Working to make New York’s largest private employer continuously better

With its sprawling, ever-growing network of more than two dozen hospitals and roughly 900 outpatient care centers all over downstate New York and Connecticut, Northwell Health is New York state's largest health care provider and private employer. In April, the nonprofit, which also comprises a med school in partnership with Hofstra University, made headlines when it merged with the Connecticut healthcare network Nuvance, thus adding more sites to its portfolio. Northwell also garnered attention in recent years for having such success allowing documentarians to film its medical staff at work during the Covid epidemic that it decided to start its own production company, Northwell Studios.

Since 2022, Northwell's CEO has been Michael Dowling, who rose from a poor childhood in Ireland (recounted in his memoir After the Roof Caved In) to one of the most powerful positions in American healthcare. Prior to being named CEO, Dowling was the COO of Long Island's North Shore University Hospital, one of the early sites in the Northwell portfolio. 

On April 22, Dowling talked to City & State about his remarkable rise, how he oversees a massive operation on a daily basis and why he thinks that constant Northwell growth is a good thing when it comes to delivering high-quality healthcare to people in the metro NYC area. This interview has been edited for length and clarity.

Mr. Dowling, thanks for talking today. I love your Irish accent.

I grew up in Limerick in extreme poverty, in a home with no electricity, real bathrooms or heat. I was the oldest of my siblings. My father was crippled with arthritis and my mother was deaf. We had nothing. I dreamed of going to college, so at 16, I went to England and started working in factories, trying to figure out how I could get to college but also help out at home. I ended up getting into college in Ireland, but I had no way to pay for it. 

So, again, I came to the U.S. just shy of 18 looking for a job, and ended up working on the docks on the west side of Manhattan. I used the money to finish my undergraduate degree at Cork University in Ireland. Then I came back here and, while working in construction and plumbing, got my masters in public welfare and economics at Fordham and ended up teaching there as well as an adjunct professor.

Then I got my PhD at Columbia and also became full faculty at Fordham. From there, I became assistant dean of the grad school of social service, when Mario Cuomo was governor of New York. He then offered me a job in his administration, and I ended up becoming a chief adviser to the governor, then the head of health and human services for New York state.

After that, I was a senior executive at Blue Cross-Blue Shield, then in 1995, I was recruited by North Shore University Hospital on Long Island to be COO. That was the beginning of the creation of Northwell. We acquired quite a few hospitals the first couple of years. I became CEO in 2002. Now we're a $23 billion organization and we just completed our merger with Nuvance last week. We now have 28 hospitals and 1,050 outpatient centers. 

I live in Northport, Long Island, a quaint old fishing village, with my wife and two kids. I have an apartment in Manhattan too, but I don't spend a lot of time there.

That's quite a life trajectory. When did you realize you wanted to go into health care?

It goes back to my family background. We had no health care, so I was always interested in health as an issue, how to make life better for my family. I was involved in student politics as an undergrad in Ireland. It's been a consistent trajectory. I've never been involved in anything other than health and wellness issues. 

What did you learn in your prior jobs that helps you in your job today?

Every job, whether it's white- or blue-collar, is about how you deal with people. Relationships are very important and getting to know people is huge. Leadership exists at every level, but it's about learning how to positively influence the behavior of others. That's true in every environment – family, friends – but you always have to be decent, respectful, have integrity, tell the truth and be tolerant. I firmly believe in these basic values, which are very different from the values being promoted by some of our political leaders.

We have a very positive culture at Northwell. I will only hire people who hold those values. I'm a big believer in throwing people into the deep end of the pool and helping them figure out how to swim. When I worked in construction, I did well because I wasn't a jerk and I told the truth. Very basic stuff.

Many people in high-profile positions like yours are afraid to criticize the current administration in D.C. the way I infer that you just did. Does Northwell get federal funding?

We get research and public health funding, and of course we also rely on Medicare and Medicaid. And we do transgender care, and we plan to continue doing so. We're not going to compromise our basic values because of what other people may think.

Have you intersected in any way so far with the new administration?

No. I was very involved with the past Democratic administrations. I believe that we're taking a giant step backward as a country, and I think it's dangerous. When you decide to cut USAID when people are dying of hunger overseas, and you feel proud about that, it doesn't make the U.S. look good at all.

Like I said, many others in high-profile positions like yours have not been as bluntly critical of the administration as you. Where does that bluntless come from?

I think you have to be honest. I came to the U.S. as an immigrant. The U.S. has been a beacon of hope for the world and I feel terrible that that may be changing. You cannot isolate yourself as a country these days in a world that is completely integrated by tech. I think the U.S. has a responsibility to do things that project the U.S. in a positive light. We should be promoting health and research.

We were, for the most part, until very recently. 

We were. I'm hoping that we'll see the error of our ways. We need some optimism.

What's a typical day like?

I go to bed at 11 p.m. and am usually up around 4 a.m. I've been getting that many hours of sleep for a long time – it's how my inner clock works. I look at my phone to see what calls came in overnight, then take my time getting dressed – no coffee or tea – and leave the house at 5:30 a.m. I have meetings every morning around 6:30 am, usually in local diners around Long Island. I meet with physicians, nurses and researchers this way. It's more informal, so people open up more and you can get to know them. This morning, I met with one of my top surgeons.

Then I get to one of my offices in Manhattan, Long Island or Connecticut. I'm not at the same location every day, but the day's format is the same. Like yesterday, I had an 8 am leadership meeting and a 9 am marketing meeting. Then I do something most CEOs don't, which is that we hire about 200 to 250 people and I meet with them all for 2.5 hours. I spend an hour taking questions from them and then 1.5 hours going through our strategic history, talking about values and behaviors and what is and isn't acceptable. I'm very direct. I say, "If you're a jackass, you won't survive here."

Then I have more meetings throughout the day, maybe on the budget or a clinical meeting, maybe on a specific division like cancer or neurosurgery. Usually I have meetings at night, too. If I get home before 9 pm, that's an early evening. Then my wife and I sit on the couch and watch TV – not the news, though. I'm a hockey fan. Then I go to bed and it starts all over again.

Oh: I also go to every Northwell site as much as I can. I take staff to dinner at night. I like to be out there. I'm not a believer in sitting in the office, away from where the action is.

Northwell is New York State's largest employer, yes?

We have 104,000 employees right now.

Why has it grown so fast?

That's been our strategy from Day 1. We've made a very conscious effort to create a large, integrated system – the more you do it, the better you'll do it, and you won't have a problem having health institutions want to join you. We get inundated by people wanting us to do more and more. The model I looked to was Kaiser Permanente in California. We've got a very innovative med school that includes undergraduate, graduate and doctoral degrees. We have a huge research portfolio. Some of our research is mind-bogglingly innovative.

Northwell also has a for-profit commercial side. We create businesses. I have my own pharmacy and supply chain within Northwell. We try to be very entrepreneurial because you have to find ways to make money other than reimbursements from Medicaid, Medicare and commercial insurance.

At least some research suggests that large health systems like Northwell don't necessarily deliver better care, and there is a general kind of community dismay when previously independent hospitals get eaten up by big networks. What would be your defense of a model like Northwell?

We've increased access to healthcare dramatically by doing what we're doing. I have 1,000 locations serving the public that didn't exist before, including hospitals that would've closed if we hadn't taken them over. But by doing so, we're able to not ust protect them but expand what they can do. We also provide care to everyone regardless of circumstances or health coverage. So to have this idea that if you're big you're bad – quite frankly, that's annoying. People who think that of us have never tried to understand what we're doing.

To provide services to under- or uninsured people in some areas, you have to make money in other areas. But we also do extensive work in the community – more so than we ever could have if we hadn't become large.

Can you give an example?

In Harlem, we're growing food with local hydroponic farms via an organization called Harlem Grown. Also, we're involved in providing mental health services in the poorest of communities. We're in about 80 high schools, and we're opening our own high school in Woodside, Queens, to focus on nursing, radiation medicine, medical assisting, mental health, physical therapy. It's called the Northwell High School of Health Science, and it'll be a partnership with the NYC Department of Education. Kids from that school can get into a career in health care. I will provide internships and hire them when they graduate. 

Someone I know who is a longtime New York State healthcare advocate/activist asked me to ask you if you plan to open more care sites in both urban and rural underserved areas.

We already have many in underserved areas and we're planning to do more. During COVID, we were one of the principal players doing testing and vaccinations. But people have to understand that as you grow in serving underserved populations, you have to grow in serving well-served populations, because quite frankly the well-insured populations fund our sites that also take Medicaid or that take patients with no coverage whatsoever. If you open up only places that serve people with Medicaid or no insurance, you're not going to be able to survive.

Are you a supporter of the New York Health Act, a bill that has languished in Albany for years despite widespread Democratic lawmaker endorsement and that would basically shut down all private insurers in the state and create a single-payer system run by the state?

Absolutely not. I'm familiar with national health systems overseas. They don't work well at all. I've had to bring many people from Ireland over here to get basic health care. Because there, yes, everyone has some kind of insurance but that doesn't help when often you have to wait years and years to be seen. I had to bring my brother over here once because he had major chest pains and couldn't get an appointment sooner than seven months out. He'd probably be dead if I hadn't brought him here.

The New York Health Act is an illusion that's not going to happen because it's unaffordable. It's well-intentioned, but it would make everyone a ward of the state and reduce access because you'd be left with a Medicare-type reimbursement system. Northwell can take Medicaid because we also get private insurance money, which reimburses at much higher rates. I'm not against the state saying that everyone should be covered or that we should have quality metrics – as long as the regulations are not overpowering. It's a fine balance. I was a regulator myself during my 12 years in government.

So what would you do to improve scope and quality of access under our current private-plan-driven, multi-payer system?

You have to facilitate the growth of large health systems like Northwell across the U.S. And the government has a real role to play. You will never be able to provide access to adequate care in underserved communities in the U.S. unless Medicaid pays providers more for doing it. But you just can't have one big health system in the U.S. – it's too big.

What are you most proud of that Northwell has done since you became CEO in 2002?

Being able to create an organization with a very positive collaborative culture. Also that we've provided a lot more healthcare access to the general public than they had before. How we've scaled is because of a lot of great people working as a team – not any one individual. Every step we've taken leads to another step. You're never finished. Never be satisfied! Complacency is the worst thing. We have a lot of competition: NY Presbyterian, NYU, Mt. Sinai.

How would you distinguish Northwell among those entities?

All the components of our organization work together in a seamless way. And we're a very good place to work – statistics show that.

What's your goal for Northwell in the next three to five years?

We've got to get better at everything we do. We just did a big merger with Nuvance. Now we've got to integrate them into our system. We've done it before but this is a big one. There's no one thing that stands out as a goal. It's a multitude of small things.

What would you say is both your biggest strength and weakness as a leader?

I'm able to inspire people in a positive way, to continually have a positive disposition. Nobody wants to follow somebody who's always negative. Also, my ability to develop and sustain strong relationships and to influence behavior.

As for a weakness, sometimes I'll have a tendency to dive into the details and stay there a little too long. Like with infrastructure improvement. We do $1 billion in construction a year. I like to dive into what the rooms look like. I know a little bit about the business from working in construction.