Some thoughts on the New York Health Act

Over the past few months, I’ve heard from a number of people asking me to co-sponsor S3577, the New York Health Act, a proposal to create a universal single-payer health insurance program that covers all residents of New York State. This was an issue that I campaigned in support of during my election last year. I had not yet signed on as a co-sponsor of the bill because I had some unanswered questions about certain specific sections of the legislation. I’ve spent the last few months talking to patients, providers, and other stakeholders to get answers to my questions and, more importantly, understand how the bill would affect them. I’ve also been engaging in conversations with the Senate sponsor of the bill, Senator Rivera, throughout my first five months in office. And while I’ve talked openly about some of the issues I’ve been trying to address in meetings with advocates, phone calls with constituents, and in other public forums, I’ll admit I have not done as good a job as I could have on describing the process I was going through and outlining my views in a format that can reach many more people at once. Hence, this essay.

At the outset, let me state unequivocally that I support the moral imperative of universal health insurance. I’ve said before and I’ll continue to say, we should not live in a world where people have to resort to sell cupcakes to pay for their cancer treatments. Period. Full stop.

But in my view, providing everyone health insurance is only one half of the equation. Insurance is only as useful as the care you can get. What good is giving everyone insurance coverage if the coverage won’t cover the medical treatment you need? Or if there are no doctors who accept that insurance in the first place? (There’s also an all-too-sad reality that for many, the medical treatment you can get is only as good as the insurance you have.) The economics of healthcare (a phrase that is unfortunate in usage but necessary in context to this discussion) requires patients to be able to pay for their treatments and for doctors/practitioners/providers to be compensated for the treatment and services they provide.

At its core, the New York Health Act will create a government-run insurance program similar to the federal Medicare program. While the United States has some of the highest healthcare costs in the world, the history of how government insurance programs like Medicare and Medicaid reimburse doctors and practitioners for the care they provide seems to tell a different story. Although Medicare beneficiaries may love their insurance coverage, their healthcare providers don’t all love the way they get compensated by Medicare. In fact, starting in the late 90s, and for nearly twenty years, Medicare sought to cut its reimbursements to doctors by more than twenty-percent, which prompted many doctors to threaten to stop accepting Medicare. Congress stepped in year after year to block the Medicare cuts, and it wasn’t until 2015 that a more permanent solution was found.

I’m not here to argue whether or not doctors are paid too much, too little, or just enough. And I don’t know whether they are or not. We can all point to the stories of healthcare costs running into the hundreds of thousands of dollars for treatments and care that may not have been medically necessary, just as we can point to the family medicine practitioner who sees patients for ten hours a day and receives just barely enough reimbursement to pay for running a small office and hiring a receptionist. The truth probably lies somewhere in the middle of both extremes. But if we are going to create a government-run health insurance program in New York, it can’t fall victim to the same type of economic pressures that manifested itself at the federal level. Unfortunately, the history of the Medicaid program in New York State isn’t too promising on this front either. This is not an insurmountable problem, just something that we have to confront and address in furtherance of the goal of giving everyone universal coverage.

As I took office in January and considered the New York Health Act, I thought long and hard about two things: (1) how do we provide everyone health insurance and (2) how do we ensure that we can provide and pay for the level of care people. need? While I’m far from an expert in healthcare economics, I believe that diligent policy analysis and thorough fact-finding is really important if we are going to get this right. And we have to get this right. The stakes are too high not to. Over the last few months, my staff and I met with and engaged advocates who have worked on this issue for a long time, patients in my district who are both happy or dissatisfied with their current insurance coverage, local doctors and practitioners, hospitals that serve southern Brooklyn residents, and other healthcare stakeholders. I also discussed the Health Act at length at my State Budget Town Hall on March 7th. All in all, we held nearly a dozen meetings or public discussions on the bill.

What did all of that work lead to? I heard from local neighborhood doctors who hate dealing with insurance companies just as much as their patients do but were also wary of relying solely on payments on the same scale as their Medicare reimbursements. I met with officials from local hospitals that serve southern Brooklyn and where patient loads are near or exceed fifty percent Medicaid beneficiaries and who rely on private insurance to help keep them open while they wait through delays in their state Medicaid reimbursements. I received letters and emails and phone calls from constituents whose stories are sadly all-too-familiar in today’s day when healthcare is treated solely as an expensive commodity. This is all to say, I heard from a lot of people who have a lot of anxiety over our current system but who also have a lot of questions about what a new system might look like.

The current version of the New York Health Act that was introduced in the State Senate this year attempts to address some of these questions over reimbursement rates and reasonable compensation. Section 1505(4) of the bill says that “the commissioner [of health] may [emphasis added] establish by regulation payment methodologies for health care services and care coordination provided to members under the program by participating providers, care coordinators, and health care organizations…. All payment rates under the program shall be reasonable and reasonably related to the cost of efficiently providing the health care service and assuring an adequate and accessible supply of the health care service.

Based on everything I’d learned from my fact finding over the last few months, the New York Health Act goes a long way to addressing some of the concerns that I’ve been hearing about and that recent history has shown to be a problem. In my view, however, the section I described above should be more clearly defined to ensure that we adequately address the issue of whether or not a government-sponsored health insurance program can provide adequate medical coverage and pay practitioners fairly and appropriately for the treatment they provide. If we want to make this work, we need a stronger legislative mandate rather than a more permissive standard to ensure that our state health insurance program gets this piece of the puzzle right. This framework is a very strong start — after all, this is very complicated stuff! It’s impossible to address every concern of every facet of every bill right on the first try, otherwise there’d be no need for a legislative process to review, amend, and perfect bills to ultimately create good public policy, especially for an issue like healthcare.

After spending the last few months in conversations about this issue with various stakeholders, and engaging with the bill’s authors directly about my concerns, I’m happy to say that the sponsors of the New York Health Act have agreed to make a change in the language that we all think strengthens the intent and purpose of the bill. Rather than a permissive standard that allows the commissioner to ensure reasonable compensation for medical care, we will tweak the bill to require the commissioner to do so. As a result of this commitment, my principal concerns about how we can make a system of universal health insurance in New York work in practice have been addressed and I will be signing on as a co-sponsor of the legislation.

Of course there’s still more work to be done to make the bill even stronger, which is why I’m looking forward to the first legislative hearing on the New York Health Act scheduled for May 28th. For example, we need to think about the concerns of public employees who gave up well-deserved salary increases during contract negotiations in exchange for health insurance coverage. How does passing the Health Act affect the status of labor contracts that are already in effect with local, city, county, and state governments? And my office will continue to conduct public engagement on the Health Act and further refine ideas on how to make it better and stronger. But as far as my process is concerned, I feel I’ve done my best due diligence to ensure that we set up the right framework to make people’s lives better in the best way possible.

I said that we should not live in a world where people have to sell cupcakes to pay for their cancer treatments, and I meant it. I just want to make sure we get it done right.