NYHealth responded to the New York State Department of Health’s request for comments on its proposed 1332 State Innovation Waiver application. The proposal would expand the Essential Plan to include New Yorkers with incomes up to 250% of the Federal Poverty Level, but it misses an important opportunity to extend coverage to more immigrant New Yorkers. NYHealth encourages the State to include health care coverage of currently ineligible immigrants in its final Waiver request:

The New York Health Foundation (NYHealth) appreciates the opportunity to provide comments in response to the New York State Department of Health’s Section 1332 State Innovation Waiver application to expand the Essential Plan to New Yorkers with incomes up to 250% of the Federal Poverty Level (FPL).

NYHealth is a private, independent, statewide foundation dedicated to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized. Since our inception, NYHealth has shared a goal with the State: to expand health insurance coverage to all New Yorkers. We have invested millions of dollars to do so and have proudly partnered with the State on many of these efforts. The Foundation and the State collaborated on numerous projects to successfully implement the Affordable Care Act and maximize its potential. Currently, we are partnering with the State to navigate the unwinding of the pandemic-era continuous enrollment provision and ensure that as many New Yorkers as possible maintain coverage.

A consistent theme of our work has been to maximize insurance coverage and expand access to care for immigrants. Immigrants have been an integral part of New York’s rich cultural heritage and economy for centuries. To this day, they comprise a significant proportion of the population and are important contributors to the economy.[1] Of particular relevance, NYHealth and other private funders supported the Community Service Society of New York to examine the costs and feasibility of multiple insurance options for undocumented immigrants, including extending Essential Plan coverage. Those analyses demonstrated that offering comprehensive coverage through the Essential Plan to undocumented immigrants with incomes up to 200% of the Federal Poverty Level create coverage options for approximately 250,000 people—nearly 30% of the remaining uninsured.[2]

While the State’s 1332 waiver proposal to expand public coverage is a step to improve access to and affordability of health care, we encourage the State to broaden its vision to all New Yorkers who are in need, including immigrants. New York State was successful in securing federal support to cover lawfully present immigrants when it established New York’s Basic Health Plan, now called the Essential Plan, in 2015. State leadership last year committed to using the waiver process to build on this success and expand coverage to more immigrants. The 1332 Waiver application is an opportunity to fulfill this commitment and to provide the State with a mechanism for financing this coverage expansion.

The inclusion of immigrants in coverage expansion through the 1332 Waiver would:

  • Contribute to the largest reductions in persistent uninsurance rates in New York, narrowing health care disparities and improving health for all New Yorkers;
  • Save money for New York State’s government while increasing reimbursement rates for our fiscally distressed health care providers by securing federal financial participation for coverage of immigrants;
  • Bolster our health care system and public health preparedness by ensuring more people have comprehensive coverage when the next medical emergency occurs; and
  • Preserve New York State’s position as a leader in health care coverage access and innovation and leverage models from states that have successfully charted the course for immigrant coverage.

 Broad Immigrant Coverage Benefits all New Yorkers and Advances Health Equity
New York State has been a leader in expanding health care coverage in many ways, including expanding coverage to children regardless of immigration status. But the State has left behind an important group of adult immigrants. Home to one of the largest and most diverse immigrant populations in the country, New York has nearly 2 million residents who are noncitizens, including more than 800,000 undocumented or unauthorized immigrants.[3],[4] Estimates show that approximately 40% of this population is uninsured, making them one of the largest cohorts of uninsured New Yorkers.[5] Without coverage, many turn to the emergency room or delay needed care, which can lead to higher costs.

Ensuring that everyone has health insurance is good for all New Yorkers—regardless of their immigration status. Research shows insurance coverage reduces morbidity and mortality experienced by uninsured patients and improves economic security by reducing medical debt and bankruptcy.[6] In addition, broad coverage promotes a high-functioning health care system and benefits the State by creating access to preventive care and reducing reliance on emergency departments. Public health efforts, including those to control COVID-19 and other pandemics and epidemics, are also undermined when uninsured people avoid health care because of financial barriers. Lack of coverage is also a major factor exacerbating health disparities.[7] Combatting health disparities has been identified as a major objective for the Hochul Administration’s health strategy; ensuring health care coverage for all New Yorkers is a strategy to achieve it.[8]

Including Immigrants in the 1332 Waiver Request Would Save the State Money
New York State would benefit from substantial savings were it to amend its 1332 Waiver request to include immigrants. New York spends at least $500 million annually on the Emergency Medicaid program for approximately 139,000 undocumented immigrants with incomes 0–138% of the Federal Poverty Level who are currently ineligible for any other form of coverage.[9] The 1332 Waiver process could be used to cover all of these immigrants entirely with federal dollars from the estimated $2 billion surplus that will be deposited in the “passthrough account,” saving New York approximately $500 million in State and local Medicaid funding.[10]

The State’s 1332 Waiver application indicates that the combined Basic Health Program/1332 Waiver will continue to generate an annual surplus of $2 billion. The inclusion of undocumented immigrants in the 1332 Waiver could be entirely funded with those federal surplus funds. This would generate substantial Emergency Medicaid savings that may be used for other important budget priorities.

The 1332 Waiver would also provide needed financial support to New York’s strained health care providers. Including previously ineligible immigrants would mean that providers would be paid Essential Plan reimbursement rates, which are far higher than the standard Emergency Medicaid rates. Providers would be reimbursed for the full continuum of care included in the Essential Plan benefit package: emergency services, inpatient, outpatient, labs, pharmacy, specialty and primary care provider visits, vision, and dental. By contrast, Emergency Medicaid only reimburses providers for emergency care necessary to stabilize a patient. Finally, providers have long raised issues with levels of uncompensated health care costs, which experts at the Urban Institute estimate to be as much as $1,174 per uninsured person.[11] Expanded coverage would help alleviate some of these cost burdens.

Other States Have Charted a Course for New York State
Other states have moved forward with covering all immigrants by securing federal financial participation in coverage expansions. For example, California has phased in Medicaid coverage regardless of immigration status for children, young adults, older adults, and now all people, inclusive of all ages and documentation status.[12] Similarly, Illinois provides Medicaid to adult immigrants, ages 42 and above, who are ineligible for federally funded health care.[13] Perhaps most relevant to New York’s situation, Colorado has secured a 1332 Waiver that establishes “passthrough” funding in order to offer comprehensive health coverage to establish a public option, which provides coverage for undocumented immigrants, among others.[14] Washington State has also used its 1332 Waiver to provide coverage for immigrants in its Cascade Care program.[15]

New York should preserve its reputation as a pioneering state and use this opportunity to include health care coverage of currently ineligible immigrants. It will be a major step to expand access and promote equity while stabilizing our health care system at this critical moment.

Thank you for the opportunity to provide these comments. We look forward to continuing to partner with the New York State Department of Health to work toward our shared goal of coverage for all New Yorkers.


[1] Center for Migration Studies. “Immigrants Comprise 31 Percent of Workers in New York State Essential Businesses and 70 Percent of the State’s Undocumented Labor Force Works in Essential Businesses” (April 2020) https://cmsny.org/publications/new-york-essential-workers/, accessed March 2023.

[2] Benjamin ER. “How Can New York Provide Health Insurance Coverage to its Uninsured Immigrant Residents? An Analysis of Three Coverage Options.” Community Service Society. (January 2016) https://nyhealthfoundation.org/wp-content/uploads/2017/12/covering-new-yorks-uninsured-immigrant-residents.pdf,, accessed March 2023.

[3] United States Census Bureau. Nativity and Citizenship Status in the United States (Table: B05001 2021 ACS 1-Year Estimated Detail Tables).  https://data.census.gov/table?t=Citizenship&g=0400000US36&y=2021&tid=ACSDT1Y2021.B05001, accessed March 2023.

[4] Migration Policy Institute. “Profile of the Unauthorized Population: New York.” https://www.migrationpolicy.org/data/unauthorized-immigrant-population/state/NY, accessed March 2023.

[5] Ibid.

[6] Benjamin Sommers, Atul A. Gawande, and Katherine Baicker, “Health Insurance Coverage and Health – What the Recent Evidence Tells Us,” New England Journal of Medicine, vol. 377, no. 6 (August 10, 2017), pp. 586-593, www.nejm.org/doi/10.1056/NEJMsb1706645; Etienne Gaudette, Gwyn C. Pauley, and Julie M. Zissimopoulos, “Lifetime Consequences of Early-Life and Midlife Access to Health Insurance: A Review,” Medical Care Research and Review, vol. 75, no. 6 (2018), pp. 655-720.

[7] Nambi Ndugga, Samantha Artiga. Disparities in Health and Health Care: 5 Key Questions and Answers. Kaiser Family Foundation. (May 2021). https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/, accessed March 2023.

[8] New York State Office of Governor Kathy Hochul. “Governor Hochul Signs Package of Legislation to Address Discrimination and Racial Injustice,” https://www.governor.ny.gov/news/governor-hochul-signs-package-legislation-address-discrimination-and-racial-injustice, accessed March 2023.

[9] New York State Emergency Services Only Utilization (Medicaid Coverage Code 07), Service Dates Calendar Year 1/1//19-12/31/2021 (2021 data used above).

[10] New York State Department of Health, “New York Section 1332 Innovation Waiver Essential Plan Expansion, Draft for Public Comment,” February 9, 2003.

[11] Linda J. Blumberg, Matthew Buettgens, and John Holahan, How Would State-Based Individual Mandates Affect Health Insurance Coverage and Premium Costs? (Urban Institute, July 2018), https://www.urban.org/sites/default/files/publication/98805/2001925_state_based_individual_mandates.pdf.

[12] Office of Governor Gavin Newsom. “Medi-Cal Expansion Provided 286,000 Undocumented Californians With Comprehensive Health Care”. State of California. (October 2022), https://www.gov.ca.gov/2022/10/19/medi-cal-expansion-provided-286000-undocumented-californians-with-comprehensive-health-care/, accessed March 2023.

[13] Illinois Department of Human Services. “Health Benefit Coverage for Immigrant Adults: Ages 42 to 54 Years Old”. State of Illinois. (July 2022), https://www.dhs.state.il.us/page.aspx?item=144320, accessed March 2023.

[14] Christine Monahan, Justin Giovannelli, Kevin Lucia. “HHS Approves Nation’s First Section 1332 Waiver for a Public Option–Style Health Care Plan in Colorado” The Commonwealth Fund (July 2022), https://www.commonwealthfund.org/blog/2022/hhs-approves-nations-first-section-1332-waiver-public-option-plan-colorado, accessed March 2023.

[15] Through its 1332 Waiver, Washington will provide state-only funding to subsidize ineligible immigrants up to 250% of the federal poverty level to purchase Cascade Care, https://communitycatalyst.org/posts/washingtons-1332-waiver-presents-opportunities-for-health-equity/#:~:text=This%20section%201332%20waiver%20authorizes,%2C%20beginning%20January%201%2C%202024.

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