This story was reported in collaboration with The Legislative Gazette.
On March 2 in Albany, hundreds of immigrant New Yorkers and their supporters woke up at the crack of dawn and made their way to the capitol building, braving cold temperatures to put pressure on lawmakers to expand health insurance coverage to undocumented immigrants. Statewide, more than one million New Yorkers remain uninsured, and 52 percent of residents have been forced to delay or skip basic care because they can’t afford it. The pandemic has underlined the crisis: a 2021 report by Families USA found that more than 8,200 New Yorkers died from COVID-19 due to a lack of health coverage. An estimated 2,700 of them were undocumented.
During her State of the State address in January, Governor Kathy Hochul had said “the health of every New Yorker depends on a strong, stable, and equitable healthcare system” and that “bold action is required before any more time passes.” But the final budget for FY2023 failed to include funding for Coverage for All, the New York Health Act, or the Patient Medical Debt Protection Act—three reforms advocates say would make health care truly accessible to the broadest array of New Yorkers.
Advocates see Coverage for All as the first step toward creating a universal healthcare system in New York. It would expand Essential Plan healthcare coverage to undocumented residents and create a state-funded insurance option for New Yorkers with incomes up to 200 percent of the federal poverty level. Black and Hispanic New Yorkers are expected to benefit most since they have been disproportionately impacted by COVID-19, dying at twice the rate of white New Yorkers since the start of the pandemic, according to the NYC Department of Health. Coverage for All would save thousands of lives, and according to an analysis by New York City Comptroller Brad Lander, it would provide $710 million in economic benefits annually.
As the group of immigrant New Yorkers and supporters made its way down sidewalks covered in a brownish-gray slurry of melting ice, snow, and rock salt, they chanted slogans like “health care is a human right” while singing, dancing, and blasting music from an array of loudspeakers. Their energy was infectious. As it moved, the group turned what are normally uneventful sidewalks scattered with the occasional politician or underpaid construction worker into a vibrant example of democratic participation.
Selene Aguilar, one of the many New Yorkers who would benefit from Coverage for All, says that she has been forced to suffer without health care under the current system. Aguilar recovered from COVID-19 about a year ago but has continued to face lingering symptoms, such as back and leg pain, eye aches, and headaches. She hasn’t been able to see a doctor, and routinely delays basic care because she is unable to afford it. “These are the inequalities that immigrants face every day,” she says.
After the rally, Murad Awawdeh, executive director of the New York Immigration Coalition, said that Governor Hochul promised $10 billion in funding for health care across the state in the executive version of the budget, but has failed to ensure that undocumented New Yorkers can access the health care they need. Supporters see Coverage for All “as an immediate step the state can take to ensure that every New Yorker has access to health care,” Awawdeh said.
The projected cost of Coverage for All is $345 million, and its costs are expected to be offset by emergency Medicaid spending and the annual economic benefits that the program will provide. Eligible individuals would also pay small premium amounts to contribute to their coverage. Assemblymember Zohran Kwame Mamdani (D-Queens) explained that New York currently has a budget surplus of $12 billion, so there’s no excuse not to spend $345 million on “recognizing the dignity of our immigrant New Yorkers” by expanding coverage to them.
Even though Governor Hochul offered rhetorical support for the program, some lawmakers have accused her of overinflating the projected price tag by as much as 500 percent. New York Focus reported that the Hochul administration’s $1.9 billion estimate is not backed up by data. According to Focus, “The governor’s team has not disclosed how it arrived at its figure.” As a result, a funding agreement was unable to be negotiated in the budget.
The Fight for the New York Health Act
The failure to get Coverage for All in the budget has slightly dimmed some progressives’ hopes of achieving another long-sought healthcare reform: creating a single-payer system in the Empire State via the New York Health Act. But with Democratic majorities in both the Assembly and Senate, Manhattan Assemblymember and longtime Health Committee chair Richard Gottfried, who first introduced the NYHA in 1992, remains optimistic this could be the year.
“We’re doing everything we can to bring critics of the bill on board,” he says. “If we can do that, I think we can get the bill done this year.” According to Gottfried, the Hochul administration has agreed to sit down and work through whatever specific concerns they have with the bill, something supporters were never able to do with the previous administration.
The NYHA would guarantee health insurance coverage—including coverage for dental care and hearing aids—without copays, deductibles, or premiums and cost less for 90 percent of New Yorkers than the state’s current system. A 2018 report by the RAND Corporation found that it would save $80 billion over 10 years compared to the state’s current system, including $15 billion annually just by eliminating administrative inefficiencies. The report also estimates that the NYHA would lead to an estimated 2 percent net increase in employment—approximately 150,000 jobs in 2022—due to increased disposable income for almost all New Yorkers and lower costs for employers.
Additional costs of the program would be covered by a payroll tax where 80 percent is paid by employers and 20 percent by employees, funding the state gets through federal Medicaid and Medicare, and a progressive income tax. Anyone making less than $25,000 per year would be exempt from the tax—$50,000 for seniors—while the state’s wealthiest residents would pay more into the system.
But even with the tax increases, more than 90 percent of New Yorkers will save money since they would no longer have to pay the premiums, deductibles, and copays involved with private insurance. The standard monthly premium in New York on the Affordable Care Act health insurance exchange in 2022 is $429, the fifth-most expensive in the country, according to the Kaiser Family Foundation. According to Single Payer New York’s analysis of the RAND Corporation report, “New Yorkers in the bottom 90% of household incomes would save an average of $2,800 per person annually—thanks to an equitable distribution of taxation based on the ability to pay.” Supporters of the NYHA say the bill would save billions in administrative waste and corporate profits annually, and that those funds could be reinvested into covering the costs of the program.
During a recent meeting of the New York State Black, Puerto Rican, Hispanic, and Asian Legislative Caucus, Assemblymember Karines Reyes (D-Bronx) said that the primary objective of insurance companies isn’t providing care—it’s to administer the money that already comes from Medicare and Medicaid or from employers that buy health insurance, and pocketing a portion of it as profit. The NYHA would remove these middlemen insurance companies that drive costs higher by paying million-dollar salaries to CEOs instead of reinvesting profits into patient care. According to Reyes, the for-profit model our current system operates under “isn’t serving patients at all. It’s serving the bottom line for insurance companies.”
Small business owners, meanwhile, have been some of the NYHA’s most vocal supporters. According to the Campaign for New York Health, the bill has been endorsed by about 500 small businesses across the state. That comes as no surprise since creating a single-payer system would provide insurance to employees working for small businesses that can’t afford to provide it for them under the current system.
The NYHA has come close to passing in recent years. The Democratic-led Assembly voted to pass it five years in a row starting in 2015, only for Republicans in the Senate to block the bill. Democrats have held a majority in the state Senate since 2019, but have still not been able to pass the NYHA. Although it had enough Democratic cosponsors to pass both the Senate and Assembly for the first time last year, it was held up in committee and never scheduled for a vote.
Last year’s failure, and the recent failure to establish a universal healthcare system in California, which has unified Democratic rule in both chambers and the governorship, can be attributed to the revolving door between public service and private industry—and lobbying from business groups with connections to private insurance companies. The Lever has reported that the California Chamber of Commerce, the National Federation of Independent Business, and health insurers are some of the most vocal opponents of universal health care in California.
In New York, journalist Rob Galbraith at Eyes on the Ties, a grassroots news site that reports on corporate influence on public policy, has reported that “executives from the three biggest health insurance providers in the region sit on the Buffalo Niagara Partnership board of directors.” The Buffalo Niagara Partnership is a branch of the New York Chamber of Commerce that lobbies against policies like raising the minimum wage and universal health care. According to Galbraith, “the three insurance executives on BNP’s board collectively brought home more than $5.1 million in pay funded by Western New Yorkers’ insurance premiums, deductibles, and co-pays in 2018.” Galbraith also reported that the Buffalo Niagara Partnership was a “central member” of the Realities of Single-Payer Coalition, a front group for corporate interests that spreads disinformation about single-payer health care.
Groups like these claim that single-payer systems are more expensive and that they take away freedom of choice in healthcare coverage. In reality, the opposite is true. The current system effectively removes freedom of choice by allowing employers and insurance companies to decide what doctor you can see unless you’re prepared to pay out of pocket. Assemblymember Gottfried says that under the NYHA, “there would be no restricted provider networks, so you would be free to see any doctor you want.”
Labor Union Opposition
Gottfried says that opposition from the private insurance industry has certainly played a role in preventing the New York Health Act from becoming law. But “given the overwhelming Democratic majorities in the Assembly and Senate, they are not the significant opposition,” he says. That would be state and city public employee unions.
Some unions, including the New York State Nurses Association and United Healthcare Workers East 1199SEIU, have been among the bill’s strongest supporters. But most are concerned about the potential costs of the program, and fear that transitioning to a single-payer system will render meaningless wage-increase sacrifices they have made in favor of better health care during bargaining sessions.
Ron Briggs, Capital Region president of the Civil Service Employees Association—one of the unions that opposes the bill—says “part of the problem is that the devil is in the details, and the details of this bill aren’t really clear.” Specifically, Briggs takes issue with the uncertainty of how much the additional payroll tax would cost taxpayers. The bill’s current language calls for employers to pay 80 percent of the payroll tax, with employees covering the remaining 20 percent. But Briggs says the actual costs are unknown, so “when they talk about 80 percent being paid by the employer and 20 percent being paid by the employee, they don’t say of what. How do you tell people you’re just going to pay 20 percent until you know what that is?”
Even though Briggs and his union don’t support the NYHA, they still support efforts to create a universal healthcare system at the federal level. Unions have been forced to sacrifice higher wages for better health care in the past, and Briggs understands that creating a universal system would help unions focus on negotiating higher wages by removing health care as a leverage point for employers. “If we could get behind a program that was going to be good for all our members and we knew the details, why wouldn’t we get behind it?” he says. “We would be able to take [health care] off the table.”
“We don’t see labor as opposition, but labor opposition is the biggest obstacle at the moment,” says New York Health Campaign Director Ursula Rozum. “We are very committed to finding common ground with labor unions because the labor movement has done so much to guarantee strong health care for their members, and they’ve really set a floor. We believe that the New York Health Act can provide better, more stable benefits.”
Rozum frequently hears stories about union members and their families losing health insurance benefits because they lose their jobs. She says that passing the New York Health Act would guarantee benefits like dental care, vision care, and home health care for seniors with no out-of-pocket costs to all New Yorkers—regardless of if they are in a union or not.
Addressing the Problem of Medical Debt
When some 3.6 million New Yorkers were forced out of work at the start of the pandemic, more than one million people in the state were already uninsured, and more than half of New York residents had recently delayed or skipped basic care because they couldn’t afford it, according to a 2019 study by the Community Service Society. That’s a ticking time bomb on the problem of medical debt, which is the primary cause of two-thirds of bankruptcies in the US.
The CSS study identified a 64 percent increase in medical debt cases in New York since 2019. A separate report from the organization found that between 2015 and 2020, more than 52,000 New Yorkers were sued by hospitals, and thousands of New Yorkers have had property liens placed on their homes or had their wages garnished because of medical debt. Many of those lawsuits have come from state-run hospitals, which are not-for-profit institutions that don’t pay state or local taxes and collectively receive more than $1 billion to provide care for low-income New Yorkers.
“Almost every problem we face in health care, whether as patients, employers, providers, or taxpayers, is made worse and harder to solve because of the crazy way we pay for health care,” Gottfriend says.
Medical debt disproportionately affects people of color since they are most likely to be uninsured or underinsured. Data from the 2020 Census reveals that uninsured rates for people of color and noncitizens were higher than their percentage of the total population, while uninsured rates for white people and “naturalized” immigrants were lower than their percentage of the total population.
That’s why groups like the Campaign for New York Health and the Community Service Society have been pressuring lawmakers to pass a package of bills called the Patient Medical Debt Protection Act that would effectively end medical debt in New York State.
The first bill would protect patients from having hospitals place liens on their homes or garnish their wages for having medical debt. Currently, sections 5201 and 5231 of the New York Civil Laws and Practice Rules allow hospitals to file liens on patients’ homes in addition to garnishing 10 percent of their wages if they win a medical debt case in court.
The next bill in the package would require hospitals to notify patients “ahead of time if the provider adds facility fees to bills” and prohibits providers from charging fees that aren’t covered by insurance. According to the Campaign for New York Health, “this legislation can be passed outside of the budget as standalone bills.”
Passing these bills outside of the budget is now the only path forward, since the final budget doesn’t include funding for any of them. As a result, progressive Democrats such as state Senators Gustavo Rivera, Alessandra Biaggi, Jabari Brisport, Jessica Ramos, and Julia Salazar have refused to support the budget deal.
Financial worries didn’t stop Governor Hochul from approving a billion-dollar handout to billionaire oil oligarch and owner of the Buffalo Bills, Terry Pugula, in a deal for a new stadium that includes a $600 million investment from the state and $250 million from Erie County taxpayers to cover initial construction costs. In addition, taxpayers will be responsible for $12.67 million annually for 30 years for capital improvements and stadium maintenance. In total, this will cost New York taxpayers about $1.23 billion—much more than the $345 million that activists and lawmakers say Coverage for All would cost.
“Every health plan in America has skyrocketing premiums and huge deductibles and copays, and restricted provider networks and out of network charges,” Gottfried says. “And that’s just not acceptable in the wealthiest state in the wealthiest country in the world.”