Still Waiting After All These Years: Many Nonprofit Hospitals’ Financial Aid Policies Fail Health Department Audits

Over a decade ago, New York State enacted Manny’s Law, which required New York’s non-profit hospitals to provide hospital financial assistance to low-income patients. The law is named after Manny Lanza, a young New Yorker with a brain condition who died after being precipitously discharged from a hospital because he was uninsured. Under Manny’s Law, hospitals must provide financial assistance to uninsured, low-income patients in exchange for receiving funds from the State’s $1.1 billion Indigent Care Pool. In 2012, the Department of Health began to audit the hospitals’ financial aid programs in response to reports of inadequate compliance.

A Freedom of Information Law request filed with the Department of Health shows that a decade later, hospitals still fail to comply with Manny’s Law—and, in fact, appear to be regressing, with the audit showing that they were less compliant in 2018 than they were the prior two years. The audit includes a list of questions that hospitals can pass or fail, and the chart below shows the total number of failed questions:

What kinds of problems did the audit reveal?

First, the audit found that a decade after the passage of Manny’s Law, many hospitals’ financial aid applications still include impermissible requirements that make it hard for patients to apply. For example, 17% of hospitals audited had incorrectly adopted a “Medicaid denial first” policy. Medicaid applications can take a lot of time to process. Requiring a patient to receive a denial before beginning the financial assistance process causes unnecessary delay for patients. Other impermissible hurdles to hospital financial aid revealed by the audit included requiring patients to provide their: past tax returns (14.3%); monthly bills and other financial obligations (13.1%); and Social Security numbers (12.0%).

Second, the audit found that many hospitals’ financial assistance policies do not protect low-income patients from extraordinary collections actions that are explicitly forbidden under state law because they are so harmful to patients. For example, one in five hospitals said that they allow accelerator clauses that mean missed payments trigger higher rates of interest (20.0%). Interest adds hundreds or thousands of dollars to medical bills that patients are already struggling to pay. (A bill to reform New York State’s onerous 9 percent judgment interest rate awaits Governor’s Hochul’s signature (S55724B/6474B).) Next, the audit reveals that hospitals are allowing collections agencies to pursue their patients without the hospitals’ written consent (9.1%). This means patients are hassled by debt collectors even while they are working on applying for financial assistance or otherwise trying to work with the hospital to pay their bill. Finally, hospitals’ policies do not explicitly prohibit forced sales or foreclosures on patients’ homes (7.4%).

Third, the audit found that hospitals apply asset tests when determining discounts, which is not allowed in almost any other health care affordability program in the state. And hospitals report that they continue to consider assets that the law says they are not allowed to consider, including a patient’s home (10.9%), retirement accounts (9.7%), college savings accounts (8.0%), and cars that anyone in the patients’ immediate family uses for their primary transportation (8.0%). This failure to comply with the law means eligible patients are denied help or are prevented from applying.

These failures to comply have serious consequences for patients who should have been protected by Manny’s Law and offered care at discounted rates. According to a 2019 poll, 45 percent of New Yorkers say they delay or avoid health care altogether because they cannot afford it. Thirty-five percent of New Yorkers say that obtaining necessary health care meant serious financial struggles such as using up all of their savings, being unable to pay for food or heat, and racking up large amounts of credit card debt. Over 52,000 New Yorkers have been sued by hospitals over medical bills they cannot afford over the past five years. Hospitals then place liens on patients’ homes and garnish their wages.

Make Manny’s Law a Reality: Fix the Hospital Financial Assistance Law

What should New York do about this? One simple change is to require hospitals to use one standard application form to be developed by the state. This would obviate the need for the Health Department’s audits of a failing system that lets every hospital design and implement its own policy. Other states already do something like this. For example, Massachusetts uses its state Marketplace to award hospital financial assistance. Advocates have recommended the adoption of a single application form  for years and so has  the Department of Financial Services Health Care Administrative Simplification Workgroup – a multi-stakeholder group of healthcare experts. It was also proposed in last year’s Patient Medical Debt Protection bill.               

After all these years, patients need our healthcare system to be simpler and more accessible. That remains the unfulfilled goal of Manny’s Law. Adopting one uniform statewide Hospital Financial Assistance form, to be used by all of New York’s hospitals, would be an important first step in leveling the playing field between patients and healthcare providers.   

There are lots of opportunities coming up over the next couple of weeks to learn more about health policy priorities and how to take action. Here’s a few of them!

TODAY: Statewide Day of Action for Guaranteed Healthcare (link)

The Campaign for New York Health is holding a day of action for the New York Health Act, which would provide comprehensive health coverage for everyone who lives or works full-time in New York. Look for #PassNYHealth to see what people are saying and join in!

  • Learn more about why we need the New York Health Act here.
  • If you missed the day of action you can always show your support for the New York Health Act by clicking this link and telling your State Assemblymember and Senator to support the bill. If they already do, the link will give you an opportunity to thank them!

Tomorrow: #Coverage4All Virtual Day of Action

There are 400,000 New Yorkers without insurance because of their immigration status. A1585/S2549 would guarantee that all New Yorkers can access life-saving health coverage if they have had COVID-19. Look for #Coverage4All and #PassA1585 all day tomorrow to help get the word out!

What else can you do?

  • Sign up for campaign updates here.
  • Become listed as a supporting organization here.
  • Contact your legislator any time using the instructions here.

Friday, 11:00-12:00: Budget Briefing for Health Justice Advocates

Join the Campaign for NY Health, the Consumer Directed Personal Assistance Association of New York State, Coverage4All, Health Care for All NY, and Medicaid Matters NY for an overview of the FY22 Executive Budget Proposal and its implications for healthcare in New York. Register here.

Friday, February 5 1:00-3:00: HCFANY Annual Meeting

What can we expect from legislative session this year? How do we push forward and ensure quality, affordable health care for everyone in New York State during a pandemic and a budget crisis? Join us to learn more about our legislative and budget priorities for 2021 and how you can take action yourself! Click here to register!

During this virtual meeting we will:

  • Award Senator Gustavo Rivera as this year’s Consumer Champion and present a posthumous Lifetime Achievement award to Kristin Sinclair, Director of the Senate Health Committee.
  • Share information about the state budget and our legislative priorities, including expanding health coverage to all New Yorkers, ending medical debt, and addressing systemic inequity in our health care system.
  • Talk about future workshops that will offer deep dives on different health policy issues and opportunities to take action.

The new 2018 census data numbers are out this this morning. 

The bad news is that uninsurance numbers increased across the country by 1.9 million in 2018, despite the positive economy. This was the first increase in uninsured since the Affordable Care Act was fully implemented in 2014. Here’s a New York Times article with more details.

BUT, there’s great news in New York, which was one of just three states in the country to have a decline in our uninsurance numbers, from 1,113,000 in 2017 to 1,041,000 in 2018 (our uninsurance rate declined from 5.7% to 5.4%). 

New York’s continued decline in uninsured residents is inextricably linked to its adoption of the high quality, affordable, Essential Plan, which saw an increase in enrollment from 665,000 in 2017 to 739,000 in 2018.  Other important factors include:

  • One-stop shopping: you can apply for the full spectrum of coverage, including Medicaid, Emergency Medicaid, Child Health Plus, the Essential Plan, Qualified Health Plans and tax credits, all through the same NY State of Health application
  • Robust Navigator funding of $27 million a year

Congratulations New Yorkers! And let’s keep up the good work!

The CDC released early results from its National Health Interview Survey and it echos some of the data we’ve already seen. In most states, fewer people have health insurance – but in New York, more people do! There wasn’t enough data to know whether or not the change was meaningful, but it matches what we know from other sources. And even holding steady is an achievement in an era where the Trump Administration is doing everything it can to sabotage health insurance programs.

This chart, from the CDC’s report, shows a small increase in the number of insured people – while it could be that we just stayed the same, we can be proud of that too given how many people in other states lost coverage.

For example, the NY State of Health released final numbers recently the last open enrollment. Over 4.7 million New Yorkers used the Marketplace to buy health insurance or enroll in public plans, the most ever! The increases happened in every single county of the State.

We’ve always argued that robust investment in our Marketplace and consumer-assistance programs pays off, but comparing outcomes here to those in other States shows just how important those investments are. Some States chose to use the federal Marketplace infrastructure when implementing the Affordable Care Act. New York chose to build its own, a harder task, but with the result that our Marketplace integrates all of our programs perfectly.

We didn’t foresee an Administration that would work so hard to hurt those Marketplaces, but the decision to create our own infrastructure has protected us from it. In those other States, funding for marketing and for consumer assistance programs is controlled by the federal government. Even the amount of time people have to enroll is controlled by the federal government. So now that we have an Administration that wants those Marketplaces to fail, they’ve cut funding for marketing and consumer assistance and drastically shortened the amount of time people have to enroll. New York has done just the opposite, and achieved the opposite result.

As we talked about last week, we still have a lot to do to get to universal coverage. People without health insurance in New York are disproportionately part of racial and ethnic minority communities. But as a state we have options, and now we have proof that State-level strategies can make a big difference.