New Yorkers at a hospital, pre-pandemic (photo: Michael Appleton/Mayoral Photography Office)
When Mariana Pineda was diagnosed with COVID-19 in April, she spent several days in the hospital being treated for pneumonia and sepsis after not being able to see a primary care doctor due to a recent change in insurance plans.
Pineda, an asthmatic, is one of an untold number of New Yorkers who put off seeking treatment for the coronavirus due to complications with insurance plans or not having health care coverage at all.
“The third day of feeling very sick at home I drove myself to urgent care because it felt like my lungs were filling with wet cement,” she said.
After her stay in the hospital and what seemed like a successful recovery, Pineda began to experience chest pain and difficulty breathing in August. A month later she underwent surgery for a pulmonary embolism and had to have six blood clots removed from her lungs.
Due to long-term complications from COVID-19, Pineda has been unable to work and was set to lose her employment-based insurance on October 19.
She was planning to enroll in COBRA, which will cost her thousands of dollars a month for coverage for herself and her four children, instead of the $400 she would usually pay monthly to get coverage through her job as a special education teacher.
“I'm not working and I don't have an income, there's no way I'm going to be able to afford the COBRA,” she said, “so I have to decide whether I just force myself to go back to work against doctor's orders to keep my health insurance.”
The pandemic has further exposed issues with how health insurance is so often tied to employment in the United States. According to the Kaiser Family Foundation, almost 50% of New Yorkers got their health insurance via their jobs in 2019. Overall, the percentage of New Yorkers with health insurance was about 95% in 2019, a record high thanks to the state’s insurance marketplace and other factors.
But massive job loss has thrown health insurance coverage into question for many thousands of New Yorkers, and during a pandemic no less.
In New York City, the unemployment rate was only 3.4% in February, a record low for the city. However, coronavirus restrictions forced many businesses to close in March, tourism came to a halt, and unemployment numbers began to rise, peaking in June at 20.3%. The most recent numbers released by the Department of Labor show that the city unemployment rate was 13.2% in October. Unemployment has been marginally better statewide. Up from 3.7% in February, it peaked in July at 15.9% before coming back down to 9.6% in October.
For some, the link between getting health insurance through an employer and sudden job loss during a pandemic has highlighted the need for the passage of the New York Health Act, a bill in the state Legislature that would create a version of a single-payer healthcare system for universal health coverage in the state. The pandemic has dealt a significant blow to people who get their insurance from their jobs, leading proponents of the Health Act to call it more urgent than ever. As of September, the number of New Yorkers enrolled in Medicaid is up by over half a million from the same time last year.
For others, however, the legislation and what it portends is still too expensive and too disruptive, as it would completely change the way health insurance works in New York, and necessitate an overhaul of the tax code and a massive expansion of state government. Governor Andrew Cuomo, a third term Democrat, has long opposed passage of the New York Health Act on the grounds that it would be too expensive and disruptive, and while it passed the Democrat-controlled Assembly multiple times, the bill has not moved in the Assembly or Senate since Democrats took control of both chambers at the start of 2019. The bill’s future appears murky, and there is little indication that either majority plans to make it a top priority in 2021. The offices of Assembly Speaker Carl Heastie and Senate Majority Leader Andrea Stewart-Cousins did not respond to requests for comment about the status of the New York Health Act in their respective chambers.
Under the Health Act, all residents of the state would be enrolled in a state-run insurance system for health care coverage, and one that would remove copays, concerns about finding “in-network” doctors, and other problems often associated with the current health insurance system. Proponents say that major inequalities in the current health insurance and health care systems that have been further exposed by the coronavirus pandemic would have been prevented or to a significant degree mitigated if single-payer health care had been in place in New York.
“If we had the New York Health Act sooner I would have had a primary care doctor all along,” said Pineda, who is working with the Campaign for New York Health to raise funds to cover the cost of her COBRA coverage and is a proponent of the legislation. “I probably would have gone to see him instead of trying to wait it out before I wound up, you know, with pneumonia and sepsis.”
The bill, the lead sponsors of which are State Senator Gustavo Rivera of the Bronx and Assemblymember Dick Gottfried of Manhattan, both Democrats, has passed the Assembly four times since 2015, but has not yet passed the Senate, and neither house has passed it since Democrats regained control of the State Senate in January 2019. Just before those elections, the Assembly passed the bill and all the Democratic members of the Senate signed on to Rivera’s bill as co-sponsors if they hadn’t already.
When both houses of the Legislature had majorities and began passing many progressive priorities, there was greater expectation among advocates and other supporters of the bill, including legislators who’ve sponsored it, that it would move. But given Cuomo’s long-standing opposition as well as questions about its feasibility and criticism from some labor unions, the legislative majorities put the bill on the back-burner while Rivera and Gottfried continued to discuss it with key stakeholders, especially the unions, and held a series of hearings on the bill while tinkering with its language, hoping for further discussion in 2020 and potential movement in 2021, after another state legislative election cycle that is unfolding this year.
Then the pandemic hit.
Assemblymember Gottfried believes that the New York Health Act would have helped prevent some of the now more than 26,000 deaths caused by the pandemic because New Yorkers would have had better, cheaper access to health care, both before and during the deadly outbreak.
“I believe a lot of people who developed COVID-19 symptoms put off going for care because they were afraid of the cost. And many of those people got a lot sicker, and many died as a result,” he said. Many New Yorkers who died, or got very ill, from COVID-19 also suffered from significant pre-existing conditions, like asthma and diabetes, that can develop or be worsened by insufficient medical care.
According to Gottfried, the bill is likely to have more support than ever in the upcoming session, beginning in January 2021, which he attributes to the pandemic and the new class of progressive Democrats taking office, some joining each of the Senate and Assembly. Several progressive candidates who beat Democratic incumbents in New York City or won open primaries in the city and elsewhere ran on the New York Health Act.
Senator Rivera, whose district has been among the hardest hit by the coronavirus in the five boroughs, says now is the time to get the legislation passed.
“We need to start going in that direction and do so aggressively,” he said. “If not, every time that we delay, it’s people that go broke because they get sick or die because they don't have care.”
The bill faces opposition from Republican legislators, who are not convinced that a single-payer health-care system would be something the state can successfully implement, as well as some moderate Democrats, labor unions, and others.
At a joint legislative hearing on the Health Act last year, Republican Senator Patrick Gallivan said a government-run, taxpayer-funded system was not the way to solve any issues within the current health-care system.
“This seems highly impractical in that no taxpayer-funded program can afford unlimited and unrestricted health care,” he said. “As I learned during a recent meeting with health-care experts in Toronto, approximately 30% of Canadian health care is funded by private insurance and out-of-pocket expenses.”
Bill Hammond, Senior Fellow for Health Policy at the Empire Center, a conservative think tank, said the legislation would be more disruptive than helpful, noting in an interview that 95% of New York’s population is already insured, and implementing the legislation would only disrupt their coverage. Hammond went on to say that the Health Act would consume the state Legislature “for the years that it takes to implement the plan, and probably forever after.”
Currently, the bill is in committee in both houses and the co-sponsors say there haven’t been any changes made to it as a result of the pandemic, though they had been making changes prior to the covid crisis based on the public hearings they held around the state last year.
In an interview on the Max & Murphy podcast earlier this year near the height of the pandemic in the city, Rivera emphasized the need for the New York Health Act and that it was imperative that the legislation gets passed as soon as possible.
“For those folks who would argue that it is complicated and is expensive: I would argue that it is neither as expensive or as complicated as the situation we find ourselves in right now,” he said.
The earliest the bill could pass is 2021, and only after significantly more debate, though that seems especially unlikely given the state’s ongoing public health, fiscal, and other crises wrought by the coronavirus outbreak. The influence of new, more progressive members in both Democratic conferences, including several backed by the New York City Democratic Socialists of America, could prove influential, but a path to passage is currently unclear. For something of this magnitude, a three-way deal with Governor Cuomo would also likely be a prerequisite to passage in the Legislature, and while Cuomo has come out in support of single-payer health care, he has said it should only be done at the federal level.
In August, Democratic State Senator Julia Salazar of Brooklyn, who is backed by the DSA, spoke about how the Legislature should be prioritizing the passage of the New York Health Act, particularly because of the impact the pandemic has had on communities of color.
“We really need to find a way to pass the New York Health Act or to ensure true universal health care,” she said on the Max & Murphy podcast. “A disproportionately high number of Black and brown New Yorkers are or have been dying from COVID-19 due to inequitable access and distribution of healthcare resources.”
Phara Souffrant Forrest, a nurse and Assemblymember-elect after winning this year’s election, in which she first triumphed in the primary over a Democratic incumbent in Brooklyn, has the passage of the New York Health Act at the top of her campaign platform. She said it was one reason she ran against Assemblymember Walter Mosley, echoing other challengers in recent years who’ve said that Democrats must really fight for the progressive policies they say they support.
During a late October interview on Max & Murphy, Souffrant, also a DSA member and endorsee, suggested that in order to repair the state’s budget and find the revenue to pay for the New York Health Act, the state needs to “instill justice into this budget where we have people paying their fair share.”
“We have 126 billionaires living in New York City that made billions during a pandemic. So money is being made. It's just people aren't getting any of it, and some people are getting all of it,” she said.
But both legislative majorities have a diversity of Democrats, and there are few beyond the furthest left candidates and incumbents who cite the Health Act as a top priority for the near future.
Gottfried said both he and Rivera are prepared to make the appropriate amendments in order to get the legislation passed and signed. What those amendments may be is not totally clear, however.
“It’s not really the state’s responsibility”
Whenever it is brought up, the New York Health Act faces scrutiny over the estimated cost of the program, though those concerns are heightened for some now that the state is facing large deficits given the massive drop in tax revenue due to the covid shutdown and resultant job losses and limited economic activity.
A 2018 assessment done by the RAND corporation has been the main source of information about the potential impacts of the New York Health Act. Overall, it showed that the state would need to collect massive additional amounts of tax revenue, but that that revenue would negate similar overall expenditures on health insurance and health care that New Yorkers currently pay. Depending on the tax structure involved, many New Yorkers would save money on health costs.
The study suggested that if the Health Act was soon passed, state government would be spending about the same amount of money in 2022 as it currently spends on health care and would only see significant savings in health care costs by 2031 -- a roughly 3% decrease in overall spending. The report went on to say that in 2022, the state would need to collect $139.1 billion in tax revenue to pay for the program, a 156% increase from what the state collected in tax revenue at the time. However, what the state collects in taxes for the program would replace what New York was spending on health care services, about $141 billion.
All New Yorkers enrolled in the state’s single-payer health care program would only pay the taxes taken out of their income -- every other cost associated with health insurance and care would be covered under the program. The Health Act is similar to how health insurance and care works in Canada and several other countries around the world, automatically providing residents access to both.
The proposed tax would be based on a person’s ability to pay -- anyone making less than $25,000 a year would be exempt. Rand’s 2018 assessment estimated that the new tax would range between 6.1% and 18.3%, depending on income, for everyone else.
However, under this model, Rand estimated that 98% of New Yorkers would end up paying less for their health care than they do now.
The state would require that all residents enroll in the program, which would essentially make private insurance in New York obsolete. This includes those enrolled in Medicare and Medicaid as well -- with permission from the federal government, the state would use the funds it receives from the federal government for those existing programs to pay for executing the new single-payer system. That would be in addition to a payroll tax, some of which would come out of workers’ paychecks and vary depending on how much money they make annually, with higher taxes on those making more income. Employers would pay at least 80% of the tax on payroll, and employees would pay up to 20%.
In order to use the funding the state gets for Medicaid and Medicare for implementing the New York Health Act, the state would need to receive a waiver from the federal government. Assemblymember Gottfried said New York may be able to get that waiver under a Democratic presidential administration, but that the state can proceed with creating a single-payer system if the legislation is passed.
“It is very clear that even without federal cooperation, a state can create a single-payer system without losing any of our current federal funding. Federal cooperation would make it simpler but is not really necessary, legally or financially,” Gottfried said, noting that a Biden administration may be more open to the idea of single-payer in New York, but did not elaborate on how the state would be able to implement the plan without a waiver.
One of the most prominent voices regularly arguing against the New York Health Act is Hammond, who says that the real issue is containing health care costs, which requires different answers. Hammond and other opponents of the legislation argue that the necessary taxes could discourage the wealthy from living in New York, and that the shifts involved would be incredibly disruptive to the way insurance and care work in the state.
“The majority of people have private coverage, it's not really the state's responsibility to take care of that,” Hammond said in an interview. “They're taking care of it on their own, either with their own money or their employer's money.”
Medicaid enrollment is up by about half a million people after the pandemic led to thousands of New Yorkers losing their jobs and their employment-provided insurance. To some, this means there are already systems in place to ensure people have access to insurance and care.
Hammond said there are more important things that state legislators should be focused on instead of creating a single-payer health-care system.
“We have a deficit of unprecedented proportions. We are right now thinking about major cuts to existing spending on schools, and transportation and health care,” he said.
The state budget deficit is estimated to be around $14.5 billion in the current fiscal year, which runs through March. Legislators and advocates have been pushing tax increases on top earners and the wealthy to plug that gap as well as to help fund the New York Health Act and other progressive priorities.
According to Lev Ginsburg, Senior Director of Government Affairs at the Business Council of New York State, introducing another income tax now could drive businesses and the wealthy out of New York.
“We already see a lot of problems in New York State with companies relocating out of the state or not coming to the state because of various expensive burdens,” he said. “We think that it would be a true economic disaster to put it in place now.”
Government Regulation, Health Care, and Labor Unions
Advocates for universal health insurance and care coverage in New York say that the system already in place for both private and state insurance plans is confusing and hard to navigate. They also point to the battles people must wage with their health insurance companies to get coverage for care.
Elisabeth Benjamin, Vice President of Health Initiatives at the Community Service Society, a nonprofit advocacy group focused on advancing opportunity for underserved communities, said that the current pricing system for hospitals is the biggest indicator of why the state needs a single-payer health system.
Hospitals charge a person depending on what insurance they have, rather than establishing a fixed set of prices for every service they offer. This can result in patients paying different amounts based on the type of insurance they have, and can discourage them from seeking care.
“If the hospitals charge the health plans more, the health plans can charge the consumer more, right? No one has an incentive, actually, to control costs,” she said.
Benjamin believes that there should be more government regulation on how much hospitals can charge patients, and said a single-payer health-care system can help achieve that. There are proposals to mandate uniform hospital and health care charges without moving to a single-payer insurance and care system.
A report done by the Campaign for New York Health, an organization advocating for universal health coverage for all New Yorkers, found that 50% of those surveyed said they were on private health insurance but couldn’t afford to use it because of copay costs. Katie Robbins, Director of the Campaign for New York Health, said that rising health-care costs likely contributed to the spread of coronavirus in New York.
“It would be really critical for a better response to this kind of pandemic to make sure that people have coverage as a guaranteed right and they don't delay because they're afraid of how much the treatment is going to cost,” she said.
The New York Health Act has garnered the support of several labor unions in New York, including the New York State Nurses Association (NYSNA) and 1199 SEIU, a union for many health care and hospital workers. Both unions potentially see job security for their members in such a system.
Having health care off the bargaining table would allow the unions to negotiate better contracts for their members and potentially lead to a stronger union presence in New York, according to Judy Sheridan-González, the President of NYSNA.
“If unions seek out support for people, whether they're in their union or not, union density grows and union credibility is much more valued,” she said.
Sheridan-González said the passage of the New York Health Act could also lead to more job creation in the healthcare industry as a result of heightened demand for doctors.
“I certainly see it in primary care. I think that the initial phase-in, if people know that they don't have to pay anything, I think more people would access preventive care and primary care,” she said.
Not all unions are on board, however: the New York State United Teachers (NYSUT) has testified against the bill, most recently in 2019.
In a statement, NYSUT spokesperson Matthew Hamilton noted that the union supports efforts for universal health care, “especially during a public health crisis,” but that the union believes “a national health care system would be the most effective way to address this issue.”