Across the United States, communities are struggling to overcome a global pandemic. And at the same time, Black, Indigenous, and peoples of color are once again disproportionately impacted due to systemic racism. In addition to overcoming the numerous inequities that have long been ignored, in the time of COVID-19, Asian Americans — particularly those who are East Asian-presenting — have seen an explosion of xenophobia and racial violence. Health Care For All New York (HCFANY) condemns this racial violence and urges our elected officials to enact policies that advance health equity. HCFANY is a statewide coalition of 170 consumer-focused organizations dedicated to achieving quality, affordable health coverage for all New Yorkers, and ensuring that the concerns of real New Yorkers are heard and reflected in policy conversations.
According to Stop AAPI Hate, a joint initiative that has been tracking Coronavirus-related incidents of harassment, hate speech, and/or violence against Asian Americans and Pacific Islanders, there were 3,795 reported incidents in the US from March 19, 2020 to February 28, 2021. Over 500 of these incidents (14%) took place in New York. NYPD data shows there were at least six attacks on Asian Americans in January and February 2021, compared to none during those months in 2020. Additionally, many bias-based incidents continue to go unreported.
Hate crimes themselves perpetuate health equity issues. Discrimination-related stress has been shown to result in health disparities, and victims of hate crimes suffer long-term effects like depression, anxiety and post-traumatic stress disorder (PTSD).
There is a long history of racism and xenophobia against Asian Americans in the U.S., particularly during times of economic hardship, alleged threats to national security, and/or disease. And there is a long history of anti-Asian racism being enacted into law, such as the Chinese Exclusion Act and the incarceration of Japanese Americans during World War II. Underlying these policies are racist and harmful stereotypes of Asians as a “model minority,” pitting communities of color against each other and rendering those who struggle invisible; or Asian Americans as perpetual foreigners and un-American in their own communities. The COVID-related hate incidents of today, fueled by racist statements and misplaced anger towards those perceived as Chinese, perpetuate this history.
Inequities faced by Asian Americans and other communities of color have also been demonstrated through the inadequacy of COVID-19 data reporting and subsequent public health response efforts. Data collection and reporting on race and ethnicity can be vastly different across state, county, and local health systems. For example, Asians are sometimes classified as “Other” and/or aggregated with other racial groups due to their smaller population size. And even when Asian American population data is collected and reported, failure to disaggregate the data by Asian ethnicity erases the variations in economic, social, and cultural diversity among Asian subgroups.
These differences have an effect on whether certain Asian populations, especially immigrants, are likely to have health insurance coverage, whether they may be at increased risk of certain chronic conditions or diseases, and what interventions may be more successful. It is impossible to address these issues without access to data that accurately defines the problem.
Immigrant communities also face barriers to COVID-19 testing, care, and vaccination because of the lack of language access and cultural relevance of accurate information on prevention, testing, and vaccines. Additionally, anti-immigrant attacks, from hate crimes to Trump-era attempts to curtail immigrant access to care, intensify fears and create barriers to care for members of multi-generational households, especially those with mixed immigration status.
To advance health equity, we must come together to fight for racial justice. We need to hold policy makers at all levels of government to be accountable to the needs of communities that are most impacted by systemic racism, and also be committed to creating systemic changes to ensure equitable access to healthcare. HCFANY applauds the State’s commitment to providing $13 Million to support Asian American community-based organizations and to support implementation of data disaggregation of diverse Asian ethnic groups. HCFANY urges state and local leaders to: (1) work in partnership with the Coalition for Asian American Children and Families (CACF) and partnering Asian American community organizations in implementing the robust collection, monitoring, and reporting of disaggregated health data; (2) expand affordable Essential Plan coverage to all New Yorkers, regardless of immigration status; (3) support safety net hospitals that treat diverse New Yorkers of all race, ethnic, national origin, and language backgrounds; and (4) ensure equity and access (especially language access) to COVID-19 information, testing, treatment, and vaccines through community-based measures like pop-up vaccine sites with appropriate in-person interpretation and translation in hard-to-reach AAPI and other underserved communities.
Medicaid Matters New York and Health Care for All New York – the two major statewide health care consumer advocacy coalitions – applaud the State Legislature for several historic additions to the adopted state budget for 2021-22 related to funding for public schools and universities, rental and mortgage assistance, assistance to undocumented essential workers and small businesses, and taking some first steps toward restoring progressivity to the state’s tax system. Millions of low-income New Yorkers who rely on our state’s public health insurance programs will benefit from these improvements to the Governor’s initial set of budget proposals.
However, our State leaders failed to break ground in health care, which is disappointing in light of a decade of austerity budgets and the ongoing nature of the COVID-19 public health crisis. Medicaid Matters and HCFANY are specifically concerned about the following issues:
- The arbitrary Medicaid global spending cap was extended for another year. As a consequence, Medicaid continues to be approached with an austerity mindset. For ten years, Medicaid has suffered from unnecessary cuts, impacting access to services for low-income people, families, people with disabilities and communities.
- Public health insurance coverage was not expanded to low-income immigrants who have had COVID-19. Instead, those who are undocumented remain reliant solely on Emergency Medicaid for acute care and charity care programs for ongoing treatment. As a consequence, many will likely forego seeking necessary care, thereby prolonging illness and suffering, risking death, and incurring medical bills they cannot pay.
- The home care crisis and institutional bias remain unaddressed. Home care workers play a vital role in serving and protecting disabled New Yorkers and seniors living independently, a role that became even more critical and evident during the pandemic. However, New York’s failure to invest in home care has created a “worst in the nation” workforce crisis that prevents meaningful access to home care services for thousands of people and results in greater institutionalization.
- This is the first time in decades that New York State has adopted a discriminatory maternity coverage policy. Instead, only citizen and lawfully residing immigrant women will enroll in free (state-funded) Marketplace coverage after their Medicaid ends—continuing a system that allows for disruptions in care.
- No new initiatives were created to address inequities that are wide-spread throughout our state’s public health, health care, and health coverage systems, despite significant federal pandemic-related funds the state has received over the past year to address these disparities. The pandemic has revealed them clearly, and they can no longer be ignored.
On the positive side, we thank both the Governor and Legislature for these new initiatives:
- Eliminating all premiums in the state’s Essential Plan that provides insurance coverage to low-income people and families who are not eligible for Medicaid. This move will enable them to keep medical, dental, and vision coverage in place without financial barriers, an important step during the ongoing pandemic.
- Protecting the financial stability of community health centers and other safety net providers by delaying the implementation of the planned pharmacy carve-out from the state’s Medicaid Managed Care program.
We also acknowledge and appreciate restorations in funding cuts initially proposed by Governor Cuomo that made no sense given our ongoing pandemic:
- An across-the-board Medicaid rate cut that particularly threatened safety net hospitals that serve large numbers of Medicaid and uninsured patients.
- Elimination of Indigent Care Pool funding to public hospitals.
- Cuts to the state’s Vital Access Provider Assistance Program that keeps certain safety net and rural hospitals financially afloat.
- Additional cuts to Article VI public health funding to New York City.
- Allowing insurers to impose restrictions on the ability of doctors to prescribe certain drugs to Medicaid patients (elimination of the provision known as “prescriber prevails”).
- Another 25% cut to home care workforce recruitment and retention money that would have further harmed community-based long-term care.
- Cuts to programs serving adult home residents.
While as a whole and on the surface it may appear that New York continues to meet the needs of those enrolled in our state’s public health insurance programs and the providers they rely on, the 2021-22 adopted budget fails to make needed investments to turn away from austerity politics, protect all immigrants, expand community-based long-term care, and promote health equity. A lack of harm must not be confused with a budget that provides for what New Yorkers need. We can do better, and we must.
The Provider Relief Fund created by the Coronoavirus Aid, Relief, and Economic Security (CARES) Act is the biggest source of support for healthcare providers caring for COVID-19 patients. Yet, CARES Act disbursements vary enormously across New York, with little relationship to COVID-19’s burden. Providers in Putnam County, which has had around 1,400 confirmed COVID-19 cases, received the lowest funding: just $1,950 for each confirmed case. Franklin County, which received the highest funding, received $297,000 for each of its 52 confirmed cases. That’s 150 times higher! (Data on provider relief payments can be found here, and data on the number of COVID-19 cases by county here.)
The funding disparity also exists within New York City. Providers in Manhattan received over ten times as much relief funding as those in Queens compared by the number of confirmed cases.
Many of the positive cases identified outside of Manhattan may have resulted in care provided in Manhattan. Yet there is still a huge disparity when comparing the funding by the number of fatalities occurring in each borough, which would reflect differences in the burden experienced by providers. For every patient that died in Queens, providers there received about $126,000 in relief. In Manhattan, providers received $662,000 for every patient that died.
Troubling variation can also be seen at the provider level. The biggest payment, $745 million, went to the NYC Health and Hospitals Corporation. However, that system includes 11 different hospitals – which means it received just about $68 million for each facility. Other hospitals in the top ten appear to be individual facilities, and all received far more than $68 million. New York Presbyterian appears twice – it received $570 million for one of its hospitals in Manhattan and another $160 million for its hospital in Queens. Montefiore Medical Center received $468 million plus additional payments for its hospitals in New Rochelle and Mount Vernon.
Why has this happened?
Provider Relief funding is also meant to replace lost revenue so healthcare providers unable to see patients can stay open, and to cover the costs of testing and treatment for uninsured Americans. But it is still concerning that there is so little relationship between the impact COVID-19 had in different parts of the state and the amount of relief providers received.
The first Provider Relief disbursements were based on hospitals’ patient revenue – which guaranteed that safety-net providers (whose payer mix includes more uninsured patients and more patients covered by Medicaid) received far less funding. Later disbursements attempted to address the initial maldistribution. High Impact payments were distributed based on a threshold of COVID-19 admissions, meant to ensure at least $50,000 for every eligible admission. Another targeted disbursement went to hospitals with low profit margins or surpluses, uncompensated care costs of at least $25,000 per bed, and a Medicare Disproportionate Patient Percentage of at least 20.2 percent. However these additional targeted disbursements clearly fell short.
Federal funding disparities are just one of the reasons safety-net hospitals are under resourced. State policies such as the indigent care pool disbursements and our failure to reach universal health coverage also play a big role. Future relief packages must do something to get relief funding to providers caring for the highest number of COVID-19 patients.
Between 2015 and 2019, New York’s hospitals sued 40,000 New Yorkers who could not pay their medical bills. Hospitals were unable to file new lawsuits against patients for a couple of months during the pandemic. However, a quick look at just the most litigious hospitals shows over 500 cases filed since courts starting accepting civil cases again.
A new map from the Community Service Society (with help from BetaNYC) shows where residents are most likely to be sued by their hospital. Residents of Fulton and Steuben County – areas where patients lack many choices about hospital care – are most frequently sued. In the New York City area Nassau, Suffolk, and Queens County residents are most frequently sued.
What can we do?
- Read the original report, which provides more data on the lawsuits, which hospitals filed them, how it impacts health equity, and describes measures that New York could take to stop these abuses.
- Tell your legislators to stop hospitals and debt buyers from taking collection actions against patients during the pandemic. S8365/A10506 would achieve this and more: it would stop interest from accruing on medical debt during the pandemic, permanently cap interest rates on medical debt at the U.S. Treasury rate from the current 9 percent, extend grace periods for insurance premiums, and stop late fees or credit agency reports against members who pay late premiums.
- Take action on CSSNY’s End Medical Debt campaign and increase support for the Patient Medical Debt Protection Act. The Patient Medical Debt Protection Act was introduced before the pandemic and already has with 34 sponsors in the State Assembly (A08639) and 18 sponsors in the State Senate (S06757). This bill does more to make hospital billing fairer for patients, including requiring a standardized itemized bill and stopping hospitals from charging unfair facility fees that are not covered by insurance.
There is an urgent need for New York to protect patients from unfair billing practices, and the Patient Medical Debt Protection Act does just that: We can’t take another 40,000 patients being sued before we fix this problem.