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Introduction
Since the implementation of the Affordable Care Act (ACA), the uninsured rate in New York State has decreased from 11% to 5%.[1] However, prior to the COVID-19 pandemic, approximately 1.0 million New Yorkers remained without insurance. During the pandemic, there were large shifts in insurance coverage as many New Yorkers lost their employer-sponsored insurance. Medicaid programs and subsidized health insurance through the New York State of Health Marketplace were options for many of these newly uninsured New Yorkers. However, several hundred thousand New Yorkers remain uninsured and do not qualify for these public programs. Moreover, many of the emergency provisions passed during the pandemic to help people remain insured will be set to expire as the pandemic outlook improves.
The high number of uninsured New Yorkers is a longstanding problem. Through the years, proposals have been made at both the national and State levels that would further expand health insurance coverage in New York State. This tracker explores several of those options, highlighting differences in how they would work, populations targeted by the policies, and potential coverage and cost impacts.
Those who would benefit from new legislation or regulations expanding health care coverage options generally fall into one of three categories:
- Undocumented immigrants, who are typically blocked by law from accessing certain ACA coverage provisions, including through the New York State of Health Marketplace. More than 800,000 undocumented or unauthorized immigrants live in New York State. It has been estimated that approximately 40% of this population is uninsured, making this the one of the largest cohorts of uninsured New Yorkers.[2]
- Lower-income individuals who cannot afford to pay insurance premiums, even with subsidies, and whose income is not low enough to qualify for zero-premium or low-premium plans such as the Essential Plan. More than 1.1 million New Yorkers earned between 200% and 250% of the federal poverty level (FPL) in 2019, and approximately 110,000 of them lacked health insurance.[3]
- A group of middle- and high-income individuals who do not see premiums as a justifiable expense and are willing to forgo health care or pay out-of-pocket. Approximately 227,000 uninsured individuals in New York earned above 400% of the FPL in 2019.[4]
Additionally, having health insurance does not guarantee that health care will be affordable, particularly for the growing proportion of the insured population enrolled in high-deductible health plans.
This tracker provides summaries of several coverage expansion proposals for New Yorkers. Although other ideas exist, detailed analyses of their cost and coverage impacts were required for inclusion. The options range from incremental approaches focused on closing the coverage gap for a targeted group of uninsured New Yorkers to a more sweeping proposal that would cover all New Yorkers and substantially change how health care is delivered and financed. The proposals would also require different levels of partnership between the federal and State governments.
It should also be noted that all of the proposals would likely face significant political, regulatory, and legal challenges, which are not addressed here. Moreover, the cost and coverage impacts are sensitive to various assumptions regarding how the proposals would be implemented and how patients, health care providers, and payers would react to coverage changes. More details on the assumptions and other methods can be found in the analysis reference documents.
[1] United States Census Bureau. Health Insurance Coverage in the United States (Table: HIC-4_ACS. Health Insurance Coverage Status and Type of Coverage by State — All Persons: 2008 to 2019), https://www.census.gov/library/publications/2020/demo/p60-271.html, accessed October 2021.
[2] Migration Policy Institute. Profile of the Unauthorized Population: New York, https://www.migrationpolicy.org/data/unauthorized-immigrant-population/state/NY, accessed October 2021.
[3] U.S. Census Bureau, Small Area Health Insurance Estimates, 2019, https://www.census.gov/data-tools/demo/sahie/#/?s_statefips=36&s_iprcat=1&s_year=2019, accessed October 2021.
[4]U.S. Census Bureau, Small Area Health Insurance Estimates, 2019, https://www.census.gov/data-tools/demo/sahie/#/?s_statefips=36&s_iprcat=1&s_year=2019, accessed October 2021.
Essential Plan Expansion for Undocumented Immigrants
What is the plan?
This proposal would build on the Basic Health Plan option in New York, called the Essential Plan. The Essential Plan is a public free- or low-premium plan for individuals with incomes above levels eligible for Medicaid. The proposal would remove the immigration status eligibility component for the Essential Plan, allowing all who qualify based on income to enroll.
Who would be eligible?
Undocumented and Permanently Residing Under Color of Law (PRUCOL) immigrants who earn less than 200% FPL would become eligible (approximately 241,000 individuals). PRUCOL immigrants are immigrants without documentation, but whose presence is known to U.S. officials and who are not at risk of deportation. PRUCOL categories include Deferred Action for Childhood Arrivals (DACA) recipients.
How many people would gain coverage?
It is estimated that the current uninsured rate would be reduced by 10%, with about 110,000 individuals gaining coverage.
How would the plan be financed?
Individuals would pay income-based premiums of either $0 or $20 per month. Although federal funding for the Basic Health Plan is currently the Essential Plan’s main source of funding, federal funding would not be available for the expansion population. Instead, the State would have to pick up the cost of the subsidized premium for the expansion population.
What would overall costs be?
Estimated additional costs to the State are $532 million, taking into account potential offsetting reductions in current spending for uninsured New Yorkers who would otherwise use the Emergency Medicaid program. Emergency Medicaid is a health safety net for undocumented or otherwise non-eligible patients to gain temporary access to Medicaid in emergency health care situations requiring immediate medical attention.
References for Legislation and Analysis of Cost and Coverage Impacts
NY Assembly A.05974/S.03900, 2019 Legislative Session, https://nyassembly.gov/leg/?default_fld=&leg_video=&bn=A05974&term=2019&Summary=Y&Text=Y, accessed May 2019.
Analysis by Community Service Society, “Coverage Expansion Proposals for New York.” http://lghttp.58547.nexcesscdn.net/803F44A/images/nycss/images/uploads/pubs/Immigrant%20Health%20Report%20Web%202.pdf, accessed May 2019. Note that updated estimates for cost impacts were provided by CSS via email May 2019.
Essential Plan Expansion for Lower-Income New Yorkers
What is the plan?
This proposal also builds on the Essential Plan, allowing individuals with incomes previously just above the eligibility level to choose to purchase the Essential Plan from the New York State of Health Marketplace.
Who would be eligible?
Lawfully present New York State residents with incomes less than 250% FPL who are not currently enrolled in the Essential Plan would gain eligibility.
How many people would gain coverage?
It is expected that the current uninsured rate would be reduced by 5%, with more than 55,000 uninsured individuals gaining coverage. Additionally, it is estimated that nearly 60,000 individuals would forgo their current individual market coverage in favor of the Essential Plan in order to take advantage of lower monthly premiums.
How would the plan be financed?
Individuals would pay premiums of $50 per month. Although federal funding for the Basic Health Plan is currently the Essential Plan’s main source of funding, federal funding would not be available for the expansion population. Instead, the State would have to pick up the cost of the subsidized premium for the expansion population. Potentially, it would also need a federal waiver to include this population in the Basic Health Plan risk pool.
What would overall costs be?
Total additional annual costs to the State would be approximately $132.5 million.
Reference for Analysis of Cost and Coverage Impact
Analysis by Community Service Society, “Coverage Expansion Proposals for New York.” Presentation shared with NYHealth April 2019.
Medicare-X Choice Act
What is the plan?
The federal Medicare-X Choice plan allows individuals who do not currently qualify for Medicare to purchase Medicare coverage. The Medicare buy-in option would be available for purchase through the federal and state health insurance exchanges established as part of the Affordable Care Act. The goal is for Medicare-X to be able to take advantage of economies of scale and the federal government’s ability to regulate prices to health care providers such that this option would be lower-cost relative to other plans available in the state exchanges (known in New York as the New York State of Health Marketplace). This proposal would be implemented nationally by the federal government.
Who would be eligible?
Lawfully present New York State residents who are under age 65 and not currently receiving Medicare benefits (approximately 15.5 million individuals).
How many people would gain coverage?
If enacted in 2019, it is estimated that approximately 18% (200,000 people) of New York’s uninsured population would gain coverage under Medicare-X by 2024. Additionally, many individuals with employer-sponsored insurance (ESI) or individual market plans may be able to obtain lower cost and/or greater insurance benefits from the Medicare buy-in relative to their current insurance. Hence there is an estimated 14% shift in enrollment from ESI plans to the Medicare buy-in and 42% from individual plans.
How would the plan be financed?
Individuals will pay premiums as well as co-pays based on the plan.
What would overall costs be?
The program is designed to finance itself through premiums and co-pays, so additional state spending will not be required. For New York, it is estimated that total health spending would decrease by about 5% ($4.3 billion in 2024), as increases in spending for uninsured residents would be more than offset by decreases for those switching to the public option from ESI and non-group plans.
References for Legislation and Analysis of Cost and Coverage Impact
Medicare-X Choice Act, S. 1970/H.R. 4094, 116th Cong. (2019), https://www.congress.gov/bill/115th-congress/house-bill/4094/text, accessed May 2019.
KNG Consulting, “The Impact of Medicare-X Choice on Coverage, Healthcare Use and Hospitals,” https://www.aha.org/system/files/2019-03/the-impact-of-medicare-X-choice-final-report-2019.pdf, accessed May 2019.
Making Coverage Expansion Provisions in American Rescue Plan Act (ARPA) Permanent
What is the plan?
This proposal would make permanent the expansion of marketplace subsidies enacted on a limited-time basis by the American Rescue Plan Act (ARPA). The ARPA made it easier for people to buy insurance plans through state marketplaces, such as the New York State of Health Marketplace, by enhancing premium tax credits (PTCs) for people previously eligible for such subsidies and by expanding subsidy eligibility for those previously above the income cutoff.
Who would be eligible?
Lawfully present New York State residents who are already eligible for PTCs (income between 100% and 400% of FPL) and—for the first time—residents with incomes above 400% of FPL (no cap) who buy their own marketplace coverage.
How many people would gain coverage?
In New York State, the number of uninsured residents is estimated to drop by 163,000 people (a decrease of approximately 15% in the number of uninsured) in 2022
How would the plan be financed?
Individuals pay a monthly premium that is dependent on income (capped at 8.5% of income). Those below 150% of FPL are eligible for a silver plan from the New York State of Health Marketplace with no premium. The premium subsidies are paid for by the federal government.
What would overall costs be?
It is estimated that federal spending would increase by $17.6 billion in 2022 (including costs from making the ARPA permanent nationally). On average, there would be considerable savings for people who currently buy nongroup insurance (such as marketplace plans): a more than 20% reduction in premium and out-of-pocket (including co-pays, coinsurance, and deductibles) costs.
Reference for Cost and Coverage Impact
Jessica Banthin, Matthew Buettgens, Michael Simpson, and Robin Wang, “What if the American Rescue Plan’s Enhanced Marketplace Subsidies Were Made Permanent? Estimates for 2022,” https://www.urban.org/sites/default/files/publication/104072/what-if-the-american-rescue-plans-enhanced-marketplace-subsidies-were-made-permanent-estimates-for-2022_0_0.pdf, accessed October 2021.
New York Health Act (NYHA)
What is the plan?
The NYHA establishes a universal, statewide single-payer plan, the New York Health Plan (NYHP). The NYHP would provide comprehensive benefits, including long-term care services, with no cost-sharing. NYHP would be run by the State. Current forms of health insurance would largely cease to operate in New York.
Who would be eligible?
All New Yorkers, regardless of age, income, or immigration status, would be eligible for the NYHP.
How many people would gain coverage?
Every uninsured New Yorker would gain access to health insurance. Additionally, many currently underinsured individuals would have their coverage expanded.
How would the plan be financed?
New progressive payroll and non-payroll taxes would replace premiums to fund health care costs. Funding for public health insurance programs, such as Medicare and Medicaid, would be shifted to support NYHP services pending federal approvals.
What would overall costs be?
If the NYHP covers long-term care benefits, estimated spending would be 5% higher than the status quo in the first year (estimated to be $326.5 billion in 2022). Over time, it is assumed that the plan would become cheaper as a result of assumed reductions in provider payment rates and administrative efficiencies.
References for Legislation and Analysis of Cost and Coverage Impact
New York Health Act, NY Assembly A.5248/S.3577, 2019 Legislative Session, https://www.nysenate.gov/legislation/bills/2019/a5248, accessed May 2019.
RAND Corporation, “An Assessment of the New York Health Act,” https://nyhealthfoundation.org/resource/an-assessment-of-the-new-york-health-act-a-single-payer-option-for-new-york-state, accessed May 2019.