“First do no harm.”  The Hippocratic Oath is a solemn ethics pledge historically taken by physicians.  It requires a new physician to swear to uphold specific ethical standards, most notably by ensuring patient safety. It is an oath that is the bedrock of appropriate medical care.

In Governor Hochul’s executive budget, tens of billions of dollars will be spent on health care. Health care groups have argued that the governor’s plan is simply not enough to cover the costs of programs, most notably Medicaid.

Yet, too little attention has been devoted to the quality of the medical care that the state, employers, and individuals pay for. There is considerable evidence that the quality of hospital care is too often substandard, and therefore it must be a priority of lawmakers to ensure that steps are taken to address the uneven quality of care as part of any final budget agreement.

Poorer quality of care can drive higher expenses.  A key measure in assessing the quality of hospital care, for example, is “readmission” rates.  Research from the Agency for Healthcare Research and Quality (AHRQ) shows that hospital readmission costs were higher than initial admission costs for about two-thirds of common diagnoses in 2016. Thus, appropriately reducing hospital readmissions not only provides better care, but is less costly. 

The costs of substandard care are well-documented. In November 1999 the Institute of Medicine report, To Err is Human: Building a Safer Health System, was released. It documented an epidemic of preventable deaths in United States hospitals. In September 2009, the director of the U.S. Agency for Healthcare Research and Quality, wrote this about To Err Is Human: “Let me be clear: I am just as frustrated as my colleagues in the public and private sectors with our slow rate of progress in preventing and reducing medical errors.” A widely-covered study published in 2023 reported that 400,000 U.S. hospital patients experienced some type of preventable harm each year.  

The costs resulting from these patient injuries and deaths are enormous. According to one estimate, the annual cost of measurable medical errors that harm patients was $20 billion. Since New York State is approximately 6 percent of the nation’s population––and if the quality of care were universally distributed (which it is not) — the state’s additional costs could be roughly $1 billion. However, there is compelling evidence that the quality of health care in New York is worse than the rest of the nation.

The U.S. Department of Health and Human Services annually publishes Medicare.gov/Compare, which reports the quality of the nation’s hospitals and other providers to the public. Researchers use that information to compare states. One organization, the “Leapfrog Group” (established by the nation’s large employers in 2000 in order to measure “hospital performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions”) has issued annual reports on the quality of American hospital care for over 20 years.  Over those two decades New York has been consistently ranked poorly.

This past year’s Leapfrog Group report found that New York State ranked 42^nd nationwide in terms of quality, with only 11.3 percent of hospitals receiving an “A” grade.

Why do New York hospitals perform comparatively so much worse?  In July 2019 the director of Leapfrog Group explained what she knew about New York’s hospital safety:

“The system as a whole didn’t seem to have emphasized safety. We’ve seen other states work together and look at what’s working well at other states and implement it. It just doesn’t seem to be happening in New York.” 

This week, state lawmakers will hold a hearing on the governor’s proposed health budget. New York hospitals’ consistent poor performance should be a top line of inquiry. Here are some questions that lawmakers should be asking of the state’s regulator of hospital safety, the New York State Department of Health: 

• Why did New York State hospitals rank so poorly?
• What has the New York Department of Health done to respond to the national rankings that have consistently found poor quality in state hospitals? 
• What progress has New York State made in meeting its goal to reduce by half New York’s hospital patients’ injuries and deaths, a promise made 20 years ago?

When we go to the hospital, we should all expect that all is being done to make us better, not worse.  It seems too often clear that isn’t happening in New York.  State lawmakers should use the budget process to get to the bottom of why New York’s hospitals are falling short of the oath to “first do no harm.”

Mario Cuomo once famously remarked, “You campaign in poetry. You govern in prose.” This metaphor, highlighting the shift from rhetoric to reality, applies to various contexts. A good example is the governor’s State of the State address.  The governor’s State of the State is a requirement of the job.  The state Constitution demands that “The governor shall communicate by message to the legislature at every session the condition of the state and recommend such matters to it as he or she shall judge expedient.”

In modern times the State of the State speech is delivered with much of the pomp found in the State of the Union address given by the President.  The State of the State is delivered before a joint session of the state Senate and the state Assembly and is covered by media outlets across the state.  The speech is typically delivered at the beginning of the legislative session and offers the governor’s vision and her plans to make the state better.  Usually the one hour or so speech comes with a detailed policy book that outlines initiatives that the governor will advance.

The State of the State is the “poetry” of the governor’s agenda.

Her “prose” shows up in her budget address.  Again, it is the state Constitution that requires that she submit “on or before the second Tuesday following the first day of the annual meeting of the legislature” a budget to the Legislature.  (In the first budget after a gubernatorial election, the governor has until February 1^st to deliver the budget plan.) 

The budget presentation is where the rubber hits the road.  Given the necessary level of details in a budget, soaring rhetoric is insufficient.  The governor must make it clear what she proposes the state do, how much programs will cost, and how those programs will be funded. 

Last week, Governor Hochul offered poetry while covering a wide range of topics in her third State of the State address.  The media coverage tracked her overall vision:  She focused on fighting crime yet said virtually nothing about the migrant crisis that has overwhelmed New York City.  She cited the state’s need to build affordable housing but sketched out only a modest plan focusing on working with New York City.  She made little reference to how she intended to offset the state’s looming budget crisis – unless actions are taken, the state is projected to run deficits over the next three years.

Her poetry was more detailed in the policy book that accompanied the speech.  For example, she devoted a section to the worsening climate crisis and the need for a wide range of actions.  Yet, she ignored the huge and mounting costs and how to pay for them.  She’s not alone when it comes to ignoring the worsening climate crisis in New York and the staggering – and mounting – expenses to protect communities and to restore damaged infrastructure.

That topic, if it’s discussed at all, will be part of the governor’s proposed executive budget, due to be released on January 16^th. 

It is the governor’s budget plan that will dominate the first few months of the legislative session.  Her plan is subject to public hearings for a month, then a largely secretive budget negotiation between the governor’s office and the leadership of the Senate and the Assembly.  The final budget is supposed to be approved by April 1^st, but in recent years that deadline was ignored.  Last year, for example, the governor insisted that criminal justice changes be included in the budget, holding up the final deal and passage until the end of April.

There has been a lot of debate – correctly – that the state is facing a crisis that stems from the increase in migrants seeking new lives in New York.  Over the past 18 months, 140,000 migrants and asylum seekers have arrived in New York.  How the state handles these new arrivals – in terms of providing housing, food, and opportunity – is undoubtedly an enormous task.

Yet, recent storms have caused enormous damage across New York.  The two most recent storms have hit Long Island particularly hard causing incredible erosion of its south shore.  Of course, damage goes far beyond coastal erosion and includes extensive flooding and other structural damages. 

In the governor’s State of the State policy book, she devotes a section to “Protecting New Yorkers from Extreme Weather.”  In that section, the governor discusses plans to protect homes – including buying out properties that are at risk – to update homes and buildings for hotter temperatures, to address coastal erosion, and to tackle aging dams that will be handling stronger storm surges. 

Her plans, however, said little about how to pay for these – and other – proposals.  So far, the governor has saddled climate damages onto New York taxpayers.  But as these costs mount – and they will – the financial pressures will squeeze taxpayers as never before.  Unless the governor devises another way – like supporting legislation to make the largest oil companies pick up these costs – a new crisis is brewing and it’s one that is only going to get worse.  The prose in the governor’s budget plans may give policymakers a clue as to how she will tackle the climate cost crisis. 

The drumbeat of bad news for New York’s public and independent colleges continues. Last month it was the news that the Albany-based 103 year old College of Saint Rose would be closing its doors. This month, the bad news is from public colleges within the State University system. The well-regarded SUNY Geneseo announced that it was facing a $10 million “financial crisis.”

SUNY Fredonia, experiencing a 40% enrollment decline, plans to cut 13 degree programs to address a $10 million deficit, while SUNY Potsdam is set to cut nine degree programs over several years to address a $9 million structural deficit. Financial struggles extend beyond these institutions, with SUNY’s four-year public colleges and community colleges encountering serious financial difficulties in recent years.

A recent SUNY report indicates that, if current expense and revenue trends persist, the system will face an annual budget shortfall of over $1 billion in 10 years. Several SUNY colleges, including SUNY Maritime, Delhi, and Buffalo State, are grappling with deficits as well.

None of this should come as a surprise. In recent years the financial strain at SUNY has been increasingly evident. Even before the covid pandemic, SUNY had been hemorrhaging enrollments. Covid made it worse.

There is no single explanation as to why this situation has occurred, but public policies seem to have been a contributing factor. The Cuomo Administration had perhaps the biggest impact with its so-called “SUNY 2020” plan. That plan instituted regular tuition hikes at public colleges and universities and also severed the relationship between increasing college student financial assistance through the Tuition Assistance Program (TAP) and the now rising costs of SUNY tuition.

It was that second aspect of SUNY 2020 that hurt colleges. Prior to the Cuomo plan, the maximum TAP award would go up every time SUNY tuition increased. This ensured that the poorest public college students would see their tuition costs covered. It had also helped boost independent (private) colleges by adding state support to those schools to cover a portion of their tuition costs as well.

The damage came when the Cuomo plan severed that relationship and froze TAP awards while public college tuition went up. That impacted public colleges since the state was not required to cover the difference between the maximum TAP award and the rising SUNY tuition. That “gap” swelled over time and became known as the “TAP gap.”

The TAP gap eroded public colleges’ finances as they were regularly being asked to cover rising tuition costs for their poorest students. Independent colleges were hit too. Since TAP awards were frozen, they too had to figure out ways to cover the financial assistance that would normally have come from the state’s TAP.

Rising costs coupled with restrained financial assistance contributed to a drop in enrollments. Fewer students equal less money for colleges that were already seeing reductions in state assistance. That “one-two” punch surely accelerated the weakening financial situations at SUNY – and smaller independent colleges – and the results are clearer every day.

Demographic trends have hurt too and the experience in New York is consistent with the national experience. Yet, pointing to the national demographic trends to explain the problem doesn’t lead to a policy response.

The knee-jerk reaction is to do more of the same: Shift increasing costs onto college students and their families. Instead, policymakers should be looking at the issue in a different way.

Colleges and universities have important jobs: they train the next generation of workers and help them to better understand civic life. In addition, they are economic engines that create jobs that stimulate and anchor local economies. They offer a stimulus to local economies that are virtually guaranteed to succeed.

Policymakers too often look at the newest “shiny object” when it comes to economic development policies. In New York, we have seen very expensive plans fail and in some cases even trigger corruption.

Why not view public investments in colleges and universities as the cornerstone to economic development instead of a pay-as-you-go experience for college students and their families?

Governor Hochul will soon unveil her budget plans. Will she follow the well-trod path of soaking college students and their families for the costs of higher education? Or will she look at the issue differently and view public investments in institutions of higher education as a social and economic good worthy of such support? Time will tell. Students, parents and college communities across the state will be paying close attention.

As we bid farewell to 2023, a year marked by global upheavals such as conflicts in Europe and the Middle East, and internal threats to democracy, the task of pinpointing the most pressing issue becomes a formidable challenge. Yet, when evaluating the threat that affects the largest swathes of humanity, the accelerating climate crisis emerges as the paramount concern.

The past eight years are already the hottest on record.  It is expected that 2023 will be the hottest in human recorded history.  The hotter climate drove extremes around the world in 2023.  For example, Phoenix Arizona saw 54 days of 110 degree temperatures or more, a new record.  Unfortunately, it wasn’t only the Southwest that endured brutal heat waves:  China, southern Europe and Latin America also saw intense heat.  There were also the devastating wildfires in Hawaii.

According to National Oceanic and Atmospheric Administration (NOAA), Africa, Asia and South America all had their warmest Novembers on record.  North America had its second-warmest November, while Pacific Island nations comprising Oceania had their fifth-warmest November.

The toll of climate change wasn’t confined to far-flung areas; the northeastern United States faced its own share of climate-related disasters. New York was plagued with terrible air quality, at one point air that turned orange kept many indoors, thanks to unprecedented Canadian wildfires.

Deadly storms rocked the state; with serious flooding upstate, including the Adirondacks, and downstate, including Long Island and New York City.  There can be no doubt that as the climate warms, these types of storms will worsen.

The escalation of such storms is an undeniable consequence of a warming climate.

Here in New York, the economic ramifications are substantial.  A study by New York State Comptroller DiNapoli revealed that over a ten-year span, more than half of New York localities’ municipal spending outside of New York City was or will be linked to climate change. New York City may need to spend around $100 billion to upgrade its sewer systems to withstand intensified storms. And those costs are on top of the $52 billion that the U.S. Army Corps of Engineers has estimated it will cost to protect New York Harbor from rising sea levels and storms.  Estimates suggest that Long Island alone could incur up to $100 billion in climate-related costs.

These financial burdens are projected to escalate, potentially reaching $10 billion annually for New Yorkers by the middle of the century.

Recognizing the untenable situation, 100 local elected officials in New York recently advocated for a legislative measure compelling major oil companies to contribute to climate-related expenses. This proposed legislation would demand these companies, responsible for significant greenhouse gas emissions, to pay apportioned fees totaling $3 billion annually. The legislation aims to prevent these costs from being shifted onto the public, as confirmed by an independent think tank’s analysis.

However, despite these concerns, the Hochul Administration appears inclined to pass climate-related costs onto the taxpayers, with over $2 billion pledged for climate projects over the past year.

There are forces that are doing all they can to undermine the steps needed to address the worsening climate crisis.  They slavishly followed the lead of the fossil fuel industry and for years argued that climate change was a hoax.  We now know that the oil industry knew for years that the burning of fossil fuels would lead to a climate catastrophe, but they chose to mislead the public instead of helping the world to avoid the situation that we’re in now. 

Their supporters have now started to shed the “hoax” argument instead describing science-based environmental measures as “radical” and “unaffordable.”  Inaction in this area equals maintaining a disastrous – and worsening – status quo.  The urgency of the climate crisis calls for decisive action and dismissing environmental measures as “radical” or “unaffordable” perpetuates a perilous status quo.

As we step into the new year, we all must hope that among Governor Hochul’s resolutions is a commitment to maintaining New York’s leadership in transitioning to a renewable energy-powered economy and to also hold corporate climate polluters accountable for the mess they have contributed to.

New York’s 2023 legislative session is nearly complete – six months after lawmakers left Albany. The state Legislature normally meets during the first six months of the year. During that time, they approve a budget and typically pass hundreds of bills covering a wide range of topics.

This year, lawmakers approved nearly 900 bills, of which more than 600 were approved in June, the last month of the session. The fact that the vast bulk of legislation was approved at the end of session is not unusual, it is typical.

Under the state Constitution, once the bills have passed both houses, they are sent to the governor for her approval. The rules that you learned in civics class are clear to that point, but in Albany things get murkier when it comes to how approved legislation is managed once the Legislature acts.

In New York, the legislative house that approved the legislation first controls when it goes to the governor. In order to keep the governor’s office from being overwhelmed, there is an informal agreement that the governor requests batches of bills when her staff is ready to review them. Under the law, all approved legislation must go to the governor by the end of the calendar year.

As a practical matter, the governor’s office often holds back on its requests for legislation to be sent if her staff are concerned about aspects of the legislation, or they expect that they will have to veto a bill that has popular support.

Thus, December is the big month for gubernatorial action. Vetoing popular legislation is best done when the public is not paying attention – like during the holiday season.

As of December 1^st, 728 of the 896 bills that were approved had been acted upon – approved or vetoed – by the governor. It became clear that December would once again be the critical month for important action. So far, that has been the case.

During the past week, the governor has been busy. She approved 46 bills, some noteworthy. Governor Hochul approved legislation to move election day for some local offices from odd-numbered years to even-numbered ones. Her justification was that voters are more likely to go to the polls in even-numbered years and therefore making the switch would boost voter participation in local races (she’s right). The governor also approved a bill that establishes the New York State

Community Commission on Reparations Remedies to examine New York’s history with the institution of slavery, the subsequent racial and economic discrimination against African-Americans, the impact of these forces on living African-Americans, and to make recommendations on appropriate remedies.

The governor also approved the so-called “birds and bees protection act,” which limits the use of a certain insecticide that can cause harm to bees, birds, and other pollinators. She also approved legislation that requires the disclosure of the “beneficial owners” of limited liability companies (LLCs). Currently, those LLCs are businesses whose owners are often secret. The legislation requires that the LLCs disclose those entities who own the companies. Both of those last two bills were approved by the governor, but only after she secured promises of significant revisions to the legislation. For example, under the LLC legislation approved by the Legislature, the information about the owners would be made publicly available in a searchable database. The governor insisted that the requirement be removed. As part of the agreements, the changes will have to be approved during the next legislative session.

During that same week, the governor vetoed 43 bills. She vetoed a bill that would have prohibited “non-compete agreements and certain restrictive covenants.” Non-compete agreements are sometimes required by employers, and they prohibit or restrict employees from getting jobs with businesses that compete with the company they work for. The governor also vetoed legislation that would have restricted state agencies from purchasing tropical hardwoods, since such purchasing leads to the destruction of important natural resources. The governor cited cost concerns. She also vetoed a bill that would have required the reporting of lobbying to influence the appointment of public officials subject to state Senate approval. Ironically, that last veto was framed as a way to protect those who were spending the money to influence gubernatorial appointments while the governor stated her commitment to transparency.

As the year draws to a close, there are only four bills left, the most notable is legislation to change New York State’s “wrongful death” law, which has been on the books with little change since 1847. Wrongful death cases are what they sound like: lawsuits brought after someone dies due to the negligence of another. The bill modernizes the definition of family to one more consistent with that found in 2023 and allows recovery for the emotional losses of surviving loved ones, as is the case in 48 other states. In addition, the governor hasn’t yet acted on legislation to change the new voluntary system of public financing for elections. This bill makes changes in the program that just started last year. The legislation has been roundly criticized by civic groups who are urging a veto.

With a handful of bills left, the governor’s work will be done – just in time. Lawmakers return in two weeks. And the process will start all over again.