Putting New York’s Veterans First

New York State is home to about 800,000 veterans, the fifth-largest veteran population in the United States.

Many of them return back from war healthy and ready to reintegrate into their communities, but for some, physical and mental wounds of war persist. Medical care accounts for the largest share of Department of Veterans Affairs (VA) spending in New York State — nearly $3 billion per year. We’ve all seen the news and heard devastating stories about the crisis of veteran suicide. Veterans are twice as likely as their civilian counterparts to experience homelessness. Our veterans need and deserve help to live healthy and full lives when they return home — and they’ve earned it.

To meet the needs of our veterans, every state has a dedicated entity — a department of veterans affairs, or DVA — to help veterans with the numerous issues they face: getting access to VA care, filing disability claims and appeals, enrolling in Veterans Treatment Courts where available, and connecting to a range of health and social services.

But wide variations exist across DVAs in terms of budget, structure, and services offered. (And even in name: In New York, our DVA is the Division of Veterans’ Services, or DVS for short.) Some offer a wide variety of direct services from employment counseling to mental health programs, while others act as central navigators that refer veterans to external service providers.

A recent report from the Institute for Veterans and Military Families (IVMF) at Syracuse University looked at all of the state DVAs and identified which ones are doing well, what innovative approaches are being tested, and the conditions that help DVAs to succeed. Ohio, Texas, and Michigan came out near the top.

What would it take for New York to be a top performer? A companion report from IVMF looking specifically at New York found that a big challenge for DVS has been a lack of stable, high-quality leadership — the agency was recently without a director for more than a year. In the leading states, the director reports directly to the governor, which is not the case in New York. New York’s DVS is also substantially underfunded, with an annual budget of about $20 million. By comparison, states with similarly-sized veteran populations have budgets around $90 million. More funding for New York’s DVS could support critical enhancements like more public-private partnerships in communities, new programming, an updated assessment of New York veterans’ needs, and a robust communications strategy.

What else could be done to make DVS stronger and more responsive to the needs of the veterans who call New York home? The first bit of good news is that we have new leadership. Colonel (Ret.) James McDonough, Jr., was appointed as the director of DVS earlier this year. (Full disclosure: I used to work with Jim when he was a Senior Fellow for Veterans’ Affairs at the New York Health Foundation.) He is an Army veteran and someone who’s passionate about improving the lives of veterans.

And earlier this week, at an event at the Foundation, he made a commitment to take up many of the recommendations of the IVMF report. Although he doesn’t have direct control over his department’s budget or who he reports to, in other areas he is poised to implement changes that will put New York in line with the highest-performing states’ DVAs:

  • Align roles, missions, and responsibilities with stakeholders across New York State. Understanding how DVS fits in with other public and private entities throughout the state that are also focused on veterans’ issues (and even those that could be, but aren’t currently) is an important step to maximizing the division’s impact. What are its unique strengths, and where might others be better positioned to take the lead? In the highest-performing states, for example, the department of veterans’ affairs serves as a central coordinating body but decentralizes the actual administration of benefits and claims assistance to the county level. New York could take a similar approach, or possibly a hybrid that makes the most of our state’s and counties’ particular strengths.
  • Improve cross-sector/agency collaboration and community coordination for health care. Top DVAs across the country have carved out a role as statewide health care coordinating body. These collaborations can help identify and address gaps in veteran services, ensure coordination, and facilitate veterans’ connections to local resources. (In Michigan, a model state, these are known as VCATs, short for Veterans Community Action Teams.) This approach may be increasingly important as more veterans seek out care in community settings, rather than through the VA.
  • Acquire a current understanding of New York’s veterans’ and providers’ needs. As they say, “Know your audience.” DVS needs to understand what New York’s veterans need and want in order to provide the most appropriate services and meet their needs and preferences. A needs assessment would inform the priorities, resource allocation, and engagement strategies not only of DVS but also of other organizations throughout the state who care about the veteran population.
  • Develop a tailored communications and outreach strategy. Veterans need to know about available resources in order to take advantage of them. New York could do a better job of ensuring that its communication and outreach activities are tailored to the specific media channels and platforms that different demographic groups (e.g., older vs. younger veterans) are most likely to use. Florida offers a good model, with dedicated resources to engage veterans who are difficult to reach, such as those in rural communities. They maintain a strong online presence to engage with younger and middle-age veterans, but at the same time, go as far as purchasing signage on top of gas pumps in rural counties to reach older rural veterans.

It’s not an easy task to become a best-in-class department of veterans affairs. But neither is it easy to serve your country and put your life on the line every day to protect it. All of us, and especially those specifically tasked with helping our veterans thrive, have an obligation to ensure that our veterans get the services they need and deserve.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on September 26, 2019

NYHealth Comments on Proposed CMS Rule to Promote Hospital Price Transparency

The Centers for Medicare & Medicaid Services (CMS) recently proposed a rule that would require hospital websites to provide consumer-directed information on rates negotiated with specific payers for 300 specified health care services that are considered “shoppable” (e.g., maternity care, knee replacement). Based on our experience supporting price transparency efforts in New York State, NYHealth provided the following public comments to help CMS ensure an optimal roll-out of the proposed price transparency efforts:

September 26, 2019

Seema Verma
Administrator, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
200 Independence Ave., SW
Washington, DC 20201

RE: CMS-1717-P

Dear Administrator Verma:

On behalf of the New York Health Foundation (NYHealth), a private, independent philanthropy, I am writing to provide comments on the proposed rule (CMS-1717-P), specifically, Section F. Proposed Requirements for Consumer-Friendly Display of the Payer-Specific Negotiated Charges for Selected Shoppable Services. The proposal would require hospital websites to provide consumer-directed information on rates negotiated with specific payers for 300 specified health care services that are considered “shoppable.”

We applaud CMS for taking action to ensure consumers have access to relevant pricing information from their health care providers. This step marks an important milestone on the journey to full, system-wide price transparency. NYHealth supports efforts to empower consumers to take a greater role in their personal health care experience. We offer considerations for CMS based on our own experiences supporting price transparency efforts within New York State.

NYHealth believes that information transparency is a gateway to improving affordability, quality, and competition in the health care system and a better health care system for all Americans. Our program on Empowering Health Care Consumers is focused on promoting transparency of health care price, quality, and patient experience information.[1] We support projects to develop information resources for patients, expand access to and uptake of those resources, and encourage diverse stakeholders such as plans, providers, and policymakers to advance transparency in health care.

A national and state-level survey by Public Agenda, co-funded by NYHealth, found that the majority of Americans are searching for price information in health care. Even among those who had never looked for price information, the majority indicated that they want to know how much a medical service will cost them before receiving the service; they simply do not know where to look.[2] The survey also found that nearly two-thirds of Americans don’t believe that there is enough price information about how much medical services cost.

While hospitals currently must provide their chargemaster rates, these rates are less useful to consumers than negotiated rates, as the chargemaster rates are almost never what the consumer actually pays. Patients with some form of health insurance pay a portion of the rate that their insurer has negotiated with the hospital. Hospitals are also generally willing to negotiate rates with uninsured or self-pay patients. As a result, the chargemaster rates are not applicable to either the average insured or uninsured consumer.

Opponents of price transparency raise the possibility that overall health care costs will increase once individuals see the prices for services. There is a belief that consumers will choose higher-priced care, believing it to be a proxy for better quality. However, more than half of Americans who have tried to compare prices say they chose a less expensive service.2 With the prevalence of high-deductible and consumer-directed health plans on the rise, consumers are on the hook for greater portions of their health care bills.[3] For many, this has resulted in having to forgo or delay care. Now more than ever, consumers have both a vested interest in and a right to know what their care will cost them.

According to the Public Agenda survey, health care consumers in New York view providers, including hospitals, as a trusted source of information about the price of medical care.[4] Several pioneering hospitals have already created online tools to assist patients in determining their financial liability before receiving care.[5] Many of these hospitals make price information available for more than 300 services. Some health care systems have even taken the step to guarantee the price quote if patients pay for services before their insurance companies are billed.[6] These exemplar hospitals demonstrate that CMS’s proposed requirements are possible to accomplish.

However, these efforts are still rare. Because price transparency tools do not aid consumers in price-shopping unless they have multiple prices to compare within one geographic area, the availability of these prices must be universal to achieve the goal of minimized health care spending. The federal government’s ability not only to require transparency, but also to provide guidance, will make this task more effective and ensure it happens in a timely manner. An evaluation of a price transparency mandate in Massachusetts found that lack of leadership and guidance from the government was a significant reason that the initiative struggled to take hold, stating, “government leadership on transparen­cy could have helped to direct greater compliance, generate more innovation in this area, and further engage the public.”[7]

Effective price transparency requires systemic change. Below, we highlight some best practices that have been learned from prior transparency efforts, as well as additional considerations for CMS to undertake in order to ensure an optimal roll-out of these efforts over time:

  • Public outreach efforts, content generation, and coordination with existing user channels are needed to educate and engage audiences. Audience engagement has proven challenging for transparency tools, as reflected in low use rates. Building a website alone is insufficient to foster changes in consumer behaviors. Hospitals should make efforts to advertise this tool to patients and generate interest. Most hospitals already market directly to consumers, so channels for patient engagement are in place. These channels should be used to introduce the tool to the patient population.
  • Tools should offer universal availability without a login. The tool should be available to all consumers seeking care, regardless of whether they currently have an account within a particular health care system. Keeping negotiated rates behind a login-required “Patient Portal,” or any other requirements to create an account or register as a patient within the system before viewing these rates, will prevent many consumers from accessing price information. The rule currently states that “users would not have to input information (such as their name, email address, or other [personal identifying information]) or register to access or use the standard charge data.” We suggest that in addition to not requiring personal identifying information, users should not be required to use any form of account, username, or password.
  • Ease of use is key and innovative designs promote usage. A tool is only helpful if people know where to access it and how to use it. Intuitive designs are key, as is prominent display. An evaluation of price transparency tools found that the more effective tools had an easy-to-find link on the website home page for the organization responsible for publishing the information. Moreover, there should be clear indicators such as “Price Check” or “Cost Estimator” in the text for the link. Price information was not as easily found when the user had to click a “Tools and Resources” link on the home page to use the cost estimator.7 Ensuring that the link to the tool is prominently featured on the hospital home page and uses plain and obvious language will help ensure that consumers can find it.
  • Information must be available in multiple languages. To maximize the total number of consumers able to use these tools, the information should be available in multiple languages. This includes the search descriptions, as well as any contextual information that hospitals provide to help patients understand the price information. Each hospital best knows the needs of the patients it serves and should be responsible for ensuring that most patients have access in their preferred language.
  • Standards must be in place for monitoring and evaluation of impact. It is critical for CMS to monitor and evaluate the impacts of these tools—not only to help ensure there are not unintended effects, but also to identify best practices. This includes developing a better understanding of any potential misinterpretations of the data by patients, as well as the extent to which hospitals may misrepresent rates. CMS should also have a system in place to ensure that rates are being updated regularly in accordance with the proposed rule.

As consumers shoulder increased financial burdens of their health care, the demand for consumer-friendly price transparency tools will grow. To maximize efficiency of the health care system, consumers must know the prices they will pay for care. Some hospitals are already providing this information, but others must be compelled to do so in order to create a truly transparent and functional health care market for all Americans.

Thank you for the opportunity to provide input on this important matter.

Respectfully submitted,

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

[1] New York Health Foundation, “Empowering Health Care Consumers,” https://nyhealthfoundation.org/what-we-fund/empowering-health-care-consumers/, accessed September 2019.

[2] Public Agenda, “Still Searching: How People in New York State Use Health Care Price Information,” https://www.publicagenda.org/files/PublicAgenda_HowPeopleinNewYorkStateUseHealthCarePriceInformation_2017.pdf, accessed September 2019.

[3] Centers for Disease Control & Prevention, “High-deductible Health Plan Enrollment Among Adults Aged 18–64 With Employment-based Insurance Coverage,” https://www.cdc.gov/nchs/products/databriefs/db317.htm, accessed September 2019.

[4] Public Agenda, “Still Searching: How People in New York State Use Health Care Price Information,” https://www.publicagenda.org/files/PublicAgenda_HowPeopleinNewYorkStateUseHealthCarePriceInformation_2017.pdf, accessed September 2019.

[5] For example: Mayo Clinic, “Cost Estimator,” https://costestimator.mayoclinic.org/, accessed September 2019; Geisinger, “Estimated Costs & MyEstimate® Tool,” https://www.geisinger.org/patient-care/patients-and-visitors/billing-and-insurance/tools-to-use/estimated-costs, accessed September 2019; University of Colorado Health System, “Billing and pricing information,” https://www.uchealth.org/billing-and-pricing-information/, accessed September 2019; UHealth University of Utah, “Estimate Your Out-of-Pocket Costs,” https://healthcare.utah.edu/pricing/calculate.php#/, accessed September 2019.

[6] St. Luke’s University Health Network, “Price Checker,” https://simpleepay.com/providers/stlukes/estimations#/, accessed September 2019.

[7] Pioneer Institute, “MA Health Insurers Have Made Good Progress in Price Transparency, But Significant Work Remains,” https://pioneerinstitute.org/download/ma-health-insurers-have-improved-their-consumer-price-transparency-efforts-but-significant-work-remains/, accessed September 2019.

Comments on Proposed Rule on SNAP Eligibility

The U.S. Department of Agriculture recently proposed a rule that would that would restrict states’ flexibility to broaden eligibility for the Supplemental Nutrition Assistance Program (SNAP). Recognizing the negative impact of the proposed policy on millions of working families, seniors, and people with disabilities, NYHealth submitted the following comments urging that the rule not be implemented:

September 12, 2019

The Honorable Sonny Perdue
U.S. Department of Agriculture
1400 Independence Ave., SW
Washington, DC 20250

RE:  USDA ID: FNS-2018-0037-0001; Proposed Rule on Revision of Categorical Eligibility in the Supplemental Nutrition Assistance Program

Dear Secretary Perdue:

The New York Health Foundation (NYHealth) appreciates the opportunity to respond to the U.S. Department of Agriculture’s (USDA) Notice of Proposed Rulemaking regarding broad-based categorical eligibility for the Supplemental Nutrition Assistance Program (SNAP), published in the Federal Register on July 24, 2019. The proposal would restrict state flexibility to broaden SNAP eligibility by relaxing asset limits and using higher income eligibility thresholds.

NYHealth believes that these changes would cause serious harm to millions of working families, seniors, and people with disabilities. We urge that the proposed rule be withdrawn.

SNAP has helped tens of millions of low-income Americans put food on their tables every year for more than 60 years. SNAP is indisputably among the most effective federal programs to combat food insecurity; it helps millions of Americans each year to stay above the poverty level.[1] Throughout its history, SNAP has also been critical in supporting national, state, and local governments in responding to unexpected food insecurity, such as in times of economic recession and major natural disasters. The proposed changes would severely undermine the program’s effectiveness.

NYHealth is a private foundation that works to improve the health of all New Yorkers, especially the most vulnerable. Our program called Building Healthy Communities supports expanded access to and demand for nutritious, affordable foods, including nutrition incentive programs that encourage SNAP use. Our work has provided us with in-depth knowledge of how food insecurity has widespread negative ramifications on the health and well-being of not only individuals and their families, but also local and national economies.

New York is one of 40 states that effectively uses the current policy of Broad-Based Categorical Eligibility, which allows states to eliminate the SNAP asset test and to use an income eligibility threshold higher than 130% of the federal poverty level (which currently equates to $2,252 a month, or $27,020 annually, for a family of three). This current policy enables more working families, families with children, seniors, and people with disabilities who have significant housing and dependent care expenses to qualify for SNAP. More than 206,000 New Yorkers could immediately lose eligibility for SNAP if this flexibility were lost.[2]

The current policy allows families, seniors, and people with disabilities with incomes just above the SNAP income threshold to maintain modest savings without losing SNAP food assistance; it also makes it easier and more cost effective to administer SNAP in our state.[3] Building modest assets allows low-income families to avoid accumulating debt and to be better prepared financially for retirement or unforeseen events that would otherwise push them deeper into poverty.[4]

A growing body of evidence links food insecurity with a number of negative health outcomes, including diet-related diseases and other chronic physical health conditions; psychological and behavioral health issues; and higher health care costs. When those struggling with food insecurity have to decide between buying nutritious, high-quality food and paying for housing, health care, transportation, or other bills, many have no choice but to eat low-cost, low-nutrition foods, or eat nothing at all. A survey revealed that 84% of households served by Feeding America, the nation’s largest network of food banks, report buying the cheapest food available in order to provide themselves and their families with enough to eat.[5]

The proposed rule would cause severe harm to children. One in six school-age children suffer from food insecurity, and many of these children get their only meals of the day at school through reduced-price and free school lunch programs. The proposed rule could potentially take away free school lunch from 265,000 children nationwide, as students in families receiving SNAP benefits are automatically eligible for free lunch.[6] Hungry children are proven to have difficulties learning and concentrating in school, and often suffer from social and behavioral problems. Problems in early childhood development associated with hunger and food insecurity often have devastating lifelong effects on a child’s ability to grow and thrive later in life.

It is also important to note the positive economic impact that SNAP spending promotes, and the ripple effect that this proposed rule would have on the economy at the local, regional, and national levels. The USDA’s Economic Research Service (ERS) has found that SNAP spending generates $1.54 in local spending per every SNAP dollar spent. That is, ERS estimates “an increase of $1 billion in SNAP benefits in a slowing economy increases GDP by $1.54 billion and supports 13,560 additional jobs, including nearly 500 agricultural jobs (farming, forestry, fishing, and hunting).”[7] A decrease in the amount of SNAP dollars circulating in communities would reduce revenues at grocery stores and other retailers, with negative effects rippling throughout our local and national food systems.

The Administration asserts that broad-based categorical eligibility has reduced public confidence that benefits are being provided to those who are eligible and need those benefits. The facts say otherwise. A Congressional Research Service report found that in FY2016, a monthly average of 85% of SNAP recipients fell below the federal poverty line, with more than 95% having income less than or equal to 130% of the federal poverty line.[8] According to USDA’s own data, only about 0.2% of SNAP benefits in 2017 went to households above the poverty line.[9] The reality is that SNAP has some of the most rigorous program integrity standards and systems of any federal program.

The proposed rule would eliminate SNAP benefits for 3.1 million individuals, take free school meals away from children, and punish working families with too little income to afford a nutritionally adequate diet. By USDA’s own estimates, the proposed rule would cut SNAP benefits over five years by $10.543 billion, while increasing SNAP administrative costs by $2.314 billion[10]—placing increased time, effort, and cost burdens on both states and SNAP applicants. Furthermore, the USDA concedes that the proposed rule would negatively impact food security and reduce the savings rates among those individuals who would no longer be SNAP eligible, and that households with one or more elderly members would be disproportionately affected. The USDA also estimates that more than 7% of SNAP households with children would no longer be eligible. The Administration’s own analyses demonstrate the negative consequences of the proposed rule.

The New York Health Foundation strongly opposes the proposed rule, which would cut food benefits for struggling people, take food out of hungry Americans’ mouths, and cause harm to our communities and economy.

Respectfully submitted,

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

[1] United States Census Bureau. “The Supplemental Poverty Measure: 2017.” September 12, 2018. https://www.census.gov/library/publications/2018/demo/p60-265.html, accessed September 2019.

[2] Mathematica Policy Research. “State-by-State Impact of Proposed Changes to ‘Broad-Based Categorical Eligibility’ in SNAP.” https://www.mathematica-mpr.com/dataviz/impact-of-bbce-proposal-on-snap-caseloads, accessed September 2019.

[3] Hunger Solutions New York. “Proposed Elimination of SNAP Categorical Eligibility.” https://hungersolutionsny.org/snap-policy/snap-cat-el-rule/, accessed September 2019.

[4] Greenstein, R. “Misguided Trump Administration Rule Would Take Basic Food Assistance From Working Families, Seniors, and People With Disabilities.” Center on Budget and Policy Priorities. July 23, 2019. https://www.cbpp.org/press/statements/misguided-trump-administration-rule-would-take-basic-food-assistance-from-working, accessed September 2019.

[5] Feeding America. What happens when a child faces hunger? https://www.feedingamerica.org/hunger-in-america/child-hunger-facts, accessed September 2019.

[6] Brown, H. “Trump administration proposal would remove 3.1 million from food stamps.” The New Food Economy. July 23, 2019. https://newfoodeconomy.org/trump-administration-food-stamps-snap-usda-perdue/, accessed September 2019.

[7] United States Department of Agriculture. “Supplemental Nutrition Assistance Program (SNAP) Linkages with the General Economy.” Updated August 20, 2019. https://www.ers.usda.gov/topics/food-nutrition-assistance/supplemental-nutrition-assistance-program-snap/economic-linkages/, accessed September 2019.

[8] Congressional Research Service. “The Supplemental Nutrition Assistance Program (SNAP): Categorical Eligibility.” Updated August 2, 2019. https://fas.org/sgp/crs/misc/R42054.pdf, accessed September 2019.

[9] Greenstein, R. “Misguided Trump Administration Rule Would Take Basic Food Assistance From Working Families, Seniors, and People With Disabilities.” Center on Budget and Policy Priorities. July 23, 2019. https://www.cbpp.org/press/statements/misguided-trump-administration-rule-would-take-basic-food-assistance-from-working, accessed September 2019.

[10] Congressional Research Service. “The Supplemental Nutrition Assistance Program (SNAP): Categorical Eligibility.” Updated August 2, 2019. https://fas.org/sgp/crs/misc/R42054.pdf, accessed September 2019.