Increasing access to New York’s health insurance marketplace

Danielle Holahan was appointed as executive director of New York State of Health in 2021 after serving as its deputy director for the prior decade. Under Holahan’s leadership, 6.6 million New Yorkers were enrolled in the state’s marketplace health program, which consists of Medicaid, Child Health Plus and the Essential Plan. This interview has been edited for length and clarity. 

How well is Gov. Kathy Hochul’s administration doing to ensure as many New Yorkers receive health care coverage as possible? 

I would say we’re doing very well. We made a lot of progress in the last several years to expand quality affordable coverage. We’re doing several eligibility expansions, including Medicaid eligibility levels to seniors. And postpartum coverage was implemented across Medicaid and the Essential Plan in 2023. Under federal rules, eligibility ends at 200% levels of poverty, but when we moved a state eligibility waiver last April, we were able to increase it to 250%. To put that in dollar terms, that’s around $37,000 per year. That’s a program that we operate in New York. It originally started in 2015 as a basic health plan in the Affordable Care Act. More recently, we removed it into a state innovation waiver so we could expand eligibility levels. We still call it an Essential Plan with no premium, no deductible, and very low cost sharing.

We’ve expanded its eligibility coverage. I was describing a few areas we’ve been able to eliminate premiums, such as Child Health Plus and the Essential Plan. We know affordability is crucial for New Yorkers to sign up for health coverage. We’re doing what we can to eliminate premiums. The last example we’ve made progress on is the streamlining process. Enrolling and renewing health coverage is easier for consumers. That was seen more recently with the public health emergency of COVID-19 that we just came out of. Wherever we could take federal flexibility to streamline processes for consumers, and keep people covered when we had to redetermine people’s eligibility. We could say the Hochul admin is doing a great job ensuring New Yorkers receive access to affordable comprehensive coverage.

According to KFF, New York had an uninsured rate of 4.8% last year, which ranked 10th in the country. Are the things that other, better performing states like Massachusetts and Hawaii are doing that New York could replicate in order to lower that rate further?

Let me back up and say when New York State of Health began back in 2013, we were authorized under the Affordable Care Act, the state’s uninsured rate was over 10%. Since we’ve been in existence, we’ve cut the rate in half and seen it cut across all racial and ethnic groups. We’ve made great progress. We’re ranked 10th as far as uninsured rates nationally, but we have the lowest uninsured rates among large states. And the fifth-lowest among children. To put us in context, we’re doing very well covering children. Large states have a lot of complexity, diversity and challenges. Clearly we’re never happy with anyone being uninsured.

We have taken a number of steps to incrementally lower the uninsured rate. The most recent step we (took) was to expand eligibility levels. When we look at the uninsured in New York, about half are eligible for fully subsidized coverage or even unsubsidized coverage through New York State of Health. All these things about streamlining enrollment and renewal processes, and expanding eligibility, whether we expand eligibility levels for higher incomes, wherever we can make it more accessible and affordable we’re chipping away at other states. Massachusetts has the lowest uninsured rate. They’re doing a number of wonderful things. We talk to our peer states all the time. Some of the work we’re doing (is) to extend $307 million reductions to the qualified health care plan market across 118,000 enrollees (for consumers with incomes up to $52,000 a year). We’ve talked with our colleagues in Massachusetts and Washington, D.C., to drive affordable options for more. We can always improve.

The most recent example is the state innovation waiver. We’re just getting started. We expanded the eligibility level in April and we’ve seen cost-sharing people already enrolled. We improved in September to extend cost-sharing reductions. A co-pay or deductible if you go to a doctor’s office, those can be quite high and a real barrier to receiving care. … We’ve made a lot of strides, but we can continue to chip away. The approval we got for cost-sharing, it can come up to $52,000 annually. That amounts to $3,500 a year when you compare it to qualified health plans without those subsidies. It’s quite meaningful in aggregate. This was a really terrific amendment. We’re eagerly implementing it. 

In September, the Hochul administration announced that the federal government had agreed to provide $10 billion through the federal-state innovation waiver to help expand access to the NY State of Health’s Essential Plan. How exactly will this work, and what will the impact be?

That waiver approval back in March, I would refer to the first phase of the waiver. We were able to basically ask (the Centers for Medicare and Medicaid Services) to weigh certain provisions of the ACA to allow us, for example, to increase eligibility for that program, so that people with slightly higher income levels are eligible for this $0 premium coverage. There were no changes for people (with) eligibility up to the 200% poverty level. The first phase was implemented on April 1. We already enrolled another 300,000 consumers at that higher level.

In September, CMS approved an amendment to that waiver to allow us to use subsidies to that qualified health care market. We were able to lower cost-sharing for consumers who have incomes above the Essential Plan levels. That was $307 million. Those subsidies were permitted to use them for people eligibility for the qualified health care market. There are other things we’re doing with that waiver. It’s an innovation waiver, you’re allowed to be creative. You have to be able to cover as many people as you covered without the waiver, the coverage has to be at least as comprehensive, and you cannot increase cost to the federal government. But if you can use the same amount of money that the state received before, that’s where you have to be creative.

We have sufficient funds to do other initiatives. One is looking at consumers who have persistent asthma. We as a state will pay to provide air conditioners to customers with the Essential Plan, and to deliver and install an air conditioner. People with asthma really suffer in the heat. That’s something new that we’re trying, and it’ll be available in April 2025.

With a new administration coming into the White House in January, is there any risk that the federal government will be less supportive or could even cancel funding of this sort? 

We haven’t heard what they have in mind for health and human services. We will review the details of any policy proposed. They’re not in office yet. Our focus will remain as it always has been extending coverage for New York and that will remain our mission. We will adapt to the new administration that comes in. As of now, we assume the methodology for paying out this waiver remains the same. It’s in law, it was approved last April and it runs through the end of 2028. We can’t predict the future but we will review any proposal that comes in from this administration as we see it.

New York State of Health opened a decade ago. How well has it achieved its mission? What are your key goals or initiatives in the year ahead?

I would say we’ve been tremendously successful. We’re very proud of what we’ve accomplished in the last 13 years here. This is our 12th open enrollment period. Right now we have over 6.5 million people enrolled across all our programs, including Medicaid, Essential Plan, Child Health Plus and qualified health plans. One in every three people in the state of New York are enrolled in our health programs.

We’ve cut uninsured in half and we continue to improve every year. We expand eligibility lower costs wherever we possibly can. I do think we’ve been successful (and) continue to find ways to do more for New Yorkers. We’re also streamlining wherever we can. The marketplaces have already made the process of applying for coverage far better for New Yorkers. We’ve made it easier for them to compare their plan options and enroll. They can enroll online, visit our customer service center and enroll in person with a certified application. 

That continues, wherever we can streamline the ACA, we’re saying to consumers if we know something about you, and can document your income, citizenship, if we know that already through a data source, we’re not going to ask you to produce a paper. Wherever we can streamline processes for consumers we will continue to find ways to improve that or expand eligibility levels. And our waiver included the DACA population and childhood arrivals. We were able to expand access to that community starting in August.

Has the phaseout of additional federal support after the end of the COVID-19 pandemic hindered your efforts at all?

Let’s talk about the unwinding of the COVID-19 public health emergency. There were a number of federal rules requiring consumers to stay in coverage. A number of people in New York lost their jobs and health insurance. Their incomes went down. So we increased the number of people enrolled in New York State of Health by 2 million. Nobody who had health care in the beginning of the pandemic lost coverage. … We retained coverage for 82% of people enrolled in New York State of Health.

New York took advantage of every flexibility available. We’re proud of how we came out during this unwind period. I think there were a lot of lessons learned. We know we retained 82% of people in the health insurance program, we know people got jobs or went back to new jobs and got health insurance coverage there. It was a good news story here in New York.

Is there any notable legislation that passed this year that affects your work? Any pending legislation that you’re monitoring?

The policies that impact us are largely at the federal level. During the public health emergency, one of the things the Biden administration implemented was an enhanced premium tax credit for health care enrollees. Those have been meaningful for New Yorkers. That allowed us to achieve record enrollment. Premiums for the qualified health care program market are lower (by) an average of $120 per month. It’s important for that market. On average, premiums went down from $363 per month to $240 a month. That reduction is due to the premium tax credit. For someone with moderate income levels, that’s a meaningful savings amount. That makes a difference for whether you sign up or not. And the funding for the waiver is tied to the funding for the tax credits. When the tax credit value goes up so does the waiver funding. We’re actively following that. That legislation is effective by the end of 2025.

If Congress does not act to extend the premium tax credit, it will be the last year, and that’s a concern for us and consumers enrolled in our health plans. We’re definitely following very closely. We have advanced premium tax credits and subsidies. It’s a great time to be enrolling in health coverage. Health coverage is more affordable than ever. Wherever we can automatically determine someone’s eligibility we will do that. Consumers have the ability to change plans if they want to. We’re able to automatically renew people.