New York State has just enacted a $175.5 billion budget that will affect the lives of State residents in myriad ways. Some issues dominated the headlines: congestion pricing for Manhattan, a statewide plastic bag ban, and comprehensive reforms to the cash bail system are in, while recreational marijuana is out (for the time being). After some back and forth, $550 million in proposed Medicaid spending cuts were restored. But other items that have largely flown under the radar could also have important implications for the health of New Yorkers, both positive and negative.
On the plus side, here’s what stands out for me:
Shoring up the Affordable Care Act: More than nine years after its passage, the Affordable Care Act (ACA) remains vulnerable to threats at the federal level. The last Congress was unsuccessful in repealing the law in its entirety, but the 2017 tax bill eliminated the penalty for not having health insurance, effectively eliminating the individual mandate. It is also possible that the courts could strike down the ACA, that administrative changes and executive actions could further erode its provisions, or that a future Congress could dismantle the law in part or in its entirety. Despite the ACA’s popularity and success, its future remains uncertain — a frightening prospect for the millions of Americans who depend on it to get the health insurance and health care they need. More than 4.7 million New Yorkers have enrolled in health insurance through the New York State of Health Marketplace. The ACA also includes important consumer protections, such as ensuring that people with pre-existing conditions can’t be charged more for health insurance and requiring that health plans cover a core set of essential benefits.
The latest New York State budget enshrines key ACA provisions at the State level, regardless of federal law. The intent, as written in the enacted budget, is “that the laws of this state provide consumer and market protections at least as robust as those” in the ACA. The budget specifically lays out the essential health benefits that every health insurance policy must cover, from emergency care to mental health and substance use services to chronic disease prevention and management. It also maintains protections for New Yorkers with pre-existing health conditions. And it codifies the New York State of Health Marketplace in State law, replacing the executive order that was issued to create it initially.
Supporting opioid addiction treatment: The opioid epidemic has not spared New York State; opioid overdose deaths nearly tripled between 2010 and 2016. A number of provisions in the enacted budget target improvements in treatment for opioid misuse. These include removing barriers to buprenorphine administration in emergency departments, a new tax on opioid pills, and additional funding for treatment and support in correctional facilities. The budget also includes a number of technical measures to improve access to affordable substance use treatment services by, for example, limiting co-pays and coinsurance for those services.
Expanding diabetes prevention: Diabetes is estimated to cost New York State $21.6 billion annually in medical expenses and loss of productivity. More than 4.5 million New Yorkers have prediabetes, which means that they are at a high risk for developing diabetes. The National Diabetes Prevention Program (DPP) is a lifestyle and behavior change program focusing on diet, exercise, and weight loss strategies that has been shown to help participants lose weight and decrease their risk of developing diabetes by more than 50%. Preventing diabetes can improve health and lower health care costs, and spreading access to the DPP can help limit adverse impacts, including heart attack, blindness, loss of limbs, and shortened lifespan.
The enacted budget expands access to the DPP to New York’s Medicaid beneficiaries, who can participate in the program through community-based organizations like YMCAs. The program is estimated to save the State $900,000 over the next year and reduce the incidence of diabetes among those at highest risk — a classic “win-win” for public health.
Amidst these achievements, there are also some health-related missed opportunities in the final budget that didn’t make it over the finish line:
Fixing the charity care funding formula: New York State and federal funds provide significant support for hospitals to deliver charity care. New York hospitals that provide care to patients who are unable to pay are compensated by supplemental payments through an indigent care pool (ICP). ICP payments cover hospital losses incurred from free care provided to uninsured patients, as well as from insufficient Medicaid rates. Supplemental payments constitute a major source of stability for safety-net hospitals, which serve a high proportion of low-income patients.
But research has found that ICP funds are not consistently allocated based on need or indigent patient volume. There is a misalignment between the distribution of ICP dollars and those hospitals that provide the most care to uninsured patients. Safety-net facilities caring for the most vulnerable patients often get the short end of the stick. Advocates, experts, and policymakers have long argued that the formula needs to be changed, and a workgroup including representatives from hospitals, unions, insurers, and consumer advocacy organizations made recommendations last year to address the misalignment. The budget offered a clear opportunity to remedy the charity care distribution problem, but no action was taken. While the current allocations are indefensible, the creation of winners and losers has consistently made this too much of a hot potato to tackle.
Disclosing the presence of toxic chemicals in everyday products: Every day, New Yorkers are exposed to many of the 80,000 chemicals currently used in the United States — few of which are adequately tested for their effects on health. Even the smallest dose of some chemicals can be harmful, including those found in commercial products such as cosmetics, personal care products, cleaning products, and children’s products. Some manufacturers have voluntarily removed these toxic chemicals from their products, but it is difficult for consumers to tell which everyday products — from shampoos and toothpaste to dish soap — may be harmful and which are safe. The “Consumer Right to Know Act,” included in Governor Cuomo’s proposed executive budget this year, would have set disclosure requirements to indicate the presence of potentially hazardous chemicals in household cleaning products and personal care products. This provision would have been an important step forward for health and consumer safety, and it’s unfortunate it was not included in the final 2019–2020 budget.
A government’s budget is about more than just money; it’s also about demonstrating priorities and values. New York State has again made the health of New Yorkers a priority, particularly in the face of federal threats to undermine health care. Still, there is room for improvement, to push even farther and make some difficult decisions that will ultimately result in a healthier, stronger New York.