How New York could cover its 1 million uninsured residents

Health care policy debate for the past decade has largely revolved around two prospects: repealing the Affordable Care Act and passing “Medicare for All.” Republicans tried and failed to repeal Obamacare dozens of times, and single-payer health care has been the long shot plan on the Democratic side.

In New York, it’s been no different, especially since Democrats took control of both the state Senate and the Assembly. After 30 years going nowhere, left-wing majorities and progressive upstarts changed the New York Health Act from a pipe dream to a frequent conversation topic – though its passage remains unlikely.

But that is often where the debate begins and ends when lawmakers and political observers discuss how to reach the more than 1 million New Yorkers who don’t have health insurance. 

The Citizens Budget Commission and Community Service Society of New York – a right-of-center fiscal watchdog and the left-wing anti-poverty organization, respectively – teamed up on a new report that provides cost estimates for five different routes the state could take to cover uninsured New Yorkers. They include the creation of a public option, expanding state subsidies and, in what perhaps could become the most contentious option, providing state-funded health insurance to undocumented immigrants.

The vast majority of New Yorkers are currently enrolled in a health insurance plan – about 95%, as of 2019, according to the report. The rate of uninsured more than halved between 2010 and 2019 because of the Affordable Care Act and state actions to implement the federal law, like the creation of the Essential Plan.

But that remaining 5%, which has not changed much since 2019, still represents a significant chunk of New Yorkers who may make too much for public assistance but still can’t afford available options, or who aren’t eligible for federally funded programs based on their immigration status. And as the country enters its third year of the COVID-19 pandemic, disparities in health care access have never been more stark. “As we come out of this, as we get past the pandemic, we say we still have issues in the health system, and reducing the number of uninsured is one of those major issues,” said Andrew Rein, president of the Citizens Budget Commission. That’s why he said his organization teamed up with the Community Service Society to provide lawmakers an analytical roadmap for a variety of potential solutions.

In the years since implementing the Affordable Care Act, the report authors argued that he state had made little progress in addressing remaining coverage inequities. “We really haven’t had a big conversation since we enacted the Essential Plan, which was in 2013,” said Elisabeth Benjamin, vice president of health initiatives at the Community Service Society and co-author of the report. She added that standing in the way of a comprehensive debate was a lack of comprehensive data, like the cost to implement different ideas. In 2018, the Rand Corp. modeled the potential costs to implement the New York Health Act. But similar analyses for other avenues to expand health care coverage did not exist, and Benjamin called discussions up to this point “uninformed.”

The report authors offered five different paths the state could explore and they estimated the associated costs with each one. The cheapest options were implementing an individual mandate and creating a new public option, both of which the report deemed would have only nominal costs. The report concluded that the individual mandate would likely cause a “nominal” amount of new people to be covered.

The public option would make a bigger splash and might cover between 45,000 and 62,000 new people. The costs would largely fall on the private insurers offering the plans and would require more federal subsidies. Benjamin said such a plan effectively would act as a middle ground between the existing public option for low-income earners, the Essential Plan, and private plans offered on the state’s insurance marketplace.

Rein added that while their report modeled state costs, it left plenty of questions for lawmakers to figure out in terms of real-life applications. “There are a lot of different nuances, so that would have to be worked through,” Rein said. “But right now we’re not having this conversation at all.”

The next cheapest option would be additional government information to help those who may not be aware of their options to get enrolled. The report estimated this would cost the state about $20 million and could get an additional 65,000 people insured if the state expanded its Navigator program, which works with organizations – including the Community Service Society – to assist people in signing up for health care through the marketplace.

Creating a state-funded health plan for low-income immigrants ineligible for public assistance would cover an additional 46,000 people, according to the report, and cost the state about $345 million, the second-most expensive option modeled. It’s also the option that Benjamin said was the most important for the state to address right now. “New York should not be last in line for that option,” Benjamin said, mentioning states like California and Oregon that have already taken steps to implement expanded coverage for immigrants. “Our immigrants in New York work so hard and have done so much for us in this pandemic.”

The most expensive path the Citizens Budget Commission and Community Service Society modeled was creating state premium subsidies to supplement those that exist at the federal level for people buying individual plans on the public marketplace. A deep subsidy would cost the state $803 million and was estimated to get 92,000 new people enrolled. A moderate subsidy would cost $371 million and could benefit 52,000 people.

None of the five options the report would alone offer a “magic bullet” solution, as Rein put it, to insuring the remaining 1 million New Yorkers without coverage. And the report was not designed to advocate for any one plan that the state should pursue. “You’ve got your carrots, your sticks and your nudges,” Rein said. “You make it cheaper, carrots; you’ve got your sticks, you’ve got a mandate; and you got your nudges, you go out and help people enroll.” The next step would be for lawmakers to take the information, and make decisions about what would work best for New York.