Testimony on the 2021-2022 State Budget

Posted March 24, 2021 by Amanda Dunker

This testimony was submitted on February 25, 2021. Download a pdf below.


Health Care for All New York (HCFANY) would like to thank the chairs and members of the Assembly Ways and Means and the Senate Finance Committees for providing the public an opportunity to provide our comments on the state budget. HCFANY is a statewide coalition of over 170 organizations dedicated to achieving quality, affordable health coverage for all New Yorkers.


HCFANY supports proposals in the Executive Budget that would eliminate premiums for people enrolled in the Essential Plan, reduce interest rates on court judgments, fund post-enrollment consumer assistance programs, and license pharmacy benefit managers.  HCFANY strongly opposes the budget’s lack of coverage expansions, its proposal to eliminate Indigent Care Pool funding for public hospitals, and its cuts to Article VI public health programs in New York City. HCFANY is also strongly opposed to cuts to Medicaid that are included in the Executive budget proposal. These include the elimination of the prescriber prevails consumer protection and across-the-board cuts to Medicaid providers.


As we enter the second year of the COVID pandemic, New Yorkers need more from the State budget to manage high health care costs. New Yorkers were already experiencing a coverage and affordability crisis before the pandemic started.[1] During the pandemic they have experienced massive economic disruption and needed unprecedented levels of care: at the pandemic’s height, over 19,000 New Yorkers were hospitalized in a single day. There were over 6,500 New Yorkers hospitalized every single day of January 2021. And to date 37,000 New Yorkers have died from COVID-19. HCFANY respectfully asks that members of the legislature consider the following recommendations to provide much-needed relief to New Yorkers:


  • Expand the proposal to eliminate Essential Plan premiums to also include the elimination of vision and dental premiums;
  • Fully enact the provisions of the Patient Medical Debt Protection Act;
  • Expand public coverage to all New Yorkers who have suffered from COVID-19 regardless of immigration status;
  • Reject budget cuts that will disproportionately hurt low-income communities and people of color such as the proposed cuts to public hospitals, safety-net providers, and Article VI public health programs and eliminating the Medicaid global cap; and
  • Fully fund consumer assistance programs that help New Yorkers enroll in and use coverage.



  1. Eliminate dental and vision premiums in the Essential Plan.


The Essential Plan provides health coverage with no deductible and minimal cost-sharing to over 800,000 New Yorkers who earn less than 200 percent of the federal poverty level (FPL) (around $25,500 a year for an individual). Currently, enrollees earning between 150 percent and 200 percent of the FPL must pay a premium of $20 a month. The Essential Plan is fully funded by the federal government and the funding formula has produced a surplus over the year. Under federal law, any surplus may only be used to enhance benefits for enrollees.[2]


HCFANY fully supports the Executive Budget proposal to eliminate the $20 per month Essential Plan premium. Eliminating the $20 a month premium, the only proposal that directly improves benefits for enrollees, would only cost an estimated $90 million. This proposal complies with federal law.


However, the Executive Budget then allocates an additional $620 million of the Essential Plan surplus to providers and insurers: $420 million to increase reimbursement rates for providers and $200 million in quality incentive bonuses to the insurers that administer the program. It is unclear if either of these measures constitute a benefit enhancement for Essential Plan beneficiaries as set forth in the ACA statute governing allowable uses of trust fund surpluses.


Accordingly, HCFANY recommends that the State also eliminate premiums for vision and dental coverage (which is a blended rate of $31 a month). More of the surplus can and should be used for enrollees. Eliminating the vision and dental premium would cost an estimated $150 million while still leaving funds for the legally dubious proposal to increase rates to providers or offer bonuses to insurance companies.


Eliminating all premiums in the Essential Plan would provide financial relief to low-income New Yorkers. It would also eliminate churning in the program, which raises administrative costs and leaves eligible New Yorkers uninsured. Vision and dental care are as important to health as other types of care. New York should not discourage New Yorkers from obtaining glasses they need to work or go to school or addressing dental problems early on by imposing a premium.[3]


  1. Enact all provisions of the Patient Medical Debt Protection Act (A3470A/S2521A)


The Executive Budget offers little to address the reality that millions of New Yorkers are uninsured or struggle to afford healthcare even when they are insured.  One of the symptoms of this affordability crisis is that over 50,000 New Yorkers have been sued by hospitals since 2015 as described in the Discharged Into Dept series of reports  issued by the Community Service Society of New York.[4] Compounding the misery of COVID crisis, a January 5, 2021 front page story in the New York Times detailed that more than 5,000 cases were filed during the pandemic between March and November of 2020.[5] All of New York’s hospitals are non-profit charities—making the ubiquitous filing of lawsuits against their patients all the more egregious.


Likewise the Executive Budget offers nothing in the way of addressing negative medical debt on New Yorker’s credit reports which is rampant, especially in upstate New York, where there are 23 counties in which over 15 percent of residents have delinquent medical debt on their credit reports. [6] Researchers at the Urban Institute have also found drastic racial disparities in many parts of New York with regards to medical debt and credit reporting. For example, in Onondaga County communities where most people are white, 14 percent have delinquent medical debt on their credit reports. In areas where most residents are people of color, that increases to 41 percent.


Share of Residents with Delinquent Medical Debt on Their Credit Reports[7]
County Overall White Communities Communities of Color Difference
Onondaga 20% 14% 41% 292%
Monroe 11% 7% 26% 371%
Albany 12% 10% 26% 260%
Erie 10% 8% 22% 275%


The Executive Budget only offers one proposal that could ameliorate medical debt for patients who will be sued in the future by charitable hospitals, which is to reduce interest rates on court judgments from 9 percent to the U.S. Treasury rate. HCFANY strongly supports this proposal, which is similar to a provision of the Patient Medical Debt Protection Act (A3470A/S2521A) that would apply to medical debt only. For nearly a decade, the Treasury rate has hovered around 1 percent. Not all hospitals that sue patients charge interest, but those that do apply a commercial rate of 9 percent. This adds thousands of dollars of additional debt for those patients and should never happen.


New Yorkers urgently need help with medical debt now. HCFANY asks that the legislature enact the remaining provisions of the Patient Medical Debt Protection Act (PMDPA). The commonsense solutions proposed in the PMDPA would prevent medical debt from accruing for many New Yorkers by making billing processes fairer:


  • Parts B-C of the bill would require hospitals to provide patients with one itemized bill written in plain language so that patients are able to understand the charges and identify errors. This would also help patients understand what they owe, when, and to whom. This is difficult when patients receive many different versions of bills and do not know whether the hospital has submitted a claim to their insurer. For example, one patient received 27 different bills after going to a hospital for his kidney stones.
  • Patients should be held harmless from out-of-network bills incurred because of misinformation provided by a health plan or provider. Claudia Knafo received an out-of-network bill for over $100,000 after choosing a surgeon from her plan’s provider directory.[8] Part I of the Patient Medical Debt Protection Act would hold consumers harmless from out-of-network bills if they relied upon information provided in their plan provider directory, their plan’s website, or an oral or written statement by their health plan.
  • Patients should not be responsible for paying facility fees, which are fees charged by hospitals and increasingly by out-patient clinics that have been purchased by hospital systems with no relation to the medical care received. One woman was charged a $149 facility fee for a mammogram, even though such a preventive test is required to be covered without cost-sharing by the Affordable Care Act. Part B of the Patient Medical Debt Protection Act defines facility fees and prohibits hospitals from charging patients for facility fees after receiving preventive services recommended by the United State Preventive Services Task Force.
  • Part G would simplify the eligibility rules for hospital financial assistance and standardize financial assistance polices across all hospitals through one uniform State Department of Health developed form. Many of the patients that incur medical debt have incomes that would make them eligible for hospital financial assistance under New York State law. However, patients do not find out about this assistance and when they do, difficult application processes and strict time frames keep them from successfully applying.[9]
  • Hospitals should use one standard financial assistance application and a standard appeal process to ensure that eligible patients receive financial assistance. Some hospitals are not making the financial assistance application process accessible to all eligible patients despite being required to do so by law.[10] Part E of the Patient Medical Debt Protection Act would require all hospitals to use one standard application and appeals process for financial assistance. This would make it easier for patients to apply and receive the financial assistance hospitals are required to provide.
  • Part F would prohibit hospitals from including provisions in their contracts with insurers that block cost information from being shared with the state. The state collects this cost information as part of efforts to increase price transparency. There are large variations in what different providers charge for the same services. Without an accurate database of charges, patients will never be able to know when a provider is charging a fair price for services.


  • Ensure that all New Yorkers have health coverage


Health coverage reduces mortality and morbidity and greatly reduces poverty.[11] New York should not turn its back on New Yorkers who still lack access to this vital source of health and financial security.


In a March 2019 survey by the Community Service Society of New York and Altarum Healthcare Value Hub, 51 percent of the uninsured said insurance was too expensive.[12] Some of these New Yorkers may be eligible for help without knowing, but for many, there are no good options. For example, many immigrants are ineligible for many coverage programs because of their immigration status. HCFANY asks that the following policies be enacted in the FY2021-2022 budget to expand coverage options and ensure that New Yorkers can easily enroll:


  1. Enact the New York Health Act


The New York Health Act would provide universal health coverage to all residents of New York and those who work in New York full-time. Enacting it would eliminate disparities in health coverage and help New York lower the cost of health care for everyone.


  1. Allocate $13 million to temporarily open the Essential Plan to New Yorkers who have had a confirmed or suspected COVID-19 infection but whose immigration status currently prohibits their enrollment


HCFANY estimates that over 400,000 New Yorkers are uninsured because of their immigration status. The most recent data from the U.S. Census shows that non-citizens in New York have an uninsured rate of 21 percent, even though overall only 5 percent of New Yorkers are uninsured.[13]


HCFANY urges the Legislature to use state-only funding to expand the Essential Plan to undocumented New Yorkers who have had COVID-19 and meet the income requirements. HCFANY estimates that providing this option would cost $13 million. New York’s Emergency Medicaid program covers testing and treatment of COVID-19 for immigrants who have no other options. However, these New Yorkers deserve full insurance coverage. In many cases COVID-19 has long-term health effects that we are only beginning to understand. Additionally, a COVID-19 infection means losing work and the means to pay for any other health care needs an individual might have. People who have had COVID-19 should be able to continue accessing health care after the acute part of their illness ends.


  1. New York should increase enrollment in existing health coverage programs by fully funding the Navigator program at $32 million and allocating an additional $2 million so that community-based organizations can conduct outreach in hard-to-reach communities.


Approximately 300,000 New Yorkers are uninsured because they are unaware that they are eligible for help affording health insurance, have reservations about enrolling, or are not sure how to enroll. The Navigator program provides independent, in-person assistance to consumers who want help shopping for and enrolling in health coverage. Navigators have helped enroll more than 300,000 people since the program started in 2013. The Navigator program has received flat funding of $27.2 million per annum since 2013, with no cost-of-living increases—unlike every other industry stakeholder in our healthcare system (e.g. hospitals, providers and insurers). Agencies have lost trained and experienced staff because this funding limitation means they cannot keep up with the increase in the cost of providing benefits, cost-of-living increases, and other non-personnel expenses.  HCFANY urges the Legislature to fund the Navigator program at $32 million to make up for increased costs over time.


Additionally, New York should allocate $5 million to community-based organizations to conduct outreach in communities that have low coverage rates. An example is immigrants, who have heard many confusing and frightening things about enrolling in public programs. These communities are more likely to trust the organizations that are already working in their communities. Those New Yorkers who are eligible for existing programs but are still uninsured are among the most challenging to reach and enroll in coverage. Broad-stroke marketing measures currently undertaken by NYSOH can best be augmented by a robust grassroots program.


  1. Consumer Assistance Programs


  1. HCFANY supports the proposed budget allocation of $2.5 million for the Community Health Advocates program and urges the Legislature to provide additional funds to maintain funding at $3.9 million.


Since 2010, the Community Health Advocates program (CHA) has provided free, independent assistance to over 360,000 consumers trying to make the most of their health insurance coverage. CHA helps New Yorkers resolve billing issues and coverage denials, get prior authorizations, respond to out-of-network and surprise bills, and locate health services no matter what type of insurance they have. Services are provided through a central helpline and community-based organizations that can provide in-person assistance throughout the state. CHA has saved New Yorkers over $47 million since it started. Every dollar the State invests in CHA produces $1.31 in savings for consumers.


These services are needed more than ever so that New Yorkers can manage the disruption caused by COVID-19. HCFANY urges the Assembly and the Senate to contribute an additional $2.5 million to the Executive Budget proposal for a total of $5 million in FY2021.



  1. HCFANY supports the Executive Budget’s proposal to fund the Community Health Access to Addiction and Mental Healthcare Project (CHAMP).


CHAMP is a first-in-the-nation independent consumer assistance program created for people in need of substance use disorder or mental health treatment. The New Yorkers served by CHAMP are often experiencing crises related to mental health or addiction; CHAMP makes sure that insurance issues do not stop their clients from getting help when they need it. HCFANY supports funding for CHAMP and asks that the legislature ensure this funding stays in the final budget.



  1. Address systemic inequality in New York’s healthcare system


New York’s past policy choices have built inequality into the structure of our health care system, including our failure to ensure that all New Yorkers have health insurance, deregulation of hospital reimbursement rates, and the elimination of statewide health planning.[14] These decisions led to hospital closures in low- and moderate-income communities and endless expansions of hospitals in wealthy communities that can pay more for care. Because wealth is so often linked to race in the United States, this often means that communities where more people of color live are the ones losing health care infrastructure. This tendency is seen when looking at the number of hospital beds across New York City’s five boroughs:


Borough Hospital Beds per 1,000 People[15] Percent of Residents Who Are People of Color[16]
Bronx 2.7 77.3%
Brooklyn 2.2 56.4%
Manhattan 6.4 43.3%
Queens 1.5 63.6%
Staten Island 2.5 26.5%



During the pandemic, graphic evidence of the immense suffering and excess deaths caused by these policy choices has piled up.[17] For some patients, survival required relatively simple care like being turned onto their stomachs: wealthy hospitals have automatic bed turners; underfunded safety-net hospitals did not even have enough staff to turn patients over manually.[18]


Despite this, several proposals in the Executive Budget continue this under-resourcing of safety-net hospitals and will even inflict budget cuts on those hospitals while the pandemic is still happening. HCFANY asks that the legislature reject proposals in the Executive Budget to cut funding for public hospitals, Medicaid, and public health programs in low-income communities. Further, we ask that the legislature enact long-term changes to health care funding and planning instead of allowing New York to return to a “normal” that means perpetual inequality.


  1. Public hospitals should not lose Disproportionate Share Hospital funding. In the long-term, this funding should be distributed to safety-net hospitals only.  


Disproportionate Share Hospital (DSH) funds are intended to support hospitals that serve the most uninsured and Medicaid patients. In New York, over $1.1 billion in DHS funding is distributed through the indigent care pool (ICP). Part X of the Executive Budget proposes to eliminate ICP funding for public hospitals. HCFANY opposes this.


New York’s public hospitals serve far more uninsured and Medicaid patients than its private hospitals. In the most recent year for which there is data, 55 percent of patients discharged by public hospitals in New York were uninsured or covered by Medicaid while only 29 percent of patients discharged from private hospitals were. Because of the disproportionate affect COVID-19 has had on low-income New Yorkers, many of these hospitals are bearing a far greater burden than others that serve wealthy patients. New York should increase its support for these hospitals, not defund them during a pandemic.


In the long-term, New York should target ICP funding only to safety-nets hospitals that serve the most Medicaid enrollees and uninsured patients. New York instead distributes ICP funding to all hospitals, which means ICP funds often subsidize profitable hospital systems that serve wealthier, privately insured patients instead of the low-income patients they are intended to help. There are large differences between hospitals even in the same areas of the state in terms of how many Medicaid and uninsured patients they serve. For example, the proportion of Medicaid patients served by Erie County hospitals ranges from 2 percent to 68 percent. In Manhattan it ranges from 2 percent to 67 percent, and in Suffolk County the range is 5 percent to 52 percent. Yet all of these hospitals are given ICP funding.


No other state distributes funds this way. Instead, other states distribute DSH funds only to the hospitals that serve the most uninsured and Medicaid patients. If New York had done this, safety-net hospitals would have received roughly $13.4 billion more over the past 20 years.[19] For some, it may have made the difference in staying open or closing; at others it may have meant having more staff and better equipment.


  1. Medicaid funding


The Medicaid global cap is a recent example of a policy that takes resources away from low-income communities without regard for the effect it will have on their access to care. The global cap imposes automatic cuts when Medicaid spending hits a pre-determined threshold. The threshold does not allow for planning based on public health data or economic conditions. Last year, Medicaid was subjected to across-the-board cuts of 1.5%. Because the threshold was hit last year, New York State is again implementing across-the-board cuts, this time of 1%.


Because of the differences in payer mix described above and the disproportionate impact COVID-19 has on people of color and low-income communities, these cuts will automatically fall on the hospitals caring for the highest numbers of COVID-19 patients. This type of policy choice produced an environment in which New Yorkers lived or died depending on their wealth. New York should not continue reducing the resources available for safety-net providers under any circumstances. It absolutely should not do this while the pandemic is still happening.

As a first step, the Legislature should make sure that New York’s safety-nets are exempt from these across-the-board cuts. Public Health Law §2807-c (34) defines enhanced safety-nets; these hospitals should be exempt.


In the long-term, New York must repeal the Medicaid global cap by enacting A226 and allowing the program to work as it is meant to work. More New Yorkers are enrolled in Medicaid than ever. Millions of New Yorkers lost their jobs and their job-based health insurance during 2020; as a result, 700,000 more people enrolled in Medicaid between March and November than did last year.[20] New York’s Medicaid program saves lives; it recently received national attention after researchers found that expanding the program reduced maternal mortality.[21] It is one of the most important ways in which New York supports community hospitals in all parts of the state. These arbitrary cuts to a program that serves as a lifeline for so many New Yorkers should stop.


  1. Article VI Funding


HCFANY is disappointed that the Executive Budget again reduces the state match for Article VI funds to public health programs. This cut will only apply to New York City, the epicenter of the pandemic and the most diverse part of New York. These funds are critical for programs that help address public health crises such as COVID-19, HIV, viral hepatitis, and TB that affect predominantly low-income, immigrant New Yorkers, and communities of color. Last year, the state budget cut the matching rate for this funding from 36% to 20%; this year the Executive Budget cuts the matching rate to just 10%. The Legislature should reject this proposal and restore public health funding for New York City.


Thank you again for providing this opportunity to testify and your consideration of our concerns. Please contact Amanda Dunker (adunker@cssny.org, 212-614-5312) with any questions. We stand ready to work with the Legislature to move forward on our recommendations.

[1] Altarum Healthcare Value Hub, New Yorkers Struggle to Afford High Healthcare Costs; Support a Range of Government Solutions Across Party Lines, Data Brief No. 37, March 2019, https://www.healthcarevaluehub.org/advocate-resources/publications/new-yorkers-struggle-afford-high-healthcare-costs-support-range-government-solutions-across-party-lines/.

[2] 42 U.S.C.A. §18051(d)(2).

[3] Marko Vujicic, Thomas Buchmueller, and Rachel Klein, “Dental Care Presents the Highest Level of Financial Barriers, Compared to Other Types of Health Care Services,” Health Affairs, December 2016, https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0800.

[4] Amanda Dunker and Elisabeth Benjamin, “Discharged Into Debt: New York’s Nonprofit Hospitals Are Suing Patients,” Community Service Society of New York, March 2020, https://www.cssny.org/publications/entry/discharged-into-debt and Amanda Dunker and Elisabeth Benjamin, “Discharged Into Debt: A Pandemic Update,” Community Service Society of New York, January 2021, https://www.cssny.org/publications/entry/discharged-into-debt-a-pandemic-update.

[5] Brian M. Rosenthal, “One Hospital System Sued 2,500 Patients After Pandemic Hit,” New York Times, January 5, 2021, https://www.nytimes.com/2021/01/05/nyregion/coronavirus-medical-debt-hospitals.html.

[6] These are: Oswego (23%), Columbia (20%), Onondaga (20%), Schuyler (19%), Greene (18%), Chautauqua (18%), Cattaraugus (18%), Sullivan (17%), Rensselaer (17%), Madison (17%), Cortland (17%), Cayuga (17%), Seneca (17%), Schenectady (16%), Jefferson (16%), Washington (16%), Steuben (16%), Ontario (15%), Essex (15%), St. Lawrence (15%), Oneida (15%), and Montgomery (15%). Urban Institute, Debt in America: An Interactive Map (urban.org).

[7] Ibid.

[8] Sarah Kliff, “A spinal surgery, a $101,000 bill, and a new law to prevent more surprises,” Vox, March 19, 2019, https://www.vox.com/health-care/2019/3/19/18233051/surprise-medical-bills-arbitration-new-york.

[9] Carrie Tracy, Elisabeth Benjamin, and Amanda Dunker, “Unintended Consequences – How New York Patients and Safety-Net Hospitals Are Short-Changed,” Community Service Society of New York, January 2018, https://www.cssny.org/publications/entry/unintended_consequences.

[10] Ibid.

[11] Benjamin D. Sommers, Atul A. Gawande, and Katherine Baicker, “Health Insurance Coverage and Health – What Recent Evidence Tells Us,” New England Journal of Medicine, August 10, 2017, 377: 585-593,  DOI: 10.1056/NEJMsb1706645; Laura R. Wherry, Genevieve M. Kenney, and Benjamin D. Sommers, “The Role of Public Health Insurance in Reducing Child Poverty,” Academic Pediatrics, April 2016, 16 (3): S98-S104, https://doi.org/10.1016/j.acap.2015.12.011 and Sanders Korenman, Dahlia K. Remler, and Rosemary T. Hyson, “The Impact of Health Insurance and Other Social Benefits on Poverty in New York State: Final Report to the Howard J. Samuels State and City Policy Center,” July 18, 2018, http://www2.cuny.edu/wp-content/uploads/sites/4/page-assets/about/centers-and-institutes/demographic-research/New-York-HIPM_2018-08-06.pdf

[12] Altarum Healthcare Value Hub, New Yorkers Struggle to Afford High Healthcare Costs; Support a Range of Government Solutions Across Party Lines, Data Brief No. 37, March 2019, https://www.healthcarevaluehub.org/advocate-resources/publications/new-yorkers-struggle-afford-high-healthcare-costs-support-range-government-solutions-across-party-lines/.

[13] United States Census Bureau, “Table S2701: Selected Characteristics of Health Insurance Coverage in the United States,” 2019, https://data.census.gov/cedsci/table?q=selected%20characteristics%20of%20health&g=0500000US36087&tid=ACSST1Y2019.S2701&hidePreview=true.

[14] Amanda Dunker and Elisabeth Benjamin, “How Structural Inequalities in New York’s Health Care System Exacerbate Health Disparities During the COVID-19 Pandemic: A Call for Equitable Reform,” June 4, 2020, Community Service Society of New York, https://www.cssny.org/news/entry/structural-inequalities-in-new-yorks-health-care-system.

[15] Ibid.

[16] US Census Bureau American Community Surveys.

[17] Brian Rosenthal et al., “Why Surviving the Virus Might Come Down to Which Hospital Admits You,” July 1, 2020, New York Times, https://www.nytimes.com/2020/07/01/nyregion/Coronavirus-hospitals.html and Harold A. Pollack and Caroline Kelly, “COVID-19 and Health Disparities: Insights From Key Informant Interviews,” Health Affairs Blog, October 27, 2020, https://www.healthaffairs.org/do/10.1377/hblog20201023.55778/full/.

[18] Brian Rosenthal et al., “Why Surviving the Virus Might Come Down to Which Hospital Admits You,” July 1, 2020, New York Times, https://www.nytimes.com/2020/07/01/nyregion/Coronavirus-hospitals.html and Harold A. Pollack and Caroline Kelly, “COVID-19 and Health Disparities: Insights From Key Informant Interviews,” Health Affairs Blog, October 27, 2020, https://www.healthaffairs.org/do/10.1377/hblog20201023.55778/full/.

[19] Amanda Dunker and Elisabeth Benjamin supra note 13.

[20] Medicaid Matters New York, “Medicaid Steps Up in Response to the Economic Consequences of the COVID-19 Pandemic,” February 2021, https://medicaidmattersny.org/wp-content/uploads/2021/02/2020-enrollment-one-pager-MMNY-2.16.21.pdf.

[21] Erica Eliason, “Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality,” Women’s Health Issue, February 25, 2020, https://www.whijournal.com/article/S1049-3867(20)30005-0/fulltext.