Consumer Advocates Take on Big Insurance-PBM Alliance During Final Days of State Legislative Session

David v Goliath (Gebhard Fugel)

They’re at it again!  (Actually, do they ever stop?)

Three years ago, the State Legislature and Governor Cuomo enacted a law guaranteeing New Yorkers the right to receive our prescription drugs either by mail order delivery or from a local community pharmacy.  However, the insurance companies and their “pharmacy benefit manager” (PBM) pals have exploited a minor provision of that law to continue to deny consumers that right to choose.  Instead, insurers are forcing patients to use mail order only, especially for so-called “specialty drugs” (often arbitrary defined as anything costing more than $250 for a month’s supply.)  They’re also imposing onerous and ridiculous terms and conditions on community pharmacies in order to certify them as in-network.

Mail order works fine for many people.  It can be convenient and save money.  However, there can also be problems for people when packages don’t arrive on time, they get lost in the mail, they get left with neighbors (thereby violating patients’ privacy), or they get left on doorsteps and then are stolen, among other difficulties.  In such circumstances, patients then have to pay full cost for a replacement, which can often be hundreds or thousands of dollars.  In some cases, their health and well-being can be placed in jeopardy if they miss doses of maintenance drugs.

Many people prefer to use a local community pharmacy instead where they can pick up their medicines at a convenient time and not miss refills.  They also prefer to consult directly with a local professional pharmacist who has a record of all their medicines on file (often prescribed by different providers) to watch out for any complications and contraindications.  They prefer this option rather than have to deal with an often minimally-trained customer service agent at the end of a phone line far away who simply reads off a boilerplate script.

Why are insurers doing this?

Simple:  follow the money.  Many of the big PBMs are wholly-owned subsidiaries of insurance companies.  Others have sweetheart deals with them.  By denying us this right to choose, insurers and PBMs are cornering and gaming the market, and trying to put our local drugs stores out of business.

The good news:

There’s a bill in the State Legislature to restore our right to choose and eliminate insurers’ outrageous terms and conditions they want to impose on local drug stores.  This bill won’t drive up drug prices or insurance premiums at all, provided consumers use an in-network pharmacy.  There’s wide, bipartisan support for this bill, and it has already passed the Assembly unanimously.

The challenge:

The bill is now hung-up in the Senate because the chair of the Insurance Committee (Sen. James Seward of Oneonta) won’t let it out for a floor vote.  He’s parroting the industry’s specious claims that community pharmacists can’t be trusted to dispense specialty drugs (despite the fact that they’ve been handling them for years.)

How the Legislative Battle is Proceeding:

The insurance and PBM industry is running radio ads, putting up billboards, and placing ads in newspapers across the state, claiming that this bill will create a new “prescription drug tax”, raise insurance premiums, threaten patient safety, and undermine the mail-order drug business.  In particular, they are scaring seniors that their drug costs will go up.

In response, New Yorkers for Accessible Health Coverage (a statewide coalition of chronic illness and disability groups) has been joined by Gay Men’s Health Crisis, NYS Bleeding Disorders Coalition, the MS Society, Consumers’ Union, the Lupus Foundation, the Pharmacists Society of the State of NY, and the Coalition of Community and Chain Store Pharmacies.  Together, they are saying to state lawmakers, “Do it again, just like you did three years ago, but close the loophole this time.  Make sure New Yorkers maintain our right to choose how we get our medicines.”

The 2014 Legislative Session ends by this coming Friday, June 20.  Advocates are hoping that, given the broad support among rank-and-file Senators, Senate leadership will take the bill to the floor for a vote despite Senator Seward’s opposition.

What you can do: read our Action Alert here.

NYC Health Advocates Announce City Budget Agenda for 2014

Members of the People’s Budget Coalition for Public Health gathered for a press conference on the steps of City Hall on May 13th to respond to Mayor de Blasio’s recently-released budget for the city’s coming fiscal year and urge that the City Council build on it to address additional unmet needs of New Yorkers. They laid out broad priorities to guide the Mayor and Council as they now enter into negotiations, to be concluded by the end of June. PBC’s priorities include: community-based health planning, addressing health disparities, expanding the health care safety net, and investing in the city’s municipal hospital and public health system.

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“The Executive Budget takes many steps in the right direction, but needs to do more to address the social determinants of health and disparities; and create a health care system rooted in our neighborhoods and communities,” said Anthony Feliciano, Director of the Commission on the Public’s Health System, “A successful health care system results from a prescription that includes access, quality, services, fairness, equity, and community. If one element is missing, the prescription does not work. Over the years, too many communities have been consistently left out of planning, or left with substandard care, or no care at all. Often the factors in determining those left behind are income, race, ethnicity, immigration status, disability status, gender identity, primary language, and sexual orientation. We know the Mayor and Council understand this reality, and urge them to support some of our health priorities to address these problems.”

“We commend Mayor de Blasio and Health Commissioner Mary Bassett for prioritizing public health activities aimed at communities that have the disproportionate share of physical and mental illness and premature death,” said Esther W. Y. Lok, Assistant Director of Policy, Advocacy and Research from the Federation of Protestant Welfare Agencies. “Engaging local residents, community and faith leaders, institutions, unions, and elected officials in the planning process is essential to the expansion of public health initiatives,”

As New York State implements the Affordable Care Act (ACA) and a recently-approved $8 billion dollar Medicaid Waiver, PBC members said it is critical that the City maintains and strengthens a public health care infrastructure that ensures continuous, high quality care delivery to those who are newly-insured as well as those left uninsured. Even with the leveling benefits of federal health reform, many New Yorkers and their communities continue to face disparities in access, distribution, and coordination of health resources.

The group called for the creation of a new “Access Health NYC” program, to provide city funding to community-based organizations to help connect uninsured people to new coverage options and/or access to services.

“While New York has done very well enrolling uninsured people into new coverage options available under the Affordable Care Act, we know there are still hundreds of thousands of uninsured across our city who still haven’t done so,” said Mark Hannay, Director of the Metro New York Health Care for All Campaign. “On-the-ground community-based organizations are the key to engaging hard-to-reach populations, and they need the resources to go out there and find the still uninsured, inform them about the law, and get them enrolled in coverage, all in culturally appropriate ways. Unfortunately, the state government chose not to fund community outreach programs, so this is an important gap that our city government can fill to make sure that all New Yorkers get health insurance.”

“Collaborative and culturally appropriate outreach services that connect people with care are very important”, said Suki Terada Ports, Vice President of the Japanese American Association of New York, “In an example of historic significance, Korean and Japanese not-for-profits worked together to enable people of Japanese ancestry to obtain health insurance. Korean Community Services stepped up to the plate to help educate and enroll limited English speaking people in New York and New Jersey because neither state had arranged for a Navigator who spoke Japanese.”

“We urge the administration to remember that the Affordable Care Act left health care reform incomplete for New York City’s undocumented residents,” said Jackie Vimo, Policy Director for the New York Immigration Coalition. “New York City immigrants and their families have options that they may not know about including services through NYC’s Health and Hospitals Corporation facilities, federally qualified health centers, and Emergency Medicaid. We look forward to working with the administration to educate immigrants in New York City about services and programs that are available to them and to crafting a durable policy solution to facilitate health care access for all New York City residents.”

“We are grateful that the Mayor’s budget outlines progressive health measures. However, more needs to be done to address health inequities and disparities,” said Noilyn Abesamis-Mendoza, Health Policy Director for the Coalition for Asian American Children & Families. “Initiatives such as Access Health NYC would greatly expand health access and services to various communities in a culturally- and linguistically-competent manner, while improved community health planning will ensure that those on the receiving end of health programs have greater agency and self-determination of healthcare resources.

The group also called for budget provisions to grow public health care infrastructure from the communities it serves. They said New York’s health system must serve all New Yorkers; enabling everyone to receive high quality, accessible health care services in their own neighborhoods. PBC called for the Mayor and City Council to put forward a vision for public health that is rooted in community input, addresses health disparities facing New York’s more marginalized neighborhoods through the stabilization of the safety net, and further builds and expands the city’s current public health infrastructure and workforce.

“Being an individual who has worked in Federal, State, City and Privately-Funded Health and Human Services programs, it is glaringly obvious that there needs to be an even larger increase in local control over, and participation in, the decisions around health care resources and public health issues,” said Stephen Beasley, Program Coordinator for CAMBA/Greater Brooklyn Health Coalition.

“Thanks in large part to the inclusive approach of Mayor de Blasio toward our safety-net hospitals and the diligent work of healthcare advocates across the City, New York has the opportunity with this year’s budget to address health disparities that have long plagued struggling New Yorkers and focus on meaningful quality improvement measures that matter to our patients and communities,” said Dr. Matthews Hurley, Vice President of Doctors Council SEIU. “We are proud to stand with our partners in the People’s Budget Coalition and look forward to working with health care professionals, community members, patients and Mayor de Blasio to ensure New York City is the best provider of care to our loved ones.”

“New York Health” Advocates Converge on Albany to Promote Universal Health Care for New York

Over 200 members and allies of the “New York Health” campaign held their annual legislative advocacy day on May 6, to push for a vote on the bill in the Assembly before the end they adjourn in late June.  The bill, sponsored by Assembly Health Committee chair Richard Gottfried of the Chelsea-Hell’s Kitchen area (A. 5389A) and Senator Bill Perkins of Harlem (S. 2078A), has 72 co-sponsors in the Assembly and 18 co-sponsors in the Senate to date, and  61 organizations and trade unions have endorsed it.

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Participants in the advocacy day made over visits to 81 members of the Legislature to ask for support for the bill, and to answer questions legislators and their staff.  In particular, they pushed for Assemblymembers to sign-on to a letter to Assembly Speaker Sheldon Silver to bring the bill to the floor for a vote, and for those who’ve not yet endorsed the bill in either house to do so.

During the lunch hour, a rally was held in the park outside the Capitol that garnered significant media coverage.  In addition to Assemblymember Gottfried and Senator Perkins, speakers included Dr. Matthew Hurley from Doctors’ Council SEIU, Judy Sheridan-Gonzalez from the New York State Nurses Association, Michael Milligan, author and actor in “Mercy Killers”, a one-man show about health care in America that has toured nationally in numerous cities, and Helen Shaub from 1199 United Healthcare Workers East.

The New York Health proposal would create a fully public health insurance program covering all New York residents.  Everyone would be eligible to enroll, regardless of age, income, wealth, employment, or other status. The benefits would include comprehensive outpatient and inpatient medical care, primary and preventive care, prescription drugs, laboratory tests, rehabilitation, dentistry, vision care, and hearing care. Everyone would choose a primary care practitioner or other provider to provide care coordination who would help to get the care and follow-up the patient needs, referrals, and navigating the system.  However, there would be no “gatekeeper” obstacles to care.  Long-term-care coverage is not included at the start, but the bill requires that the Board develop a plan for it within five years of implementation.

Health coverage provided through the program would be publicly funded.  Health care would no longer be paid for by insurance companies charging premiums, deductibles and co-pays that are not set according to ability to pay. Instead, New York Health would be paid for by assessments based on ability to pay, through a progressively graduated state payroll tax (paid 80% by employers and 20% by employees, and 100% by self-employed) and a surcharge on other income and placed into a dedicated New York Health Trust Fund. The current federal funds now received by the state for Medicaid, Child Health Plus, and the Affordable Care Act could also be added in, along with Medicare funding.  A broadly representative Board of Trustees would advise the Commissioner of Health on the program.  The “local share” of Medicaid funding —a major burden on local property taxes— would be ended.

Health care providers, including those providing care coordination, would be paid in full by New York Health, with no co-pays or other charges to patients. The program would develop alternative payment methods to replace old-style fee-for-service (which rewards volume but not quality), and would negotiate rates with health care provider organizations and practitioners. (Fee-for-service would continue until new methods are phased in.)


What to Do for the “Still Uninsured”? “New York Health” Offers a Path Forward in the Longer-Term

While nearly a million New Yorkers enrolled in coverage via the state’s new “New York State of Health” health benefits exchange marketplace during the recently completed “open enrollment” period that ended on April 15 (approximately 70% of whom were formerly uninsured), that still leaves 1.5 million New Yorkers without coverage in place.  “Anytime enrollment” is still possible for adults eligible for Medicaid (up to 138% of the Federal Poverty Level (FPL), approximately $15,000 for an individual, or $42,000 for a family of four), for children living in families up to 400% FPL (approximately $92,000 for a family of four), and for individuals and families who experience a special life event that qualifies them for a 60-day “special enrollment period” (see full list at  And of course, the next general open enrollment period will begin on Nov. 15th.

What do we do about the still uninsured until then?

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In the short-term, we can refer them to the various safety net providers in our communities, such as public hospitals, community health centers, and other such entities.  And we’ll need to support those entities from any funding cuts, and ideally push to beef them up so they can adequately address the task at hand.

In the longer term of course, projections from the Congressional Budget Office when the Affordable Care Act (ACA) was enacted 4 years ago indicated that the ACA would only cover about 30+ million nationwide of the country’s 50 million uninsured.  The ACA only goes so far.

For those who get coverage under the ACA, major problems need to be addressed.  These include making the coverage much more affordable to use concerning deductibles and co-pays, particularly for those of modest income just above Medicaid eligibility, and broadening out the very narrow provider networks that many plans have, which also could include the ability to go out-of-network when needed.

All that may be well and good enough in the short term.  However, what can we do in the longer term to bring true universal health care to New York and America?  The ACA has a solution for that too.

Starting in 2017, options become available to states to “go a different way” from the ACA as long as they meet the overall coverage goals of the law.  (After all, the ACA is a floor, not a ceiling, for states.)  This opportunity offers states the possibility of moving toward fully universal insurance programs that would cover all residents.  Vermont is pursuing such an approach from the start as it implements the ACA, moving toward a public-administered, publicly-funded program under a “single-payer” approach.

The “New York Health” bill here in New York (A. 5389-A / S. 2078-A), sponsored by Assembly Health Committee chair Richard Gottfried and Senator Bill Perkins, is modeled on the Vermont approach, adapted to the specifics of our state’s insurance system.  Advocates for this bill are pushing hard to obtain additional co-sponsors for it in both houses of the Legislature, and are hoping for a one-house vote in the Assembly before the end of this year’s session in late June.


NYC Labor Officials Gather for Second “Union Healthcare Summit”; Needed Fixes to Affordable Care Act and “New York Health” Bill Main Topics of Presentations and Discussion

Following up on its successful Union Healthcare Summit in late February (see post of February 26, 2014 below), Labor Press convened a follow-up meeting to further dig into the two major topics that emerged at the first event:  provisions of the Affordable Care Act (ACA) that threaten the long-term viability of union benefit and “Taft-Hartley” funds, and moving toward a “single-payer” approach to health coverage here in New York.  Featured speakers included:  Gemma DeLeon, Executive Vice-President of the Retail, Wholesale, and Department Store Union; Ben Johnson, President of the American Federation of Teachers of Vermont; James McGee, Executive Director of the Transit Employees Health and Welfare Fund of the ATU Local in Washington, DC; and Richard Gottfried, Chair of the Health Committee in the New York State Assembly.


The event began with some framing questions posed by moderator Gene Carroll, Co-Director of the New York State AFL-CIO/Cornell Union Leadership Institute:

  • How are organized labor’s world and their industries changing with regard to health care?
  • What are the impacts of these changes on union members, the yet-to-be-organized, and beyond unions per se into the larger community and society?
  • What are the implications of these changes, and what is their trajectory?
  • How can organized labor imagine reconstituting and reasserting its power in the context of health care reform?  (For example, collective bargaining for the whole community, state, or nation.)
  • What can be done differently to meet the identified challenges?
  • How can unions better align themselves internally on health care matters, between the concerns of health and welfare funds, collective bargaining goals, political and policy positions, and rank-and-file members’ concerns?

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Mr. McGee began the formal presentations talking about his own personal education and “journey” (as he termed it) on health care issues, beginning with his days as a rank-and-file member in Pennsylvania to the present day.  He described how those crafting comprehensive health care reform legislation in Congress during 2009-10 (the product of which was the ACA) ignored looking at Taft-Hartley/multi-employer union-management health plans as a model for national reform for employment-sponsored coverage, which he characterized as a major error.  He stressed the importance of the principle of “solidarity” that these plans exemplify within a group of workers, and the concept of “pay while you work, so it’s there when you don’t.”

Mr. McGee described the ACA as simultaneously a step forward in major ways concerning new rules and requirements for insurers and plans, a step backward in other ways that undermines employment-based/related coverage, and an opportunity to be seized to reform how best to provide health care coverage to all.  In relation to union-based coverage, he asserted that the future of health care benefits no longer exclusively centered around the bargaining table, but rather within the halls of government as a new central player.  A major opportunity he identified coming out of the ACA was to move away from piecemeal fee-for-service toward other, more global methods of provider reimbursement.  He also said that the ACA offered states the ability to move toward fully-public “single-payer” universal health care systems that could be modeled on multi-employer plans.  Such a program could restore the important goals of continuity and affordability of coverage, regardless of employment circumstance, and reinforce the principle of solidarity writ large.

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Mr. Johnson discussed developments in Vermont where the state government is moving to use the ACA to establish a fully-public program covering all residents of the state starting in 2017, when federal waivers become available to states to move beyond the ACA per se.  He began by describing the political constellation that came to pass that made such progress possible, and how union and progressive political activists leveraged the opportunity during the 2010 election for governor in that state to set the stage for 2011.  They also used advances in organizing large numbers of home care and child care workers to advance the issue.

Since 2011 when the state passed general legislation committing itself to pursuing this forward-thinking approach, Mr. Johnson described labor supporters as pursuing two different organizing phases.  First up has been what he called the “inoculation” phase where leaders directly engaged their members on the issue in a frank and candid way, and discussed the possible outcomes of the eventual “legislative sausage-making” process of crafting the eventual program.  He reported how they discussed that there could, and likely would, be some changes and diminutions of coverage compared to what members currently have, to assess whether or not everyone would be on-board with the effort for the long-haul.  The response was affirmative.

The second phase he described as “make it happen”, currently underway.  During it, he said the choices for labor and their allies have been: 1) universal health care yes, 2) universal health care no, and 3) universal health care how.  He cautioned against focusing on the third path at the outset, as that merely creates fodder for opponents to use, and instead urged proponents of universal health care to keep one’s “eyes on the prize” overall.  He noted that many will want to immediately focus on the myriad policy details to be worked through, but that important as they will eventually be, doing so at the outset, beyond the broad strokes, diverts from the task at hand to build the broad public support that will be necessary to withstand propaganda and fear-tactics from opponents.

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In her remarks, Ms. DeLeon directly addressed problems organized labor has with various aspects of the ACA.  She noted that unions’ experience with the law is not monolithic, that different unions and union sectors are facing different challenges coming from it, but that all shared the overall ideal of comprehensive, affordable, and continuous coverage for all their workers and their families.  While she said the ACA is well-intentioned with many positive aspects for millions of Americans, there were also serious unintended consequences, especially for workers in low-wage jobs and industries.  She described new trends of employers shifting workers to part-time so as to avoid various aspects of the ACA, such as offering coverage altogether thereby forcing their workers to use new state health benefits exchanges where the coverage may not be as good or as affordable than what they are losing.  Other employer trends include dropping dependent coverage, instituting very high deductibles, and narrowing their provider networks.

In the immediate-term, she called for fixing, not destroying, the ACA, and to avoid inadvertently allying with right-wing forces who are out to repeal it.  In the longer-term, she said labor’s full support for a fully-public national health insurance program, while perhaps the ideal goal, would be a long, slow, and painful for organized labor because of all the uncertainties that still have to fully play out concerning the ACA, and the uncertainties of moving to this alternative.  However, she noted that under such a program, unions could still attract workers within organizing drives for representation, working conditions, and other benefits and wrap-around health coverage, as is the case in other western countries.

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The panel concluded with remarks by Assemblymember Gottfried, who represents the Chelsea and Hell’s Kitchen areas of Manhattan.  He discussed the “New York Health” bill he authored and is sponsoring with State Senator Bill Perkins, who represents Harlem.  This bill would have New York institute a fully-public universal program similar to what Vermont is pursuing.  He described the bill’s approach as one of guaranteeing comprehensive insurance coverage for all New Yorkers based on “ability to pay”.  He characterized current efforts to reform health care delivery and payment under the ACA and in other efforts by employers, other stakeholders, and state government as a mixed bag, with outcomes dependent on who designs and administers the reforms, and to whose benefit they are designed to accrue.  He said that, fundamentally, reform of any type must be publicly accountable via government.

He described the ACA as shifting the burden of health care provision onto individuals which he said actually undermines the ability of patients to control and take responsibility for their own health care.  He said that ultimately access to health care was a governmental and public responsibility, as embodied in the New York Health bill, and that it would be a much better approach for both patients and health care providers.  He also said that New York’s government, despite its flaws, has a better political climate than the national government in Washington to move forward on health care.

New York Human Service and Labor Activist Leaders Gather to Map Out Joint Efforts for 2014; “Going on the Offense” is Major Theme

Now that the state budget process has concluded for 2014 and the Easter-Passover holidays have passed, progressive political activists of various stripes gathered in Albany on April 30 to share updates and plan mutual strategies through this year.  The gathering, dubbed “Going on the Offense for an America and New York that Works for All of Us”, was jointly sponsored by the Restore the American Promise (RAP) campaign and the All of Us campaign.  Both are two statewide efforts focusing on budget advocacy at the federal and state levels as they affect health, human service, and workers’ rights issues.

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The meeting began with some background on each campaign.  RAP was launched in 2011, initially to protect major national social programs like Social Security, Medicare, Medicaid, and Food Stamps during the federal debt ceiling fight of that summer.  Since then, it has broadened its agenda to include related strategic issues such as restoring tax fairness, promoting economic recovery and job growth, and countering an overall “politics of austerity” that has dominated much of American politics since the advent of the Great Recession.  The All of Us campaign was launched in the Spring of 2013 in response to political gridlock in the New York State Senate that stopped many major progressive issues from being taken up in the final days of the legislative session.  The gridlock was attributed to special interest dominance that reflected the priorities of the wealthy elite and well-resourced corporate interests, in contrast to the needs and concerns of the vast majority of everyday New Yorkers.

Next, briefings were given on pro-active campaigns underway for 2014, both nationally and across New York, addressing Social Security, health care programs, safety net social programs, economic and income equality efforts, tax fairness, and immigration reform.  Speakers included: Eric Kingson, National Co-Director of Social Security Works; Mark Hannay, Director of the Metro New York Health Care for All Campaign; Heidi Siegfried, board member of the Hunger Action Network of New York State; Emily Goldstein, Organizer with the Alliance for a Greater New York (ALIGN); Amy DeJardins, Field Director for the New York State AFL-CIO; Bessie Schachter, Program Director of the New York State Immigrant Action Fund; and Ron Deutsch, Executive Director of New Yorkers for Fiscal Fairness.

Keynote speaker over lunch was Richard Kirsch, Senior Fellow with the Roosevelt Institute and a Senior Advisor with US Action, who spoke on “Messaging Our Campaigns Together.”  Focusing on the theme of “Works for All of Us”, he modeled how to speak to the general public, progressive base voters, and persuadable voters about seemingly disparate issues.  He combined them under broad rubrics of economy, government, democracy, and nationality.  He stressed the importance of focusing on shared values rather than spouting statistics and policy ideology, and of drawing contrasts between the larger whole vs. exclusive constituencies, and between sweetheart deals vs. common benefits and shared needs.

Following lunch, participants were briefed by Jess Wisneski (Legislative Campaigns Director for Citizen Action of New York) and Mike Kink (Executive Director of Strong Economy for All) on key Congressional and State Senate districts across New York where incumbents are crucial for moving progressive issues forward this year and next, and how things are shaping up in those districts for this fall’s midterm elections.  Important Congressional districts are on Long Island, Staten Island, the Hudson Valley, the North Country, Central New York, and the Southern Tier.  Strategic State Senate districts were identified on Long Island, in the Bronx, Brooklyn, and Queens, in the Hudson Valley, the Capital District, Central New York, Rochester, and Buffalo.  They stressed the importance of reaching out to the public in these districts to engage them on our shared values and issues, and the importance of this year’s elections since voter turnout is often lower during off-year elections.

Participants were next briefed on upcoming strategic moments and periods during the spring, summer, and fall when it will be opportune to engage lawmakers, the public, and the media.  They then broke up into regional workgroups to discuss all that had been shared in the meeting, and to begin to plan activities in their local areas.

Annual Federal Budget Process Proceeds, with Obama Proposals on the Table and House Voting Latest “Ryan Plan” Forward; Health Care Provisions are Familiar

Since the 2010 mid-term elections when control of the U.S. House of Representatives flipped from Democrats to tea party-dominated Republicans, Washington politicians have been engaged in an ongoing war over whether, when, and how best to reduce the annual federal budget deficit.  Health care programs such as Medicare, Medicaid, the State Child Health Insurance Program (SCHIP), and the Affordable Care Act (ACA) sit squarely in the middle of the struggle given their combined significance in the overall budget.

Beans and ledger

In the various pieces of deficit reduction legislation enacted since over the past 3 years (the Budget Control Act of 2011, the American Taxpayer Reduction Act of 2012, and the FY 2014 and 2015 appropriations bills enacted this past January), these health care programs have been held relatively harmless.  There have been some modest cuts in provider reimbursement rate in Medicare, and some diversions of ACA-related funding dedicated to new public health initiatives, long-term care insurance programs, and new non-profit “insurance co-ops” set-up in many states.  (Ours here in New York is “Health Republic”.)

The general annual federal budget process begins when the president releases his proposals in late winter, followed by each house of Congress developing and adopting their own one-house resolutions in the early-mid spring, which are just spending and policy blueprints without details.  Then a conference committee meets to develop an agreed-upon budget that each house then approves by late spring.  A presidential signature is not required since it is just a guidance document for going forward in the process.  Congressional leaders and administration officials then meet over the summer to hammer out specific appropriations bills based on their proposals.  Their final agreement then goes to Congress for adoption by Oct. 1st, when the federal government’s new fiscal year begins.

In his budget for the coming FY 2015, President Obama has left Medicaid, SCHIP, and the ACA largely as is, with no significant changes.  His proposals for Medicare are to reduce spending by $400B over a 10-year period through the following major initiatives:

  • Reductions in payments for prescription drugs ($136B), most of which would result from raising rebates for drugs provided to low-income people on Medicare ($116B).
  • Reductions in payments to providers ($132B), most of which would result from post-acute care services ($104B).
  • Increases in premiums, deductibles, and co-pays for upper-income beneficiaries ($64B)
  • Reductions in subsidies to private insurers who participate in the “Medicare Advantage” program ($32B)
  • Lowering the overall target annual growth rate for Medicare from GDP+1% to GDP+0.5% ($12B)

The President also proposed to end ongoing sequester cuts to Medicare.  Overall, his proposals mirror those he’s put out in previous years.

In early April, before recessing for the Easter-Passover break, the House of Representatives adopted its own budget, with the following health care provisions:

  • Repeal of the ACA, including ending funding for: 1) state Medicaid expansions; 2) premium subsidies for private plans; 3) closing the Medicare Part D coverage gap (“donut hole”); and 4) Medicare preventive services.
  • Transforming Medicaid from an entitlement program that grows to meet demand into a flat block grant to states, with weaker federal rules and oversight.
  • Folding SCHIP into Medicaid while ending SCHIP funding per se.
  • Reduction in Medicaid spending by 26% over the next 10 years ($1.5TR).
  • Transforming Medicare into a flat-rate voucher program to buy into either private insurance plan or Traditional Medicare.  It would start in 2024 for new beneficiaries, and the vouchers would be indexed to the general inflation rate (instead of medical inflation, which is typically 2-3 times higher.)
  • Raise the Medicare eligibility age from 65 to 67 over a 10-year period, starting in 2024.
  • Raising premiums for upper-income beneficiaries starting in 2019, and lower the income thresholds that trigger such them over time.
  • Sequester cuts to Medicare remain in force through 2024.

The Senate leadership has indicated they will not be developing a budget proposal this year in lieu of the budget and appropriations bills enacted in January.  Accordingly, both the President’s budget and House budget are mainly seen as campaign manifestos for this fall’s mid-term Congressional elections, and neither differ much from recent years.  Not much activity is expected in the budget process from here forward until at least the late fall.  Therefore, the next meaningful budget fight likely won’t start up until a year from now when efforts to craft a budget for FY 2016 gets underway.

The outcomes of the upcoming elections will determine who gets to put what on the table then, and what ideas (good or bad) move forward.  If “pro-health care” candidates prevail, the Affordable Care Act and its provisions improving Medicare and Medicaid will proceed, and SCHIP will continue as is.

Reference sources:  Center on Budget and Policy Priorities, Families USA, Kaiser Family Foundation

“Get Covered New York” Celebrates ACA Outreach Accomplishments

A day after all “open enrollments” finally ended in New York, participants in the “Get Covered New York” (GCNY) project gathered on the evening of April 16 to celebrate their successful outreach efforts to uninsured New Yorkers about new health care coverage options available in New York under the Affordable Care Act (ACA).   Over food and drink in a loft in Manhattan’s Chelsea district, they shared food, drink, and moving and humorous stories of their experiences over the past year.  Joining them were colleagues from similar efforts across New York City spearheaded by Enroll America and Organizing for Action.

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GCNY was launched in the spring of 2013 as a joint initiative between New York City-based organizations active in the leadership of Health Care for All New York, and community-based activist groups affiliated with Greater NYC for Change.  The project’s goals have been to educate the public about new ACA-authorized plans available to New Yorkers, and outreach to the uninsured in community settings and directing them to various in-person assistors to help them get enrolled in coverage.

Initially, GCNY set up a simple website and developed basic educational and outreach materials.  They next trained over 120 volunteers on the basics of ACA coverage who then hit the streets over the course of the summer and fall of 2013, showing up across the city at street fairs, church socials, community festivals, soup kitchens, food pantries, health fairs, concerts in parks, and the like – over 80 events in total, many in neighborhoods with high rates of uninsured.  They collected contact information from uninsured people as they went, compiling them into a database of over 4,000 names.  Once open enrollment began on October 1st, they began to contact these people back via weekly phone banks and email reminders, leading to over 1,500 phone conversations alone.  They not only urged people to get enrolled, they also collected personal stories from some, comparing the “anxious before” and “relieved after.”  Many who were called said they very much appreciated the tenacity of GCNY volunteers, and the help and encouragement they provided.

According to the New York State Dept. of Health, over 960,000 New Yorkers statewide have now enrolled in health plans, approximately 70% of them being previously uninsured.  GCNY participants took some well-deserved credit for a portion of those numbers.  They vowed to next shift their outreach efforts to target low-income people who can still sign-up for Medicaid, as well as small business owners and operators who can continue to enroll their employees into coverage.

Health Care Advocates and Union Leaders Meet with City Council Staff to Promote Budget Recommendations

It’s a whole new day (and government) in New York City in 2014!  With a new Mayor, Public Advocate, Comptroller, Council Speaker, and 21 Council Members, most of whom are proudly self-proclaimed political progressives, hopes are running high that significant strides can be made to enhance access to health care coverage and services and address outstanding public health problems.

PBC meeting wtih Council staff 4--8-14 002

Gathering together under the umbrella of the People’s Budget Coalition for Public Health (PBC), an effort spearheaded by the Commission on the Public’s Health System and the Federation for Protestant Welfare Agencies, a diverse range of health care advocates and their union partners have joined forces to craft a proactive budget agenda which they are sharing with City Hall officials and their staffs with an eye toward influencing their initial budget proposals.  This approach differs from previous years when they usually had to wait for budget proposals to come out before acting in response.

On April 8, PBC members met with City Council central staff for the Health and Finance Committees, and staff for Council Health Committee chair Corey Johnson.  Participating groups included the Center for Independence of the Disabled-NY, Children’s Defense Fund of NY, Choices in Childbirth, Coalition for Asian-American Children and Families, Commission on the Public’s Health System, District Council 37 AFSCME, Doctors’ Council SEIU, Federation of Protestant Welfare Agencies, Greater Brooklyn Health Coalition, Local 420 DC 37 AFSCME, Manhattan-Staten Island Area Health Education Center, Metro NY Health Care for All Campaign, NY Immigration Coalition, and the NYS Nurses Association.

The group laid out overall priorities of:

  • Increasing democratic control over and community participation in decisions concerning health care resources and public health measures
  • Developing preventive health programs that educate and empower local communities in self-care
  • Addressing disparities in health, health care, and insurance coverage for racial and ethnic minorities, immigrants, women, children and youth, seniors, people with disabilities, and LGBT people.
  • Preserving and expanding the health care safety net, particularly the NYC Health and Hospitals Corporation (HHC)
  • Expanding primary care and dental care services
  • Addressing the crisis of hospital closures

They also proposed new programs focusing on women of child-bearing age, workforce diversity, community health planning, and community-based outreach to the uninsured to help them access services and enroll in coverage.

Mayor De Blasio released his preliminary budget proposals for FY 2105 back in February.  Various Council committees held hearings on it during March.  City Council staff indicated the Council would be releasing its formal response in late April.  The Mayor’s final budget proposal is due out in early May.  The Council will then hold a second round of hearings before undertaking negotiations with the Mayor in June, with the goal of reaching an agreement by July 1st when the new fiscal year begins.

Enrollments in New Coverage Options under the Affordable Care Act Swell Beyond Expectations, and Uninsurance Rates Drop Dramatically

Everyone expected a last-minute rush to enroll in new health insurance plans created under the Affordable Care Act as the 2014 deadline for “open enrollment” approached on March 31st.  In the end, many are amazed at the preliminary numbers as they continue to roll in.  Kudos go out to all who helped outreach to the public and who helped uninsured people enroll!

Waiting in Line

In New York, over 900,000 people have so far enrolled in either Medicaid, Child Health Plus (CHP), or new, private “Qualified Health Plans” (QHPs) through the state’s new health benefits exchange marketplace known as “New York State of Health” (NYSoH).  Approximately another 350,000 or more people remain certified to enroll but haven’t yet completed the process, and they have until April 15th to do so.  Of the enrollees, over 70% were previously uninsured.  Slightly more than half qualified for public insurance programs like Medicaid and Child Health Plus, with the balance enrolling in QHPs.  No details are yet known about how many qualified for premium subsidies and cost-sharing reductions for QHP coverage, but previous estimates were in the 70-80%  range.

The New York State Dept. of Health has estimated that between 1.6-1.8 million people would enroll in coverage by 2016, so the state is already more than half-way toward it’s goal.  With two more open enrollment periods ahead in the fall of 2014 and fall of 2015, officials are very optimistic going forward.  The state is expected to release more specific demographic data on 2014 enrollees later this month.  Data is still not known about those who enrolled in new health plans outside of the NYSoH exchange marketplace.

Nationally, the Obama administration announced on March 31 that 7.1 million people had enrolled in QHPs through exchange marketplaces, which exceeded their target for 2014.  Since then, two studies have come out expanding on these numbers.  On April 7, Gallup-Healthways Well-Being Index released survey results that the national uninsurance rate fell from 18.0% in Sept. of last year to 14.5% in late March.  Rates fell most dramatically among African-Americans (20.9% to 17.6%), and low-income households making less than $36,000 annual income (30.7% to 27.5%).  On April 9, a survey by Rand American Life Panel estimated a net gain of 9.3 million Americans gaining health coverage as of mid-March, clocking the drop in uninsurance from 20.5% to 15.8%.

While enrollment into private QHPs is now over for 2014, the numbers will continue to rise for the rest of the year because “anytime enrollment” is still possible through NYSoH for those who qualify for Medicaid and CHP, and for small employers (50 or less full-time equivalent employees.)  In addition, individuals and families who may experience a qualifying life event such as marriage/divorce, loss/change of job, relocation to a new state or region, etc. will qualify for a 60-day “special enrollment period” into either a QHP, Medicaid, or CHP.  Further information on these options is available from the NYSoH website and Call Center (855-355-5777), or from the state’s designated consumer assistance program, Community Health Advocates (888-614-5400).