New York City Guarantees Healthcare for All Residents

Ken Terry

January 09, 2019

New York City on January 8 announced what Mayor Bill de Blasio termed "the largest, most comprehensive plan in the nation to guarantee health care" for a city's residents.

While a more ambitious single payer bill may be taken up by the New York State legislature this spring, and a brace of universal coverage proposals are bouncing around in Congress, de Blasio told attendees at a press conference that the city government has an obligation to act now.

Under the universal healthcare plan, about half of the 600,000 uninsured New York residents will be able to enroll in a strengthened version of New York's public health insurance option, MetroPlus. Those who are ineligible for MetroPlus, including undocumented immigrants, will be able to access the physicians, pharmacies, and mental health and substance abuse services of NYC Health + Hospitals, the city's public health system, which includes 11 hospitals and 70 clinics.

Enrollees in this program, known as NYC Care, will have a regular primary care physician and will also be able to see specialists, with out-of-pocket costs tied to enrollees' incomes.

The program is scheduled to begin this summer and it is expected to be fully implemented within 2 years.

NYC Care is patterned after Healthy San Francisco, a universal coverage program that was launched in 2007. But there are important differences, noted Mitchell Katz, MD, CEO of NYC Health + Hospitals, at the news conference announcing the decision. NYC Care will offer a broader range of services and will also affect far more people than the West Coast model, said Katz, who formerly had roles in both the San Francisco program and My Health LA, a similar program in Los Angeles.

Healthy San Francisco, which doesn't have an insurance component but uses the city's public hospital and community clinics, serves only 20,000 people, a small fraction of the residents that NYC Care could potentially help, he noted.

About 300,000 uninsured people, de Blasio said, are eligible to enroll in health plans on the New York State insurance exchange but can't afford the plans or have chosen not to buy coverage. Many of the latter, he noted, are "young invincibles" who think they don't need health insurance. The city hopes to lure them into MetroPlus — available to uninsured adults who are not covered by other public programs — by making it easier for them to enroll. As for the cost, MetroPlus charges on an income-based sliding scale.

The vast majority of the other 300,000 uninsured are undocumented immigrants who are ineligible for an exchange plan or MetroPlus. A customer service system will be built to help guide them to the healthcare services they need, Katz said. As a result of NYC Hospital + Health hiring a large number of primary care physicians, he added, most NYC Care patients should be able to see a doctor within a week, or even within a day or two if necessary.

The Power of Messaging

When the message gets out that New York City guarantees healthcare to all residents who need it, de Blasio predicted that a large percentage of the uninsured will respond. The Healthy San Francisco experience supports his contention: in 2013, before the Affordable Care Act provided alternatives, 84% of the city's uninsured residents, or more than 60,000 people, participated in the program, according to a report in Health Affairs.

The cost of NYC Care, when fully implemented, is expected to be about $100 million a year. This money, de Blasio said, will come from the NYC Hospital + Health budget and will not require a tax increase. He added that the public hospital system, which was financially ailing a few years ago, recently posted a surplus. (However, the New York Times reported that the system is still running at a deficit.)

In the long run, the mayor said, the program will save the city a lot of money by enabling people to get primary and preventive care in doctors' offices rather than visiting the emergency room after they get sick. De Blasio also emphasized the importance of giving everyone access to mental health and substance abuse care.

"If people get mental health services when they need them, at the right point in life, that means you avoid everything from, God forbid, homelessness or incarceration or people losing their jobs," de Blasio said in an interview on MSNBC's "Morning Joe" show. "There are immense savings humanly and economically to getting it right."

Ambitious Program

Ken Jacobs, chair of the Center for Labor Research and Education, University of California at Berkeley, agrees that universal access to mental health services can have great collateral benefits. "The overlap between frequent flyers in ERs, mental health facilities, jails, and homeless shelters is very high," he told Medscape Medical News. "Solutions that get people the mental health [care] they need can bring savings in a wide range of areas."

Jacobs, who has studied the impact of Healthy San Francisco, said that the program had been successful in creating a comprehensive, coordinated health program for the uninsured. However, he noted, it didn't save money. "More money was spent overall, but the value gained by those extra dollars was significant in terms of access to care and outcomes."

Whether $100 million is enough to finance NYC Care, Jacobs said, will depend partly on what other revenue streams are leveraged and who participates in the program. Healthy San Francisco, he says, allows participation by people with incomes up to 500% of the federal poverty level. In contrast, My Health LA focuses on people who would have qualified for MediCal if they hadn't been undocumented.

Combining the direct access component with the public insurance option could help finance the New York program, Jacobs said. "In NYC Care, there could be some savings if people are currently using the public healthcare system who could be enrolled in the public option with strong outreach. That's more revenue for the system."

Moreover, he noted, ER visits declined in the San Francisco program and the same trend can be expected in New York. But he cautioned that better, more coordinated healthcare doesn't necessarily save money within the healthcare system itself if it helps people live longer. "It makes a big difference in the quality of life, work productivity, taxes paid and so on. If you're accounting entirely within the healthcare system, you don't find real savings."

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