A Wish List for 2019

December is a time for reflecting on the past year and looking ahead to a fresh start. At this time of year, I always think about what I want to see happen in the New Year.

I’ll spare you the traditional resolutions of “eat better, exercise more, and be sure to get a flu shot” and instead share my wish list for 2019 when it comes to ensuring that all New Yorkers are as healthy as they can be.

1. Healthy, affordable food at farmers markets for all SNAP recipients.The Supplemental Nutrition Assistance Program (SNAP) is the cornerstone of the nation’s nutrition assistance safety net. Known long ago as food stamps, SNAP helps low-income households purchase food. It is the single most important tool to combat food insecurity.

Fresh, local food became more widely available to people of all incomes when farmers markets began accepting SNAP payments. Customers access their SNAP benefits using an Electronic Benefit Transfer (EBT) card. Across New York State, 439 farmers markets and farm stands now accept SNAP. An estimated 60,000 New York households use SNAP at farmers markets; they redeemed more than $3.5 million in SNAP benefits at markets in 2017. Layered on top of SNAP, a variety of food incentive programs help make healthy foods even more affordable and encourage healthy eating.

I wrote this summer about the impending crisis facing SNAP recipients at farmers markets, when the leading provider of the technology for processing SNAP payments and related incentives at farmers markets, known as Mobile Market+ (MMP), announced it would abruptly withdraw because of insufficient revenues. Governor Cuomo stepped in with short-term funding to keep the program going through February 2019, but a long-term solution is needed. If SNAP recipients lose their ability to use those benefits, it would be a major step backward in healthy food access for low-income people.

I’m happy to report that a long-term, sustainable fix appears to be in the works through a public-private partnership. My first wish, of course, is that such a solution comes to pass. But having an agreement on paper isn’t sufficient. There needs to be a seamless transition of MMP, with no interruption in service. Existing MMP retailers need to roll over automatically to prevent attrition, and a robust marketing and outreach plan should expand the customer base to ensure that even more people can use their SNAP benefits and take advantage of healthy food incentives at farmers markets. Retailers should receive top-notch customer support, including technical assistance, training, and service to ensure an excellent customer experience.

2. Affordable health insurance for every New Yorker. For the last two years, the Affordable Care Act (ACA) has been on life support. An outright repeal by Congress seems off the table for now, given the results of the midterm elections. But a federal judge’s ruling last week that the ACA is unconstitutional makes the law’s future — and millions of Americans’ health insurance coverage — uncertain. Full preservation of the ACA had already been on shaky ground; the current administration has been chipping away at the coverage gains and protections that millions of Americans saw through the ACA. Short-term plans, association health plans, the repeal of the individual mandate, a lack of marketing and promotion during open enrollment…the list of ways that the ACA is being undermined goes on and on.

Fortunately, New York State has stood up against these threats. Outreach and support to enroll eligible New Yorkers in health insurance is robust; in fact, enrollment in 2019 coverage is outpacing last year’s sign-ups. The State’s Department of Financial Services has said that short-term and association health plans — which could erode consumer protections, destabilize insurance markets, promote adverse selection, and raise prices — will not be permitted in New York State.

With 1 million people still uninsured in New York State, more work needs to be done. There are lots of ideas being shared at the State level to expand health insurance coverage. From finding ways to cover undocumented immigrants, to implementing a State-level mandate, to providing State subsidies to make coverage more affordable, to establishing a single-payer system, multiple proposals are on the table. They all warrant careful consideration.

3. Access to a Veterans Treatment Court (VTC) for every New York State veteran. Most veterans return home and adjust well to civilian life, but some face challenges as they reintegrate into their homes and communities. For those veterans who do have difficulty transitioning, behavioral health and substance use issues are associated with various related problems such as homelessness, unemployment, and strained relationships. Sometimes these challenges lead to involvement with the criminal justice system.

Veterans treatment courts (VTCs) are a type of specialty court that provide an alternative to incarceration for veterans who have committed low-level crimes and have mental health or substance use issues. Veterans who choose to use treatment courts are offered mental health and/or substance use counseling and can be connected to various veteran-specific community-based services and agencies. VTCs have been associated with reduced recidivism, lower alcohol and drug use, more stable housing, more opportunities for employment, improved relationships with friends and family, and improved mental health.

It’s a point of pride that the very first VTC in the nation was established in Buffalo, New York. Today, the State is home to 33 veterans treatment courts in 25 counties. About two-thirds of New York veterans have access to a VTC if they need one. That’s good — but not good enough.

At the New York Health Foundation, we’ve spent the last several months convening a working group to develop a consensus plan to ensure that every veteran in New York has access to a high-quality VTC. Led by the national organization Justice For Vets, the working group includes representatives of the New York State Unified Court System, district attorneys, state officials, law enforcement, veterans themselves, and other important stakeholders. The most efficient and effective path to universal access to VTCs is a transfer policy, so that veterans facing criminal charges in a jurisdiction without a VTC can be transferred to a county that does have one and get the care and services they need. My wish is for New York State to adopt such a policy in 2019.

Of course, none of these wishes will come true just by wishing. Making these changes a reality will require hard work, cooperation, coordination, and even compromise. But I have faith that we in New York will come together and make our collective wishes come true. And I’ll add one more wish: a happy and healthy New Year for you and your loved ones.
By David Sandman, President and CEO, New York Health Foundation
Published in Medium on December 17, 2018

Comments on the Proposed “Public Charge” Rule

The use of public charge criteria in immigration policy has been largely restricted to the receipt of cash assistance. But a proposed rule by the U.S. Department of Homeland Security would disastrously expand the list of programs that would be considered in public charge determinations to include Medicaid, Supplemental Nutrition Assistance Program (SNAP), and housing. Recognizing the negative impact the proposed change would have on the health of New Yorkers and Americans across the nation, NYHealth submitted the following comments urging that the proposed rule be withdrawn in its entirety:

December 7, 2018

The Honorable Kirstjen M. Nielsen
Secretary of Homeland Security
U.S. Department of Homeland Security
20 Massachusetts Avenue NW
Washington, DC  20529-2140

RE:  DHS Docket No. USCIS-2010-0012; Proposed Rule on Inadmissibility on Public Charge Grounds

Dear Secretary Nielsen:

The New York Health Foundation appreciates the opportunity to respond to the Department of Homeland Security’s (DHS) Notice of Proposed Rulemaking to the changes regarding “public charge,” published in the Federal Register on October 10, 2018.

Recognizing the negative impact the proposed change would have on the health of New Yorkers and Americans across the nation, we urge that the proposed rule be withdrawn in its entirety.

The use of public charge criteria in immigration policy has been in place since the late 1800s. Its purpose has been to identify persons who would not be able to care for themselves. However, the application of public charge policy has been largely restricted to the receipt of cash assistance. The proposed rule would disastrously expand the list of programs that would be considered in public charge determinations to include Medicaid, Supplemental Nutrition Assistance Program (SNAP), and housing. The proposed rule directly undermines Health and Human Services Secretary Azar’s recent statement to prioritize these types of social determinants of health, acknowledging the vital role that adequate nutrition and stable housing play in ensuring health and wellness.[1]

The New York Health Foundation is a private foundation that supports programs to improve the health of all New Yorkers, especially the most vulnerable. Many of the organizations we fund deliver critical services such as mental health treatment, opioid and other substance addiction treatment, and primary care to vulnerable populations, including immigrant New Yorkers. New York State is home to more than 4.5 million immigrants. 2.1 million of those live in a household with at least one non-citizen immigrant. 580,000 children under the age of 18 who are U.S. citizens live in a household with at least one non-citizen immigrant.[2],[3]

Given our history of support for the underserved, we have a deep understanding of the needs and challenges faced by immigrant communities. We are keenly aware of and alarmed about the deleterious impact the proposed rule change will have on their health.

Coverage Losses and Inefficiencies in Care
Under the proposed rule, health care coverage for millions of people who are lawfully present in the U.S. or seeking to lawfully enter the country (for example, to be unified with family members and to work) will be jeopardized. Millions will lose Medicaid insurance. While the Administration estimates 142,000 people will drop out of Medicaid as a result of the proposed rule, the figure does not account for the people who will disenroll out of fear and misunderstanding of the policy, meaning that the real figure could be 35 times larger.[4] The Kaiser Family Foundation estimates that as many as 4.9 million people nationally could drop out of Medicaid and SCHIP.[5]

Legal immigrants will continue to have health care needs. Without Medicaid, they will be more likely to seek care at hospital emergency departments, resulting in higher uncompensated care that shifts health care costs onto safety-net providers and state governments. The resulting steep rise in the number of uninsured immigrants will further strain an already stressed safety net system and lead to higher health care costs. The particular impact on safety-net providers and health care providers in communities with large immigrant populations will weaken not only their fiscal health but also their ability to serve the broader community. Executive leadership of New York City Health + Hospitals, the largest public health care system in the nation, has described the proposed rule as “antithetical to the sound practice of medicine.”[6]

Chilling Effect on Access to Services
New York and other states with large immigrant populations are already witnessing a chilling effect from the proposed rule. In a climate of fear, mistrust, and misinformation, legal immigrants are disenrolling themselves and their children (regardless of the child’s citizenship status) from health care and other public programs or declining benefits to which they are entitled.

The Community Health Care Association of New York State, the State’s primary care association for federally qualified health centers, recently surveyed its members and found that more than half have already seen an increase in the number of individuals who are eligible for but not enrolling in Medicaid, SNAP, Section 8 Housing, and the Women, Infants and Children (WIC) program because of concerns over deportation, inability to attain a green card, or inability to sponsor a loved one to attain legal permanent status. Some parents have even refused benefits for their citizen children, fearing their own or their other children’s ability to gain legal permanent status. Additionally, New York State health centers have reported that since the beginning of 2018, immigrants’ concerns about accessing Medicaid benefits have resulted in decreases in early access to prenatal care among expecting mothers as well as decreased medication adherence rates, including among high-need patients. The fear of using public benefits has also led to increased behavioral health needs, poor school performance, food insecurity, and housing instability.[7]

Similarly, the president and chief executive officer of the Mount Sinai Health System, which provides health care to more than 110,000 children recently pointed to the devastating consequences when children go without care because of their family members’ fear that seeking care could disqualify them from receiving a green card:

“Some children will not receive necessary vaccines, making them susceptible to preventable diseases, such as measles, mumps, Hepatitis A and B, and polio. Illnesses will not be addressed when they are easily treatable. Without proper prenatal and perinatal care, there will be an increase in birth complications. 

What inevitably happens when someone goes without proper care is that minor health issues are ignored until they become so serious that the patient shows up at the emergency department with a severe condition that is costly to treat. We see it happen every day at our hospitals.” [8]

Negative Economic Impact
The negative economic impact of the proposed rule change would be sizable, with a total estimated cost of $164.4 billion.[9] On a national level, economists estimate that the effect of the proposed rule would extend to 24 million people in the United States, including 9 million children under the age of 18.[10] The total annual income of workers affected by the public charge rule is estimated to be more than $96.4 billion. Should those workers leave the United States, the negative indirect economic impact would total more than $68 billion.[11]

As a result of Medicaid disenrollment, estimates are that New York State could lose as much as $7.6 billion in federal funding and economic ripple effects from, for example, reduced revenues at grocery stores as fewer SNAP dollars flow and at hospitals as families lose health insurance. These ripple effects could also lead to the loss of up to 34,000 jobs in New York State.[12]

The Need to Strengthen Health and Economic Security
The proposed rule on public charge will harm individuals’ health and the viability of the social safety net in the short-term. It will also have permanent consequences for our nation’s health and economy. We should honor our history as nation of immigrants by preserving the ability to grow up healthy, work, and be productive. We respectfully urge the Department of Homeland Security to withdraw the proposed rule in its entirety and fulfill America’s promise of opportunity.

Respectfully submitted,

David Sandman, Ph.D.
President and CEO
New York Health Foundation

cc:   Ms. Samantha Deshommes, Chief Regulatory Coordination Division, Office of Policy and Strategy, U.S. Citizenship and Immigration Services

[1] The Root of the Problem: America’s Social Determinants of Health, Azar, A.M., Hatch Foundation for Civility and Solutions, November 14, 2018.

[2] State Profiles, Migration Policy Institute, 2016.

[3] Only Wealthy Immigrants Need Apply: How a Trump Rule’s Chilling Effect Will Harm New York, Fiscal Policy Institute, October 10, 2018 .

[4] Public charge rule keeps immigrants away from health programs, advocates say, Goldberg, D., Colliver, V., and Rayasam R. Politico, November 20, 2018.

[5] Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid, Artiga, S., Garfield, R., and Damico, A. Kaiser Family Foundation. October 11, 2018.

[6] The “Public Charge” Proposal and Public Health Implications for Patients and Clinicians. Katz, M.H. and Choski, D.A. JAMA, November 27, 2018.

[7]Testimony from the Community Health Care Association of New York State, Rose Duhan, president & CEO, before the New York City Council Committee on General Welfare, Committee on Immigration, and the Committee on Health

Oversight Hearing: The Impact of the Proposed “Public Charge” Rule on NYC, November 15, 2018

[8] One sick immigration rule: The ‘public charge’ regulation will make America less healthy, Davis, K.L., New York Daily News, October 10, 2018.

[9] Economic Impact of Proposed Rule Change: Inadmissibility on Public Charge Grounds, New American Economy Research Fund, October 2018.

[10] FPI Estimates Human & Economic Impacts of Public Charge Rule: 24 Million Would Experience Chilling Effects, Fiscal Policy Institute, October 18, 2018.

[11] Economic Impact of Proposed Rule Change: Inadmissibility on Public Charge Grounds, New American Economy Research Fund, October 2018.

[12] Only Wealthy Immigrants Need Apply: How a Trump Rule’s Chilling Effect Will Harm New York, Fiscal Policy Institute, October 10, 2018