue to reap the benefits of state funding without providing the assistance it promises. The $1.2 billion per year needs to go to the people that need it most.

Schoolchildren Making a Difference in Access to Healthier Food in the South Bronx

Lack of access to healthy food is an unfortunate reality for the residents of many South Bronx communities. Fast food restaurants and bodegas make up much of the food landscape and healthy options are few and far between. To address this issue, Bronx Health REACH partnered with Citizen Schools, an after school program for low income communities across the country, to teach an 11 week apprenticeship program on food access at MS 331. 14 students from the middle school and Bronx Health REACH staff worked with West Tremont Deli Grocery Corp, a neighborhood bodega frequented by many students and teachers, to provide healthier food options. Prior to working with Bronx Health REACH and Citizen Schools, the bodega had been a participating store in the New York City Department of Health and Mental Hygiene’s Healthy Bodegas Initiative, a program focusing on increasing the availability and promotion of healthier foods in local corner stores.

The 11 week apprenticeship, called Adopt-A-Bodega, incorporated education on nutrition, healthy eating, food access, and marketing techniques with direct action. After learning about health issues, the students brainstormed about what they would like to do to change the bodega right in front of their school that serves many of them on a daily basis. As a class, they came up with four student/ teacher lunch specials that included a healthy deli sandwich (or salad) on whole wheat bread, a bottle of water, and a piece of fruit for a discounted price. Though the bodega owner was initially skeptical about the promotion, it ended up being very popular and the increase in his business made him more open to working with the students on other initiatives.

In addition to the lunch special, the students worked with the bodega owner to sell healthier snack options, such as granola bars and Baked Lays, which the students had taste tested during one of their lessons. The students also requested that the bodega stock more fruits and vegetables, but the owner initially refused as there wasn’t any room to put them. The NYC DOHMH donated a beautiful wooden produce display that was placed in the very front of the store, next to the cash register, so that customers had easy access to it. This display allowed the bodega to stock nearly double the amount of fresh fruit and also increased business because it presented the food in an appealing way. As the students learned, many successful business ventures hinge on presentation.

Throughout this apprenticeship, the students learned that supply is heavily influenced by demand. If you demand healthier food, and business owners see that they can increase sales, they will be more likely to provide the healthier food. Using this model of social change, Bronx Health REACH hopes to continue improving access to healthy foods in bodegas across the Bronx.

Efforts to increase healthy food options as a way to address the childhood obesity epidemic are receiving national attention and support. First Lady Michelle Obama’s Let’s Move! campaign includes the Healthy Food Financing Initiative, which provides financing for developing and equipping grocery stores, small retailers, corner stores, and farmers markets selling healthy food in underserved areas. Throughout the country, cities and states are working within their communities to identify food deserts and find solutions to increase healthy food options in those areas. (Read a prior blog post about food deserts here.) 

In the South Bronx, West Tremont Deli Grocery Corp has made an important contribution in making the neighborhood a healthier place to live. Bronx Health REACH and New York State Senator Gustavo Rivera hosted an event on December 21^st to honor the bodega owner on his dedication. Read more about the event and Senator Rivera’s comments here.

NYC public schoolchildren are less obese than 5 years ago, but is everyone benefitting equally?

After years of relentless increase, New York City Mayor Michael Bloomberg announced last week that obesity rates for public schoolchildren in NYC have decreased over the past five years. The 5.5 percent decrease in obesity rates was the biggest decline in any large city in the country, where most rates are stagnant or rising. As NYC Health Commissioner Dr. Thomas Farley put it, “What’s impressive is that it’s dropping at all.”  

This announcement came after intensive city, state, and nationwide efforts to put childhood obesity on the public’s radar as a serious and urgent health issue. In NYC, the Department of Health, the public school system, and many community organizations have been implementing programs to reduce childhood obesity by increasing access to healthy food, teaching nutrition to schoolchildren, and increasing opportunities for physical activity.  While this decline is certainly a step in the right direction, over 20% of public schoolchildren in NYC are still considered obese and further drops in obesity rates will depend on the continuation and expansion of these efforts.

In addition, though drops were felt across all racial and ethnic groups and economic levels, it was not an equitable distribution. The results, published in a report by the Centers for Disease Control and Prevention, show that declines in obesity were sharply higher among middle-class children than low-income children. In terms of race and ethnicity, the greatest decreases were observed among white children and Asian/Pacific Islanders. Though black and Hispanic children also showed some decrease, it was to a much lesser degree. As this data indicates, there is a real need for concentrated and targeted efforts to reduce childhood obesity and improve health among low-income communities of color.

Bronx Health REACH has been working within schools and communities to reduce childhood obesity through classroom-based nutrition education, the creation of school wellness councils, and partnerships with local businesses to increase the availability and affordability of healthy food. (To read more about Bronx Health REACH’s efforts in this area, click here.) The communities in which we work are largely low-income and have majority black and Hispanic populations, which as the recent report shows, have the highest prevalence of childhood obesity in New York City. These are the areas that require the greatest intervention and increased resources. This recent report proves that lowering childhood obesity rates over a relatively short timeframe is possible, now we need to make sure that efforts to do so are equitable.

America’s Health at a Glance: Findings from the OECD report

Last week, we posted a blog entry about the observations of a group of visitors from the United Kingdom on the state of health care in the United States. Our country’s fragmented and inequitable health care system shocked our visitors and they expressed great concern that the UK’s conservative led government was leaning toward a U.S. style health care system. The recent release of Health at a Glance 2011, a report published by the Organization for Economic Cooperation and Development (OECD) on the health systems of its 34 member countries, affords another opportunity to see how the U.S. stacks up to other countries throughout Europe, North and South America, and the Asia-Pacific region.

The report looks at a variety of indicators in health status and the health workforce and breaks down key findings by country. Overall, medical care has improved in OECD countries and life expectancy has increased dramatically over the past 50 years. However, the United States suffers in comparison to other OECD countries in a number of ways. While the U.S. stands out in the area of cancer care, its rate of avoidable hospital admissions for chronic conditions, such as asthma or pulmonary disease, is much greater than the OECD average. For diabetes prevalence, only the U.S. and Mexico have more than 10% of the adult population living with the disease. The U.S. is also the most obese country in the group, with 34% of its adult population classified as obese in 2008, an increase from 15% in 1980. In childhood obesity, the U.S. ranks second only to Greece.

In health care expenditures, the U.S. ranks first by far, spending 17.4% of its GDP on health care in 2009. The next closest country is the Netherlands, which allocates 12% of its GDP to health care, but has much better health outcomes. Almost all the countries in the OECD rely on the public sector as the main source of health funding, but in the U.S. more than half of health spending in 2009 was through the private sector. In other words, the U.S. spends a larger portion of its GDP on health care than any other OECD country, but it also spends proportionately less from the public coffers than the other countries in the group. Despite these huge expenditures, health outcomes in the U.S. are mediocre at best and dismal at worst when compared to other developed nations. 

These reports should serve as a wakeup call that our health care system is failing the American people. Health spending per capita is much higher in the U.S. than any other OECD country, but yet our obesity and diabetes rates are skyrocketing. The already high hospital admission rate for chronic disease will only increase as diabetes and obesity related complications require medical intervention. And the troubling childhood obesity statistics are a dangerous omen for future generations and their impact on the system. The Affordable Care Act offers some remedies for these pressing issues, such as promoting a more integrated and coordinated model of care and providing more support and incentives for primary care doctors, but to get the U.S. to where it should be there need to be major changes in how health care is delivered. Being the richest country in the world doesn’t mean as much when its people can’t live a healthy life.