New York City's mayor, Mike Bloomberg (search), faces many of the same historic budget shortfalls that the mayors of most major U.S. cities face today. At every turn, he assures us that balancing the city's budget is job No. 1.
"Raising taxes is not an option...Doing everything possible to balance the budget and control expenses must be our first priority," he said during his campaign. After 16 months in office, it's difficult to see what substantial steps the mayor has taken to control expenses, aside from the centerpiece lay off of city workers and the closing of firehouses. He has not only raised taxes and municipal fees; he's spent much of the last several months ringing doorbells in Albany, the state's capital, in an effort to secure a bailout.
And like most citizens of major U.S. cities, New Yorkers know that they can now forget the primacy of a balanced budget. On every occasion that City Hall has either actively boosted or refused to cut spending, it has done so for ideological reasons.
By January of this year, Bloomberg's belief that "raising taxes is not an option" had disappeared and the raising of taxes had become the option of choice. "Doing everything possible to...control expenses" had been converted into balancing the budget while "continuing to invest in our future."
Though New Yorkers have seen City Hall affect several measures that seem to reflect nothing more than the mayor's personal beliefs, such as the smoking ban (search), in truth Mayor Bloomberg has always subordinated budget concerns to a do-gooder philosophy. Even while there is talk of curtailed garbage pickups, Bloomberg ploughs headlong toward his goal of fully insuring New York City through Medicaid (search).
In managing the city's Medicaid program, the mayor faces one huge variable that many smaller municipalities do not: New York City's undocumented immigrant population. The greater New York City area is one of the country's top five destinations of undocumented immigrants, and according to some observers it is the No. 1 destination for employment-age males.
U.S. hospitals write off between $1 billion and $2 billion each year in health care costs for the treatment of undocumented immigrants. Those costs are attributable chiefly to care of the 300,000 undocumented immigrants that flow across the U.S.-Mexico border annually. The total Medicaid expenditure for the emergency medical treatment of undocumented immigrants now approaches $ 3 billion per year (nationally).
New York City has no real ability to gauge the number of its undocumented immigrants, as the group is perennially unresponsive to the census and other measures designed to determine who lives here. This makes efficient management of programs like Medicaid all the more difficult.
As is the case with most large cities, it is because the real dimension of New York's undocumented immigrant population is unknown -- though likely in the millions -- and unregulated that it can unexpectedly mushroom to budget-breaking proportions.
Medicaid, which regularly accounts for 10 percent of the city's budget and is already the most expensive such program in the nation, has swelled an additional 40 percent, or approximately 132,000 new enrollees, under Mayor Bloomberg.
In the early months of the administration, while he was telling New Yorkers to prepare for critical economizing, the mayor was dispatching "enrollment counselors" to targeted city neighborhoods so that more people would be added to the city's Medicaid rolls.
Even if none of the newly enrolled sees a doctor this year, each new adult signed up will cost the city $1,300 and each new child $375. To get an idea just how much money is involved, consider that New York's Gov. Pataki, in bargaining with the city over cuts and a bailout, proposed $1 billion in Medicaid cuts.
While it may be true that managed care is, over the long term, less costly to the public budget than simply paying each bill as it is presented by a provider, the one-quarter share that the city must contribute to its Medicaid payments is already $4 billion. Could now ever be the right time to be doing this?
The mayor can't appreciate the effects this massive enrollment will have on the city's budget in coming years. At the State of the City address at the Brooklyn Botanical Gardens in January, he pleaded for federal and state relief from Medicaid costs even while he was signing up new enrollees at a record rate.
New York City owns more wasteful and underutilized hospitals than any other city in America, and while Gov. Pataki argued for the substantial cuts to city hospitals that might have lead to real savings over several budget years, Bloomberg succeeded in keeping them intact, at least for the moment.
Senators Kyl and McCain of Arizona have introduced legislation that would reimburse the states an additional $1.45 billion per year as payment for medical services to undocumented immigrants that are not reimbursable under Medicaid.
Some have suggested that a less expensive solution might be to compel hospitals to determine the immigration status of those seeking help in emergency rooms, which would enable a hospital to render care that is certain to be reimbursed under Medicaid (and thereby avoid mammoth unreimbursed medical costs).
Nonetheless, the doctors in most of New York's emergency rooms will tell you that ethics prevents them from considering a patient's immigration status at all in deciding upon a course of care. Others will say that even if the law were changed to explicitly require inquiry into a patient's immigration status, they would disobey the law.
Many of the best informed say that they are completely aware that EMTALA, the law which compels basic emergency medical treatment (regardless of immigration status of the patient's ability to pay), does not prevent a hospital from inquiring as to a patient's immigration status, but they choose not to.
New York City already had the most expensive and generous Medicaid program in the country before Mike Bloomberg took office. Under him, it has grown exponentially. As New York and other large U.S. cities continue to be a beacon for the country's undocumented immigrant population, all Americans can expect an even greater percentage of their tax dollars to be consumed by the Medicaid programs of our large cities.
Matt Hayes began practicing immigration law shortly after graduating from Pace University School of Law in 1994, representing new immigrants in civil and criminal matters. He teaches at Berkeley College, and is author of The New Immigration Law and Practice, a textbook to be published by West Legal Publications in October, 2003.