July 2026—Open a new high school. Bypass the insurers. Take a broad definition of health. Bring core services in-house.
That is some of what Northwell Health CEO emeritus Michael Dowling did while spearheading Northwell Health’s expansion during his 23 years as president and CEO of what is today New York’s largest not-for-profit health care provider and private employer. Dowling stepped down in October 2025; Northwell executive vice president John D’Angelo, MD, succeeded him.
Under Dowling’s leadership, Northwell Health became in 1992 New York State’s first integrated health system. It now encompasses 28 hospitals across New York and Connecticut.
Compass Group laboratory leaders held their April meeting at Northwell, where Dwayne Breining, MD, Northwell’s director of pathology and laboratory medicine, introduced them to Dowling and led a conversation with him. Among Dowling’s advice for laboratory leaders: Push back on the assault on science, and collaborate as health systems to create your own future.
The Compass Group is an organization of not-for-profit IDN system laboratory leaders who collaborate to identify and share best practices and strategies. The conversation with Dowling begins here.
Dr. Breining: When you were leading our health care system, you reached out to the other medical systems across the country and collaborated with them, which is what we in the Compass Group do. What drives that, and what do you see as its value?
Just a few brief comments before I answer your question. I started at Northwell 30 years ago. I was chief operating officer for about six years before I became CEO. When I came to North Shore Health System, there was one hospital and there was a discussion going on at the time with another small community hospital. So I was involved with the first merger, and then six years later I became CEO. Our big merger with Long Island Jewish Medical Center was our 10th merger.
Many people think the health system began when North Shore and Long Island Jewish came together, and that is not true. We had nine hospitals before the big merger, and that big merger got a lot of recognition because we were sued by the U.S. Justice Department, which took us to court. We had a two-week court trial and we won. And the Justice Department did not challenge another merger in the United States for another 20 years. That was a huge loss for the Justice Department. They just didn’t have the context, they didn’t know the region, they didn’t know the politics.
To your question: I’ve always been a strong believer in the continual exchange of ideas among people from different parts of the country because every time you’re together you learn something and teach something. So the coordination and partnership that exists among health systems across the country is phenomenal, and we have great relationships with systems around the country. I have known every CEO of every health system over the past 20, 30 years and have worked with pretty much all of them.
There is a wonderful opportunity now for big systems that have developed over the years to begin to collaborate, partner, and create joint businesses, especially when not in locations where they directly compete with each other.
If health care reform is ever going to occur, it will be driven by large integrated health systems. It would be foolish to think that it’s going to occur because of the direct action of government. It’s going to depend on what we do, and rather than sit back and think someone else will do it for us, we have to be the ones who do it. We’re in a much better position today to do that than at any other time in the past.
A bit about my beginnings: When I came to the U.S. from England at 17 years old, alone, I started out as a longshoreman on the west side of Manhattan, then worked in construction, then as a plumber for plumbing companies, and then I cleaned bars at night. I tell young people, don’t ever allow your current circumstance to limit your future potential because you never know what’s going to happen. I left my home in Ireland at age 16. I grew up in extreme poverty. I went to England and worked in steel factories—all because I had to help my family. You never know what’s going to happen. You have to be optimistic and positive, think ahead, inspire young people to see no limits, because it’s all about attitude.
Dr. Breining: Some of us in the laboratory have retail backgrounds. I grew up working in restaurant kitchens. Occasionally we’ll get into conversations in the lab and it’s remarkable how many valuable skills many of us learned while doing that work, which then apply to what we do today. And it’s not part of any medical technology training program or medical school curriculum. How much of your early experience translates to the high-level work you’ve done for the past 25 years?
We’re all shaped by our backgrounds. We’re formed by our experiences. The house I grew up in didn’t have electricity, running water, bathrooms, or heat. It had mud walls and a mud floor. You learn resilience from that. I don’t stress out about things that others stress out about because when you go through an experience like that it builds a sense of grit, toughness, and it puts everything in perspective.
It does something else: It allows you to see what the world is like from the bottom. The trouble with a lot of CEOs whom I have come across over the years and other leaders in and outside health care is they look from the top down. Their perspective is up here, but the work goes on down here. So you always have to look bottom up and not just top down. Every person in any leadership capacity has to keep that in mind.
My favorite thing as CEO was walking the floors of the facilities, being in the laundry rooms, in the supply chain facilities, walking the lab, talking to the frontline staff, closing the gap between the CEO suite and the bottom. So many CEOs I know stay up; they’ve never been down. But it’s down there where the work goes on. And it’s always important when you move up in an organization not to get overly enthralled by your role in making things happen. You facilitate things, but the actual work happens much lower down. And that’s true whether it’s in the lab, in a hospital, in an ICU, or in an emergency department, and that perspective is important, especially as you move up the organization.
Leaving home at 16 taught me how to take a risk. I love taking risks. When we built this health system, we were the first to do so in New York. There were no health systems in New York or in fact in the Northeastern United States. Every time we decided to go forward with a new merger, we were told, “It’s not going to work. It’s too risky. It’s too dangerous. It won’t happen. You won’t succeed. If you go into Manhattan, they’ll eat you alive because you’re going in with the big boys.” I love going in with the big boys because you can go in and you can win.
Risk-taking is important. Immigrants by nature are risk-takers. You leave something familiar to go to a new place where the future is not clear. You’re taking a risk. If you’re in the business we’re in today, whether you’re in the laboratory business or you run a health care system, if you don’t take risks, you stifle. You go backward.
I was a pretty good athlete and played on many of the top teams in Ireland, which teaches the importance of teamwork. It’s all about teams; nobody succeeds by themselves. You succeed as a result of the interplay with all the relationships you develop over the years and the education that goes on because of that interplay. Sports also teaches you the benefit of competition, how to win and lose with decency and respect.
Dr. Breining: Health care in general and the laboratory industry in particular is facing challenges with staff shortages and finding the specialty staff that’s willing to get the education that’s needed to have a career in the lab. But our ability to understand the challenges and the situation of our line level workers is what pays dividends in responding to those stresses.
Given the payer environment and much more, it sounds like from your comments about cooperation and sharing information that the trend of mergers and cooperative activity among health systems is going to continue.
No two health systems are exactly the same. When you see a health system, you see a health system. Some health systems call themselves health systems but they are just the combination of entities where there’s no integration. They haven’t fully integrated as an interdisciplinary organization that works together on an ongoing basis. So the integration part of a health system is very important.
Many of you in the Compass Group have insurance companies. We don’t. We started an insurance company as part of Northwell because I’ve always believed it was important to control the revenue side as well as the expense side, if you want to put it that way. We did it, however, at the wrong time—it was when Obamacare passed, and they had a certain risk adjuster methodology that made it almost impossible to succeed.
When we started our insurance company, it did well at the beginning. We had positive customer satisfaction and we grew very fast. But because of the risk adjuster that Congress put in after Obamacare passed—our biggest competitor in New York was UnitedHealthcare—every time we collected a premium dollar, we had to send about 40 percent of it to UnitedHealthcare because the assumption was it had sicker patients than we did. But you always have relatively healthier patients when you start an insurance company; you end up with sicker patients later on. The risk adjuster didn’t take that into consideration, so we had to get out.
That was a disappointment but it did allow us to do other things. Now we have Northwell Direct, which is where we contract directly with employers, bypassing the insurance companies, because if you think about it, why should an employer have to go through a middleman to deal with the direct delivery of care? You can cut out the middleman. And I think you’ll see trends like that a little more going forward.
It’s also something that collectively a number of the big health systems around the country could create together, a kind of a direct-to-employer initiative. We’ve had quite a bit of success with this in New York already.
But I want to comment on what you said about employees and the workforce. I’m one who believes that instead of complaining about the future workforce shortage, ask yourself what we should be doing about it now, because if you look out across the horizon in all of your local communities, you have hundreds of thousands of high school kids wondering what careers they will choose. At Northwell, we looked at that cohort of potential future employees and spent time figuring out how to get them connected to us—how to begin the training and the education while they’re in high school and then develop the pathway to careers.
Each year at Northwell we touch about 150,000 high school kids. Last year, we opened our own high school, the Northwell School of Health Sciences. It’s a New York City school in Queens. We have 230 students. We are educating them in, among other areas, nursing, mental health, and health administration. There is nothing more inspiring than going to that school today and spending time talking to those students and listening to their presentations.
Create your own workforce. There is a cadre of potentials out there. That’s something you are doing and it’s something we should do more of. There is talk about a nursing shortage; that should never be the case if we did what we need to do, that is, if big health systems decided to get kids interested in nursing careers.
I was at that school a couple of weeks ago. I walk around and ask the students, “What do you want to be?” They say, “I want to be an Ob-gyn” or “I’m going to be an NP” or “I’m going to be a PA.” We already have 2,600 applications for 230 slots going into next year. The potential? Extraordinary. Create your own future and be dedicated to it.
Dr. Breining: We have a lot of conversations and do a lot of planning and strategy around that and we’ve worked hard. We bring many high school science classes and groups through the lab for tours, and it goes over like gangbusters. It’s great. We realized a few years ago that by high school many kids have already decided they’re going to go in a different direction. So we started reaching out to middle school science teachers and bringing them through. And it’s amazing what that little bit of exposure to the lab can do.
We realized, too, that there used to be more casual interaction of kids and family members in health care environments. They would visit the workplace regularly. Now there’s so much liability, so much regulation that that sort of casual exposure doesn’t happen. So you have to figure out a way to engineer it, like these school programs.
We are all in the education business. Take Northwell, for example. We are the third largest academic teaching center in the United States. We have about 2,200 residents and fellows. We have our own medical school and our own nursing schools. If you put all of our educational enterprises together, we are as large as some universities. We are in the education business, and so are most of you. Don’t make the distinction between having a delivery of care business and a separate education business.
One of the things that will have to happen over the next decade or two, given all the changes we see in AI and elsewhere, is that the traditional educational institutions, if they don’t dramatically change, will be left behind. But that’s where we can have a huge influence in becoming the catalyst to do things ourselves and force others to change in response or work with them to get them to change.
Our medical school is different from most traditional medical schools in the area. All our medical students are trained as EMTs in the first nine weeks. They ride the ambulances. They’re all seeing patients from day one. It’s not two years in the classroom and two years in the clinical arena; it’s four years in the clinical arena. When we started the medical school with that curriculum, everybody said, “This is not going to work.” I remember meeting with the Liaison Committee on Medical Education and they said, “This is crazy. You can’t do this.” I said, “We’re doing it. You’ve got to change the way you do things.”
Imagine if 10 of the health systems that are at this meeting got together and said, “How do we educate the future workforce, and how do we do it collectively? How do we get the institutions that are out there not doing it as well as we’d like to change the way they’re doing it based on what we need, because we’re the ones delivering the care?” Even in the lab business, for example. Extraordinary potential.
Talking about the explosion of knowledge, Northwell hosted a meeting in Washington this week where we brought together about 100 of the top people from around the country and the world on quantum biology. I gave the introduction. It’s extraordinary what they will be able to accomplish in the next decade. Knowledge continues to grow. And it’s not anybody else’s role. It’s ours. We have to be in the lead.
Dr. Breining: There’s always some new technology we need to incorporate and get on top of. And your point is well taken: If you don’t make health care a lifelong learning experience on the education front, you’re not going to keep up.
We’re in an interesting time now. On the one hand, you have extraordinary advancements and potential with artificial intelligence. We have to recognize there is a nasty underbelly to it, of course, and danger to some of it.
I’ve been nationally focused on gun violence as a public health issue—we had a meeting two days ago. And I believe health care organizations have to broaden their definition of health because everything enhances health. Everything you do impacts health. It enhances it or dilutes it.
A new area we have to focus on is the ill health effects of social media: the acceleration of depression, anxiety, and suicide among young people. In some of our mental health facilities that we opened in the past couple of years, we are treating seven-, eight-, and nine-year-olds for the addiction to social media. We have to take a broad definition of health.
But the larger point I’m making is we have a massive expansion now of new knowledge. We have massive technological advancements. Large and very good health systems are beginning to work together, and we’ve been doing this for a long time in this [Compass] Group. And we have a federal government today that is taking a giant leap backward, where we have an assault on public health, on decency, respect, humanity, kindness, and caring. We have an assault on science. We have a growth in distrust. Progress moves at the speed of trust. If there is no trust, there is no progress. If there is a massive and growing distrust in science promoted by our leadership and government these days, that’s dangerous.
We have to continue to promote the opposite, to be optimistic and keep moving forward, because it’s not what happens to you in life that matters; it’s how you respond to it that matters. This is way beyond politics. Think of all the benefits we have today as a result of the scientific advances that occurred during the past 50 years. Think of where we were in the 1960s and ’70s compared with where we are today and what we can do today, as a result of scientific discovery, that we couldn’t even imagine doing in the ’60s and ’70s.
If you put a clamp on that now, then our kids and our grandkids will not benefit from the advantages we’ve benefited from. Health care organizations need to be standing up and talking about this and not be afraid to be public about it. So it’s a combination of our needing to do what we’re doing, to advocate for what’s right, and to move forward, not take a giant leap backward. And that’s where some of our leadership today is taking us.
The final question below came not from Dr. Breining but from another member of the Compass Group:
What are your thoughts on the systems that seem to appreciate their laboratories and regard them as integral to the mission of the system, as you’ve done at Northwell, versus the other systems that seem to think laboratory is something that can be outsourced, something that can be capitalized? Many systems are eager to get rid of their laboratory operations, or seem to be.
I am a big believer that big systems should get rid of the middleman and bring the service in-house. This is why we did a laboratory at Northwell. This is why we have our own supply chain company, our own pharmacy business, our own transportation network, our own planes. You can selectively outsource to a partner, but you should bring in the core functions that are essential to how you operate. But health systems can create businesses together. If they do, they’re in a much stronger position to fight against the big labs that are private, commercial, and independent. To me, it’s best to cut out the middleman as much as you possibly can, bring it in, and get big systems to collaborate and partner and develop new businesses. That’s where I see things happening.
No system can fully survive going forward if its revenue is primarily based on government revenue. You have to create alternative sources of revenue. You can’t depend on Medicare or Medicaid reimbursement if that’s the bulk of your revenue.
And on the issue of the relationship with payers: If the payers and big providers don’t figure out how to collaborate over time—it won’t happen now but over time—then government is going to jump in and create the alternative for us, and that’s going to be disastrous. I’m familiar with the health systems that exist in Europe. I’ve worked with them. It is a nightmare. We don’t want that.
So you have to create alternative funding streams. Big systems have to collaborate, come together with joint business partnerships, and do things themselves. Create your own future. Don’t sit around hoping somebody else will fix it for you. That’s not going to happen.
The last thing that every health system should never forget, as some systems have, is that we have a community mission. We have to be out in the community helping people enhance their health, which goes way beyond providing medical care, whether it’s nutrition or exercise or something else. We should promote the idea that every high school should focus on physical activity, nutrition, good food, exercise. If we were to do that and do it well, that would enhance health even more than any of us can achieve in our normal course of business.