Let's Advance Health in Brooklyn

Brooklyn is a special place, full of life and energy and renewal. My father and a couple of generations of my family are from Brooklyn, so I feel a strong connection to the borough even though I've never lived there myself. Most importantly, I see great promise in Brooklyn to become a healthier place for all of its residents: young or old, wealthy or poor, sick or well.

A lot of attention has been paid to Brooklyn's hospital crisis and the seemingly intractable challenges surrounding it: Hospitals in central Brooklyn serve many people who lack insurance coverage. A large proportion of the population has complex medical problems to manage. Healthier, more affluent Brooklyn residents tend to go to Manhattan for their care, where hospitals deliver more high-tech, high-amenity care that brings in very high reimbursement rates. Together, these dynamics lead to a revenue stream based on the current reimbursement approach that is not viable: too many uninsured people, too many serious medical problems and not enough high tech services and procedures that have high price tags associated with them. The status quo in Brooklyn is unsustainable, but there has been a pervasive inability to come to consensus about how to solve the problem and an unwillingness to make tough decisions about closing or restructuring failing hospitals.

I think we have a real opportunity to change our thinking and make meaningful progress in Brooklyn.

First, looking at Brooklyn's health woes as strictly a "hospital" problem misses a big piece of the equation. In hospitals, people get expensive medical care once they get sick or develop a chronic illness. But we also need to think more broadly about the health of a community: a state of wellbeing that can be maintained by effective programs to help people live healthy lives and avoid illness.

Framed in this way, it is clear Brooklyn's health issues are bigger than just the hospital crisis. Life expectancy among men is a full two years shorter in Brooklyn than in Manhattan. The latest County Health Rankings from the Robert Wood Johnson Foundation show that, among New York State's 62 counties, Kings County ranks 57th when it comes to health factors that affect their quality of life; 18 percent of residents report being in poor or fair health. Kings County also does poorly (58 out of 62) on measures related to the availability of primary care services, mental health providers and dentists. And Kings County is close to the bottom (61 out of 62 New York counties) in terms of the social and economic factors that affect health, including violent crime, education and employment.

So we need to move beyond the question of, "What can be done about Brooklyn's hospital problems?" and ask the broader question: "How can Brooklyn be as healthy a place as possible?"

Factors outside of hospitals, clinics and doctors' offices have a disproportionate impact on the health of a community. Community-wide approaches like creating safe playgrounds, cleaning up parks and adding bikes and bike lanes to boost physical activity; expanding access to healthy, affordable food in schools and grocery stores; and improving schools, social services and social connections would go a long way in improving the health of Brooklyn's residents for the long run.

Of course, all of these things cost money; how could these community-wide interventions be paid for in Brooklyn? I figure we spend about $25 billion a year on health care in Brooklyn (this is a very rough estimate: New York State spends more than $200 billion a year on health care, and about 13 percent of the State's residents live in Brooklyn, so let's say 13 percent of our health care dollars go to Brooklyn).

As hospitals work to become more efficient as part of a reformed health system, surely they can realize savings -- even just 2 percent of current spending on medical care would translate to more than $500 million! -- that could be redirected to support community-wide approaches that improve health. In turn, these initiatives could create a positive dynamic where improving the health of the population lowers medical costs and makes further public health interventions possible. And, as hospitals adapt to a new imperative to not only treat sick patients but also keep people healthy, investments in population health activities are a natural fit.

In addition, a reimagined medical care system for Brooklyn should be built on capitated methods of reimbursement -- payments that create steady streams of revenue based on the number of people cared for, rather than on the number of specific services delivered. This is where the entire medical care system is headed over the next 10-15 years, moving away from fee-for-service and toward payment models that reward the value of health care, not the volume of tests and procedures. Why not start in Brooklyn with capitation rates set at levels that can sustain efficient and effective medical care while encouraging the use of primary care and population-level disease prevention activities?

Let's turn the conversation around, from one solely driven to resolve a "hospital crisis" to one where we focus on ensuring a healthy future for all the residents of Brooklyn. Let's work toward investing $500 million or more per year in lower-income communities across the borough. This may seem like a lot of money, but it is small compared to the expensive care we pay for because we fail to invest in health. This action plan would address the health inequities we have ignored in Brooklyn for far too long, and it is well within our reach as a citizenry.