Author: David Sandman

It’s a tough time to be an optimist. The recent election affirms the country’s polarization; war rages abroad; and inflation is high.

In health care circles, the COVID-19 pandemic persists and take-up of the latest vaccines is sluggish. Flu and RSV are exacerbating the strain on the health care system. Polio has reemerged. New Yorkers who are food insecure are making impossible choices like skipping medicine and meals to make sure their kids can eat. Sky-high food prices are making it expensive to put Thanksgiving meals on the table. And when it comes to all of these challenges, we see stark racial and ethnic disparities, with Black and Hispanic New Yorkers faring worse than their white counterparts.

And yet, as we look ahead to Thanksgiving and the winter holiday season, I’m on the hunt for bright spots. Amidst the many challenges we’re facing in New York and as a nation, here are a few things I’m feeling thankful for:

The worst of COVID is behind us. The pandemic isn’t over and it’s likely that COVID will always be with us in some fashion. We still need to be vigilant about protecting ourselves and others from the virus: on average, 3,000 people each day are hospitalized with COVID across New York State, and about 15 people are dying each day (by comparison, that’s about 7% of the number we saw during the last COVID spike in January 2022). But with vaccines, testing, and treatments widely available, COVID looks and feels much different than it did two years ago and even one year ago, when both tests and treatment were in short supply. I’m thankful for the progress we’ve made.

The health care safety net has held. A rare silver lining of the pandemic is that health insurance coverage rates in New York State are now at record highs and the number of uninsured New Yorkers has declined. This progress is partly attributable to the 2020 federal public health emergency declaration, which included increased Medicaid funding to states and a continuous coverage requirement that prohibited states from terminating Medicaid enrollees’ coverage. Just last week, the public health emergency was extended and I’m thankful for it. It could have been devastating for those resources to dry up during a potential winter COVID spike. The extra time will also enable better preparation for the eventual transition.

Insurance coverage will remain more affordable. The 2021 American Rescue Plan included a temporary increase in subsidies for people purchasing health insurance through Affordable Care Act Marketplaces, including the New York State of Health Marketplace. It also expanded eligibility for subsidies to more middle-income people, for whom coverage might have previously been out of reach. This summer, federal legislation extended the enhanced subsidies for three years. As a result, more New Yorkers will have the protection and peace of mind that comes with stable health insurance coverage.

Seniors are poised to have more affordable prescriptions. This summer, we saw the passage of landmark legislation that will lower prescription costs in the Medicare program. It requires the U.S. Secretary for Health & Human Services to negotiate prices for some of the most common drugs covered by Medicare; mandates that pharmaceutical companies deliver rebates if the prices of drugs for Medicare beneficiaries rise faster than inflation; and caps out-of-pocket prescription spending for Medicare Part D beneficiaries at $2,000 annually. It will also end cost-sharing for vaccinations covered under Medicare Part D; that means seniors will no longer have to pay anything out of pocket for protection against shingles, for example.

Monkeypox hasn’t become the next COVID. Over the summer, I wrote an op-ed highlighting the parallels among HIV/AIDS, COVID, and the emerging monkeypox (MPV) outbreak in New York City. I feared that history was repeating itself again. We still haven’t fully learned from the experiences and mistakes of HIV or COVID. But we seem to have dodged the worst-case scenario when it comes to MPV: infection rates have declined significantly since the initial outbreak. Health centers and other trusted community-based organizations provided public education, vaccination outreach and administration, testing, and treatment, with a focus on the groups at highest risk for infection. I’m thankful for those efforts to curb an outbreak of infectious disease that could, once again, have devastated communities who have been historically marginalized.

I’m not a Pollyanna; I know there’s plenty in our health system that needs fixing. But there are also reasons for hope and encouragement. Embrace them and be inspired to keep working to make things better.

On a personal note: I’m thankful for my family and friends, my health, and rewarding work with great colleagues. I wish a happy holiday to you and your families and tables that overflow with laughter and love. Please comment and share what you are grateful for.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on November 21, 2022

Chronic disease prevention.
Tobacco control.
Air and water quality.
Maternal and child health.
Mental health.
Racial health equity.
Mitigation of COVID-19, flu, monkeypox, and other communicable diseases.

These factors — and more — are key to keeping New Yorkers healthy. It’s a massive undertaking to monitor and address all these areas and doing so is the responsibility of our State and local health departments. New York State’s Prevention Agenda serves as a blueprint for action to improve New Yorkers’ health; it lays out a comprehensive set of goals and tracks progress (or lack thereof) over time.

Earlier this month, Politico reported that State Health Commissioner Mary Bassett had updated the New York State Public Health and Health Planning Council about the Prevention Agenda. According to the article, Dr. Bassett said, “I spent some time on all of these issues just to remind all of us of the scope of work of the Health Department. We are very much committed to the whole health of the population, which extends beyond the control of microbes to include the environment, non-communicable and chronic diseases.”

When I reviewed the report, I saw progress in some areas while other indicators are moving in the wrong direction. But what struck me most is how outdated much of the information is: many of the data points were years old and pre-pandemic. For example, New York saw gains in pediatric asthma management, but they’re only tracked through 2019. How did the pandemic affect those numbers? If they got worse during 2020, have they bounced back now that COVID isn’t placing as much strain on our health care system?

Similarly, we have data through 2020 about children who’ve completed their early childhood vaccination series. After improvement between 2018 and 2019, we see a small dip in 2020. That makes intuitive sense; it’s been widely reported that many people delayed preventive services like routine vaccinations in 2020 owing to the pandemic. Have those rates stabilized, or have they continued their decline given growing vaccine hesitancy in the wake of rampant misinformation about COVID-19 vaccines?

Surveillance and data are the foundation of public health practice. Our dedicated public health officials will struggle to adapt nimbly and with confidence if they can’t be sure whether things are going in the right or wrong direction. How can they make informed decisions about priorities and resource allocations when we can’t track data in closer to real-time? I’ve written before about how woefully under-resourced public health departments are and the price we’ve paid for that disinvestment. A lack of timely data further hamstrings their ability to direct limited resources in the most effective ways.

Every researcher and policy professional knows that data lags are a fact of life. It’s not realistic to expect that we can have real-time data for every measure that matters. But the pandemic showed that it is possible to generate and share reasonably high-quality, actionable, and current data when we really need it. A few examples:

• COVID-19 data dashboards: Particularly in the early days of the pandemic, tracking COVID case counts, hospitalizations, and deaths on a near real-time basis at the county and community levels was critical for estimating risk, making policy, and targeting limited resources. Publicly available, user-friendly dashboards — like this one from The New York Times — are especially helpful for communicable diseases, where individuals can play a role in protecting themselves and keeping others safe.
• U.S. Census Bureau Household Surveys: Beginning in April 2020, the Pulse survey began asking people about pandemic-related challenges such as food scarcity, employment, delayed medical care, mental health, and so on. Questions were added and dropped as the landscape changed. Over time, the survey began asking about vaccination status and it has recently added a question about long COVID symptoms. The survey provides real-time, non-clinical data that can be easily viewed using an online interactive tool. Best of all, the data are very current; data are now available through October 17, 2022 — just two weeks ago.
• Wastewater analysis: Wastewater surveillance has been invaluable to public health officials over the last few years, allowing them to detect everything from COVID-19 (which can show up in wastewater several days before it appears in positive tests or hospitalization) to opioids to polio. New York State has a dashboard showing where COVID-19 has been detected in wastewater across the State, and it’s updated weekly. With the reemergence of polio in New York (I still can’t believe I’m typing that sentence in 2022), officials are working to improve wastewater surveillance for it, and counties are exploring using it to detect flu, Hepatitis, and opioids.

The COVID-19 pandemic underscored both the necessity and the possibilities for more current public health data. The Centers for Disease Control and Prevention has launched a Data Modernization Initiative designed to create a world in which “data moves faster than disease.” So-called “syndromic surveillance” systems move faster than traditional methods; they capture real-time health data and scan for anomalies suggesting outbreaks before diagnoses are made. If redesigned for purposes other than outbreak detection, they could be another powerful tool. The New York City Department of Health and Mental Hygiene has used “nowcasting,” a technique that originated in meteorology and relies on statistical modeling, to monitor COVID-19 in closer to real-time and make decisions. This innovative approach could also have applications beyond predicting outbreaks.

Relying on old data to confront today’s challenges means we have one hand tied behind our back when responding to public health challenges. Investing in data infrastructure is not the sexiest thing to do, but it could make a real difference. Accelerating the availability of timely and reliable data will empower us to better respond to immediate crises and to improve a wide range of chronic health issues.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on October 31, 2022

In the late 1990s, I attended a speech by then-U.S. Secretary of Health and Human Services Donna Shalala.

I don’t remember what she spoke about, but I do remember her getting interrupted and heckled by AIDS activists who were angry at the Clinton Administration’s policy on needle exchanges. And they had every right to be. The Administration had accepted a federally-sponsored scientific review of incontrovertible evidence that found that needle exchange programs reduced the spread of AIDS in intravenous drug users, without increasing the use of drugs. Shalala was even quoted as saying, “The scientific part was easy.” Yet, the Clinton Administration refused to authorize funds for such programs, fearing it would look soft on drugs. It was a political cop-out and the government still has blood on its hands for that decision. How many lives could have been saved if the political will was there to back the science?

It is decades later, and another public health crisis — the opioid epidemic — requires us to be bold. Drug overdoses in New York State and nationally are at crisis levels, with the highest number of overdose-related deaths ever recorded. While the COVID pandemic dominated the news, the opioid epidemic only got worse. The latest reports show that drug-involved overdose deaths in New York State increased by 37% between 2019 and 2020. Opioid-related deaths are growing even faster: a 44% increase between 2019 and 2020. That’s an average of nearly 12 New Yorkers dying every day from opioid-related overdose.

It’s likely that those numbers have climbed even higher as people grapple with the consequences of the ongoing pandemic, including mental health distress, loss of income and housing stability, and disruptions in prevention and treatment services. The cumulative impact of the pandemic, the increasing prevalence of fentanyl in the drug supply, and pervasive racial disparities in overdose deaths are taking a devastating toll, particularly in New York City.

New York City has a history of embracing high-risk, high-reward strategies to address public health crises. Even without federal support, New York City became home to one of the first needle exchange programs in the United States. It had to be so; by the early 1990s, NYC was experiencing the largest HIV epidemic among injecting drug users of any city in the world. Approximately one-half of the estimated injecting drug users in New York were believed to already be infected with HIV.

As opioid addiction continues to ravage lives and communities, one effective model for reducing overdose deaths remains legally precarious: overdose prevention centers, or OPCs. OPCs are clinical, safe, hygienic spaces where people can use drugs under the supervision of trained professionals to prevent deaths and get connected to care and drug treatment. They are co-located in existing needle exchange programs and provide health and social services like free meals and counseling services. Research proves that OPCs reduce drug-related illnesses, improve access to health care, and reduce drug-related crime and public drug use. OPCs have long been in operation in Canada, Europe, and Australia, and not a single overdose death has occurred in any facilities worldwide.

In the United States, though, a 1980s-era provision of the federal Controlled Substances Act prohibits making facilities available “for the purpose of unlawfully…using a controlled substance.” That provision wasn’t designed to prohibit overdose prevention centers, but the unintended consequences could be significant. Absent clear federal guidance, state and local governments are wary of establishing OPCs, despite their proven results.

I’m proud that New York City is once again leading the nation. Late last year, OnPoint NYC became the first organization in the United States to open government-sanctioned OPCs, in East Harlem and Washington Heights. Since their opening, these centers have prevented more than 300 overdoses and served more than 1,000 people.

Although State and federal action is needed to explicitly legalize OPCs and open up pathways for reimbursement and expansion, City officials, including the Mayor, have been supportive. The City Council has also called on Mayor Adams to allocate an additional $10 million to open an overdose prevention center in each borough. Two more OPCs are expected to open this summer in midtown Manhattan and the East Village, under the auspices of Housing Works.

At the existing two sites, OnPoint NYC has exceeded expectations in its first several months of operation, reversing more overdoses in five months than experts expected it would in a full year. OPCs also make good financial sense: the New York City Department of Health and Mental Hygiene preliminarily estimates that OPCs will save up to $7 million annually in health care costs from drug use and overdose. A rigorous, third-party evaluation by academic researchers is expected to further cement the case.

OPCs are a partial response to an opioid epidemic that demands a comprehensive approach. Although a bill to legalize OPCs stalled in Albany, the New York State legislature recently approved several bills to address other elements of overdose prevention, like eliminating insurance co-pays for opioid treatment programs and allowing night clubs to administer Naloxone and other overdose treatments. Drug treatment programs need to be available and affordable.

New York City is poised to demonstrate to the nation that OPCs are a safe, effective, and compassionate tool to curb the consequences of the opioid epidemic. Philadelphia, Seattle, San Francisco, and Rhode Island, along with several other states, are in various stages of establishing OPCs; California and Maryland have already looked to OnPoint NYC as a model for their own work.

History doesn’t have to repeat itself. Embracing needle exchanges sooner would’ve saved lives. Now, we are older and wiser. Reversing the opioid crisis and saving lives will take courage. New York is leading the way with overdose prevention centers. Indeed, in hindsight, we may ask again, “What took us so long?”

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on June 15, 2022

Photo: OnPoint NYC staff at an overdose prevention center in East Harlem. Photo by Timothy A. Clary.

Imagine that you’re dealing with cancer and huge medical bills keep piling up.

Or that you are recovering from a hospitalization and you’re now being sued for outstanding bills and dodging debt collectors. Or that you were injured in a car accident and ended up in an ambulance that wasn’t covered by insurance and now you owe large sums of money. Maybe these debts are forcing you to consider selling your home or moving in with relatives to save on rent.

It’s not hard to imagine these scenarios because they happen regularly in the United States.

As RIP Medical Debt (a nonprofit that has helped eliminate more than $6.7 billion of medical debt for more than 3.6 million families yet has barely scratched the surface of the problem) puts it, “Medical debt is a uniquely American injustice.”

It’s true:

• Medical debt is the most common reason for bankruptcy in the United States.
• Estimates vary, but a survey found that 41% of working-age Americans have problems with medical bills or are paying off medical debt.
• A recent analysis found that people in the United States owe approximately $195 billion in medical debt.
• That same analysis showed that an estimated 23 million Americans — nearly 1 in 10 adults — have “significant medical debt” of more than $250.
• Americans who have a disability are more than twice as likely to have significant medical debt than those without a disability.
• The U.S. Census Bureau estimates that 28% of Black households carry medical debt, compared with 17% of non-Hispanic white households.

We are seeing some steps to address medical debt nationally. Starting this summer, the three major credit reporting agencies will expunge medical debt from many consumers’ credit reports — if it’s paid off or if it’s less than a year old. Starting next year, medical collection accounts of less than $500 will also be excluded from credit reports. That’s a good start, but those measures will only affect about 70% of medical debt — meaning that many Americans who are saddled with high medical bills will continue to have ruinous credit scores.

As part of a broader set of measures to “protect consumers and lessen the burden of medical debt on American families,” the White House just announced it will build on those private-sector efforts and eliminate medical debt as a factor for underwriting in all federal agencies’ credit programs. The Biden administration has also pledged to address predatory and aggressive billing and collections practices; make it easier for veterans to get their VA medical debt forgiven; and provide more educational resources to help patients understand their rights.

Here in New York State, medical debt burdens patients. In 2020, 6% of New Yorkers were put into collections over medical bills — with double that rate for people of color in parts of the State (this interactive map from the Urban Institute shows the substantial variation of medical debt across New York State by geography and race). In the most extreme cases, New Yorkers face lawsuits and property liens or wage garnishments because of medical debt. More than 52,000 lawsuits were filed against patients by New York hospitals between 2015 and 2020. Low-income communities and communities of color outside of New York City have been particularly hard hit by unfair billing practices.

Thanks in part to advocacy efforts like the Community Service Society’s End Medical Debt campaign, New York State is taking action to address medical debt. The statute of limitations for medical debt lawsuits was reduced from six years to three years; a loophole in the State’s surprise bill law was closed (although some gaps still remain) to cover emergency services; and interest rates that may be charged on any consumer debt were reduced from 9% to 2%. Legislation that would prevent hospitals from placing liens on patients’ homes or garnish their wages recently passed in the Assembly, but remains pending in the State Senate. More still needs to be done to make it easier for eligible patients to know about and receive hospital financial assistance in New York.

Even in a sharply divided country, easing medical debt is a ripe topic on which to find common ground. It’s not a partisan or ideological issue. I don’t know anyone, regardless of their politics, who believes that getting sick and needing health care should be financially ruinous for patients and their families. It’s an economic and moral stain on our system, and patients deserve more protections for their physical, mental, and financial health.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on April 26, 2022