December 14, 2021
Health Care for All New York (HCFANY) would like to thank the chairs and members of the Assembly Health Committee for this opportunity to provide our comments on issues affecting Medicaid. HCFANY is a statewide coalition of over 170 organizations dedicated to achieving quality, affordable health coverage for all New Yorkers.
Barriers to care during pregnancy, childbirth, and postpartum include a lack of affordable health coverage, difficulty finding care, and inadequate benefits that expose families with young children to unaffordable medical bills. New York State can address these barriers by expanding Medicaid coverage postpartum and for young children, removing premiums for Child Health Plus (CHP) and improving the program’s benefits, and ensuring that the certificate of need process is responsive to underserved communities.
New York should extend Medicaid coverage from 60 days after the end of pregnancy to one year. Medicaid provides health insurance during pregnancy and for 60 days postpartum for those who meet income requirements (223% of the FPL, about $28,000 for a household of one). On the 61st day, New York pays to enroll the former Medicaid beneficiary into a Silver-level Marketplace plan. Once in the Marketplace plan, the new parent becomes responsible for higher cost-sharing and a $1,300 deductible—both of which can be insurmountable barriers to care for many new parents.
Health insurance reduces maternal mortality. The State’s current policy means one group of people, undocumented immigrants, has no access to coverage at all because federal rule prohibits them from enrolling in Marketplace plans. For those who are allowed to enroll, a Silver Marketplace plan may be better than providing no options but obtaining care with this coverage will involve substantial cost-sharing. The Silver plans come with a $1,300 deductibles and other cost-sharing barriers may reduce appropriate utilization for new mothers.
Even without affordability barriers, a new health insurance plan likely means changing providers at a time when continuity of care is vital. The Centers for Disease Control and Prevention recommend ensuring access to care for at least a year after pregnancy to avoid care disruptions that lead to preventable deaths.14 Death and severe morbidity related to pregnancy and childbirth are a crisis in New York State that disproportionately affects Black New Yorkers.2 Many of these deaths are preventable and many occur more than 60 days postpartum.
New York could ensure stable Medicaid coverage for one year after the last day of pregnancy by filing a State Plan Amendment with CMS. Enacting A307A/S1411A would authorize the Department of Health to do this and would also provide state-only funds so that people ineligible for federal funding can enroll. The costs to the State for this coverage would be an estimated $30 million annually – less than one tenth of one percent of the State’s Medicaid spending. Doing so would safeguard the health of not only our State’s most vulnerable mothers but by extension, their infant children as well.
Implement continuous Medicaid eligibility for infants in their first three years of life. Our State can further safeguard the health of the youngest New Yorkers, protect children against insurance churn and coverage losses, and offer continuity of care during a period of critical growth and development by implementing continuous Medicaid eligibility for infants in their first three years of life. Currently, State law requires automatic enrollment into Medicaid coverage for the first year of life, which has substantially improved access to care related infant mortality. These gains should be built upon by extending this coverage period to three years.
The $9 premium for CHP enrollees living in families earning below 250% of the federal poverty level should be eliminated. Premiums of any amount cause coverage disruptions and delayed care for low-income people. 4 This happens because premiums discourage enrollment in health insurance in the first place and cause churning when payments are missed.
New York State does not require premiums for children in families earning below 160% of the FPL. However, families earning between 161% and 250% of the FPL pay $9 per child per month, up to three children. In 2019, this meant that 69,000 children (almost half of the children required to pay the $9 premium) had their coverage terminated for at least one month. New York can eliminate these disruptions by removing the premium requirement. New York enacted a similar policy change for people enrolled in the Essential Plan last year which succeeded in reducing coverage disruptions. This could be done for CHP enrollees through a statutory change enacted through the State budget for an estimated annualized cost of $8.3 million.
CHP could expand its benefits to ensure the children who use it receive all the care they need. CHP provides comprehensive coverage, but still has some benefit gaps that could mean children go without care or that families are left with large medical bills for their children’s care. New York State could add the following CHP benefits for a cost of $44 million a year:
- Air ambulances and emergency ambulance transportation (for example, emergency transportation between hospitals);
- Medical supplies other than the currently covered supplies needed for ostomy or diabetes care;
- All medically necessary orthodontia to match the guidelines for Medicaid. CHP insurers frequently interpret the current guidelines for orthodontia so narrowly that children with a clear medical need for orthodontia are denied coverage. Most of these denials are then overturned. The CHP guidelines should clearly state that all medically necessary orthodontia is covered to eliminate these wasteful and unnecessary delays;
- Children and Family Treatment and Support Services (includes Crisis Intervention, Community Psychiatric Support and Treatment, Psychosocial Rehabilitation, Youth Peer Support and Training and Family Peer Support), Children’s Home and Community Based Services, Assertive Community Treatment (ACT) and Residential Rehabilitation for Youth (RRSY); and
- Expanded services for undocumented children in foster care to match what they would receive if they were enrolled in Medicaid.
Reform the Certificate of Need (CON) process to promote health equity, transparency, and community engagement. New York State has lost more than 40 acute care hospitals over the last 20 years, leaving some low-income communities of color that were hardest hit by COVID 19 with too few beds to meet the need. Moreover, elimination of maternity, intensive care and inpatient psychiatric units, emergency departments and a full range of reproductive health services at some hospitals is causing hardships for medically-underserved New Yorkers. Approval of proposed mergers, downsizing and closing of health facilities is carried out by the NYS DOH and by the Public Health and Health Planning Council (PHHPC) without thorough assessments of how the transactions would affect access to care for underserved individuals and communities. We thank the Assembly for passing a measure (S1451A/A0191A) requiring a health equity assessment as part of CON applications. This bill also passed the Senate, but awaits Governor Hochul’s signature.
Further, we ask the Assembly to encourage the Governor to add another consumer representative to the PHHPC, which now has only one consumer seat among 24 members, is dominated by representatives of big health systems and has a cumbersome process of taking public comment.
Finally, we strongly urge the restoration of regional health planning so that state regulators can determine whether proposed transactions would fill identified gaps in care, or simply exacerbate existing health inequities. The entire CON process needs reform to improve transparency and community engagement so that we can ensure that decisions are based on community needs, instead of market-driven industry business plans.
Thank you for consideration the testimony of Health Care for All NewYork. Should you have any comments or questions, please contact Amanda Dunker at: firstname.lastname@example.org.
Sophie Wheelock and Mark A. Zezza, “To Provide Seamless Postpartum Insurance Coverage, Keep It In The Medicaid Family,” health Affairs Blog, October 26, 2021, https://www.healthaffairs.org/do/10.1377/hblog20211022.658362/full/.
Kaiser Family Foundation, “The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings,” 2017, https://www.kff.org/medicaid/issue-brief/the-effects-of-premiums-and-cost-sharing-on-low-income-populations-updated-review-of-research-findings/#:~:text=The%20effects%20on%20individuals%2C%20providers%2C%20and%20state%20costs,maintaining%20Medicaid%20and%20CHIP%20coverage%20among%20low-income%20individuals
ASPE Issue Brief No. HP-2021-03, “Medicaid Demonstrations and Impacts on Health Coverage: A Review of the Evidence,” Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, March 2021, https://aspe.hhs.gov/pdf-report/medicaid-demonstrations-andimpacts.