Commissioner for a healthier N.Y.

Gov. Hochul yesterday nominated Dr. James McDonald to be the state health commissioner. McDonald, who has been serving as the acting commissioner since the beginning of the year, has his work cut out for him presiding over a department that supervises a proposed $215.6 billion in spending, including $196.4 billion in Medicaid, which underpins New York’s highest in the nation per capita health spending.

The department’s policies and programs directly impact health for all 20 million New Yorkers. It licenses hospitals, regulates nursing homes, recommends infectious disease and pandemic policy to the governor and administers insurance exchanges.

The extent to which New York’s Health Department is utterly off the rails after 10 years of Andrew Cuomo and a fast-departing interim Hochul commissioner, may be gauged by the fact it doesn’t have, and never has had, any plan whatsoever to control and prevent diabetes — the state’s most widespread, costly and damaging epidemic, especially in low-income and marginalized communities.

Diabetes alone accounts for 20% of the astronomical Medicaid budget — with the state’s per-person cost for a Medicaid diabetes patient almost double the national average. But Hochul’s budget proposal doesn’t contain a single penny to implement well-known strategies to prevent new cases and to minimize terrible complications when people do have diabetes.

A minimal investment in those preventive programs would literally save billions of tax dollars and thousands of lives.

It is up to the new commissioner to grapple with the health hierarchies that leave masses of people — especially Black and Brown people — far sicker than they should ever be.

That means challenging the state’s vast medical industry — the interlocking academic medical centers, huge hospital systems, managed care organizations, insurers and auxiliary services seen in no other state. While a commissioner does not “command” this industry, licensing and other powers allow a commissioner to push it toward greater public accountability and, above all, better patient outcomes.

It would be hard to overstate the dysfunction in what is better described as a sickness industry. As mass illness from diabetes and other chronic diseases gets worse and worse, the system remains cemented in costly procedures and endless expensive emergencies while ignoring preventive care and wellness.

Its very atmosphere is so distressing that even the famously-dedicated frontline health care workers are leaving by the thousands. They see only too well a system that directs billions to insurers and pharmaceutical giants, and millions to high level administrators, while they are left overwhelmed by a tsunami of patients who are sicker than they should be.

Good self-management education is the vaccine for the age of chronic disease. It protects people from the worst and is most effectively delivered by community groups who can make it accessible to people who most need it. When my organization trained peer educators — most of whom had been homeless themselves — to provide a six-session diabetes self-management course to 201 participants in homeless shelters, emergency room visits plunged by 45% and hospitalizations by 74% within six months. This alone saved an average $1,000 to $2,000 per participant in just six months. Multiply that around the state.

As the new commissioner, McDonald must prioritize wellness and self-care, bringing a clear eye for better protocols — such as Lifestyle Medicine with its proven ability to vastly improve, and even reverse, a range of chronic disease.

And McDonald must bring an equally clear eye for New York’s political shoals. It requires that the governor stands by his efforts. Consider just one statistic. For more than a decade, New York’s diabetes-related lower-limb amputations have been rising at double the national rate. Average lifetime medical costs for these disfiguring operations are more than $500,000 (surgery, anesthesia, prosthetics, etc.) With an estimated 50,000 amputations since 2009, preventive care would have saved some $25 billion in lifetime medical costs for amputations, mostly from Medicaid and Medicare.

Even the conservative American Diabetes Association considers that effective early intervention can prevent 85% of diabetes amputations. Yet no commissioner has expressed a word of concern about this routine and preventable mutilation of the mainly low-income New Yorkers who have diabetes.

The day a commissioner orders every hospital in the state to develop a plan to avoid unnecessary amputations — known as a “limb salvage plan” — is the day it will be clear that health in New York is finally changing, that the state will save billions, and patients need not fear the worst from the nation’s most costly and dysfunctional health system.