Carrie Tracy, JD, is Senior Director of the Health Initiatives Department at the Community Service Society, where she conducts health policy analysis. Previously, Ms. Tracy conducted policy analysis on health care, immigration, and other issues at the Northwest Federation of Community Organizations. Ms. Tracy has a BSFS from Georgetown University School of Foreign Service and a JD from the University of Washington School of Law.
Healthcare cost burdens on patients in New York during the coronavirus pandemic
One common problem was insurance status. Uninsurance, was a problem for a long time that broke through. The Affordable Care Act (ACA) was amazing. It’s such a blessing for New Yorkers, and New York State implemented it to the fullest. We were able to bring our un-insurance rate down to 5% before COVID hit. A lot more people had insurance, and it was more effective.
But we still had a million people in New York who were un-insured for various reasons. One trend that had been going on long before the ACA but has continued and accelerated a little bit is that even people who have insurance have higher deductibles higher cost-sharing, high co-pays. So even if they’re insured, when they go to the doctor, they end up with bills that they might not be able to pay.
Another was hospital inequities. This was something that people on the ground had been talking about for years. But the system had kind of crept along, COVID broke it. My colleagues at CSS, wrote a report last June, examining this issue we’ve been working on health care funding for a long time. In June, after a couple of months of COVID, in New York City, we did some research. What we found was that there were these huge inequities between where the hospital beds were, and where people needed those hospital beds.
In Queens, that was the epicenter of the epicenter. At one point there were 22 cases for 1000 people, but only 1.5 beds per 1000 people living in Queens, whereas in Manhattan, people were able to work from home or leave the city entirely. There were many fewer cases. There were 12 cases per 1000 people 12 and 6.4 beds per 1000 people in Manhattan. We knew for many, many years, the resources in our healthcare system have gone to some hospitals and not to others. Part of that is our hospital funds or insurance funding.
We don’t have a single-payer system like the New York Health Act, which would pay every hospital the same amount for every episode of care, no matter who you were. Right now we have this system that’s broken up in a million different ways. For people with commercial insurance, the hospitals get paid the most for treating them, followed by Medicare and then Medicaid. Then people that are uninsured have to struggle on and try to pay themselves.
People of color and people who are low income are most likely to have Medicaid or be uninsured. We have a segregated housing system in our country. Hospitals that are located in low-income communities or communities of color, are more likely to get lower reimbursement rates.
They’re struggling to stay open. And so around the state in the last 20 or 30 years, we’ve seen how hospital closing after hospital clothing concentrated in communities of color and low-income communities.
When COVID hit, the people who were hardest hit were people who were essential workers, people who lived in crowded housing, people who couldn’t leave the city when the pandemic began. Those were the communities that also were missing hospital beds, or had under-resourced hospitals, to begin with, and had a hard time dealing with an influx of patients. That was another real crisis that we saw.
The third was medical billing. We’ve been working on medical billing for many years, all of us saw that this was an increase in crisis, more and more people were having trouble with it. But that pandemic, again, added this huge crunch to it. People were afraid to go to the hospital if they had already had a bad experience with a medical bill. They got sicker and sicker before they went. In addition, billing offices closed during the pandemic, the hospitals weren’t able to keep their billing opposite offices open. But those bills are automated. Which meant that people were getting these bills at home while losing their jobs, having to pay the bills. When they tried to call the billing office to resolve the bill or say, I don’t think this is my bill, nobody could answer the phone. So we had this increasing pressure on people.
Hospitals were quick to sue people. What we found before the pandemic was started, was that out of, 200 hospitals in the state 139 hospitals, were suing some patients, but 25 of those hospitals, were responsible for 93% of the lawsuits.
There was a median amount of $1900, for the actual hospital bills that were being sued for, but once these cases had, gotten to a judgment, people were being asked to pay $2300. If people didn’t have the money for the $1900, they weren’t going to have money for all these extra interest and court fees. In context is $1900, going to break a multibillion-dollar hospital budget, or is it going to ruin somebody’s financial future?
Also, the New York State has this indigent care pool, we’ve been working on this for many years. State and federal funding provided over a billion dollars to help hospitals that disproportionately serve folks with Medicaid or people who are uninsured, because we know that those hospitals are struggling to keep the doors open.
In New York, instead of focusing the money on those safety-net hospitals, they were giving every hospital in the state a piece of this money. What we found was that the top 10 hospitals that were suing patients got $55 million more in just one year than they reported themselves, as spending on people who they gave discounts for their care. They were getting this huge windfall of money from the state to cover people who needed financial assistance, but they weren’t processing people or giving them the financial assistance and instead they were sending them lawsuits.
When the pandemic hit in January, the billing office were closed when people lost their jobs. We were hopeful that hospitals would stopped suing. We researched it and what we found was that 55 hospitals continued to sue patients, they sued nearly 4000 people during the pandemic between March and November, they were getting billions of dollars in federal Cares Act funding. Despite all this money that was coming into the state to these hospitals, the lawsuits continued. People continue to get default judgments, which meant they either didn’t know they’d been sued, or they couldn’t afford a lawyer to help them with it.
Disparate impact of medical debt on communities of color. In several of the medical debt hotspots around the state, we saw that people of color were more likely to have these medical debt problems.In Albany County, 26% of people of color experienced medical debt problems, whereas 10% of white people in that county had that issue. Then we did a follow-up just a couple of months ago in March 2021, to look just in Albany at that hotspot to see what was happening.
Once again, there was this disparate impact by race adding factors such as wage garnishments where hospitals, were garnishing wages in some cases people worked at Walmart, in retail and food industries, even people who worked at their hospitals, sued for medical debt. Many of these things were issues that have been going on for a long time, they’ve been problems we’ve been working on, but COVID brought it out into the public more and also just really stressed people out a lot more.
Safety-net policies and resources
The first suggestion is Community Health Advocates (CHA). CHA and navigator. Call our toll-free helpline it’s 888-614-5400 because we have trained advocates on our helpline and also in every county who can help people who qualify for insurance to sign up for it. We also can help people apply for hospital financial assistance. We have experience negotiating with doctors who don’t provide financial assistance to help Bring down the debt to something that people can afford or get a payment plan.
New York State has this has since 2008, advocates fought hard to get it, the hospital financial assistance and it said that any hospital in the state that gets this indigent care funding, (which is every hospital) has to offer their patients financial assistance. This is also part of the Affordable Care Act. It also included requirements that hospitals provide financial assistance. For example, if you’re uninsured, and your income is up to 300% of poverty, you should be offered by the hospital, the ability to apply for financial assistance, or if you have insurance, but it’s not covering the service. Some people who have insurance hospitals also offer discounts on their deductibles and co-pays. Many hospitals go higher than 300%.
Every hospital in the state is required to have a financial assistance application:
It should be simple
It should be visible on their website
When you go to the hospital, they should tell you about it
It should be on all your medical bills
Every hospital in the state is required to have an application and a policy, and they’re required to put it on their website where you can find it. They’re also required to have staff who can tell you about it, there should be signs up in the hospital and waiting rooms, and in the emergency room.
In reality our experience is it’s not always that simple. Even hospitals that say that they’re covering people up to 600% of poverty, or they have policies in place, they’re not always getting the word out to everyone. Sometimes people say “I called the hospital and said, I can’t afford this bill. And they said too bad you have to pay it”. And that’s how I ended up in court. That’s a problem. And we want to get the word out to everybody.
In addition, at very beginning of the pandemic, New York State acted to have Emergency Medicaid, which covers people who are undocumented and qualify for Medicaid by income but don’t qualify for full Medicaid because of their immigration status.
Emergency Medicaid covers COVID and COVID-related services.
During this legislative session, the governor proposed and the legislature expanded on getting rid of all the premiums for the essential plan, which is part of the Affordable Care Act. It’s called the basic health plan and the ACA. For people whose income is just too high to get Medicaid, up to 200%. Anyone who gets to the essential plan right now has paid no premiums at all for basic medical care and also for also for vision and dental.
For receiving care you’ll see some small, modest cost-sharing for regular medical care, but free preventive care, just like the ACA. Every insurance policy has to offer you free preventive care under the ACA. The Essential Plan provides great coverage, call your navigator and ask about it. Also, New York has had open enrollment ever since COVID hit you’ve been able to go to the marketplace at any time and apply for insurance for the first time or renew your coverage. They’ve been automatically renewing people’s Medicaid coverage and an essential plan coverage so that people didn’t fall through the cracks and end up uninsured at all.
The Navigator Program, and requirements for qualification For every Obamacare marketplace, ours was the New York State of Health is required to fund community-based navigators. They’re community-based organizations in every county of the state that the state gives a grant and then holds training, you have to go through initial certification training to become a navigator. Every year once you’re a navigator, you have to do several pieces of training to make sure that you’re up to date on all the changes and policies and stuff. Navigators are trained and certified and they’re free. People should never have to pay a navigator. And they’re completely unbiased.
They’re not like brokers where some brokers might get a commission, depending on which insurance company they put you and navigators, it’s free and they don’t get any commissions. They’re completely unbiased. We’re not allowed to tell you which plan to pick, we can tell you the difference between plans but we can’t say you should pick this one or that one. Its very independent.
The New York Health Act
The New York Health Act (NYHA) is New York’s single-payer legislation. Under the New York Health Act, every single person in New York state would get the same insurance, regardless of their income, where they worked, everybody would have the same insurance. There wouldn’t be any premiums that would be paid for, with payroll taxes, and other sources of funding from the state. New Yorkers wouldn’t have to pay a premium every month it would be free.
It also would mean that every provider gets paid the same rate instead of some hospital, instead of instances where some hospitals get paid more or less depending on who comes in their door. NYHA would help to stabilize the healthcare system and make sure that everybody gets great quality care. It would mean that everybody in New York State, regardless of your immigration status, or your income, where you live, would have this same high-quality healthcare.
This is a program that would solve a lot of different systemic issues. The Community Service Society and Health Care For All needs your support on the New York Health Act.
The Patient Medical Debt Protection Act
In this work that we’ve done around medical billing and looking at lawsuits, we identified several problems that we saw people having. We solved a couple of things for example we shorten the statute of limitations that hospital could sue patients, from six years to three years. The fixed interest rate, the amount of interest the hospital can ask you to pay once they win a case against you in court, how much interest they can ask for is something we’re going to talk about this year.
There are other issues like getting rid of facility fees, which are fees just for walking in the door, not related to any care, that’s a new trend in billing. Right now if you go to the hospital an issue such as a heart attack you get a bill from the lab, a bill from the pharmacy, a bill from the radiologist one from the anesthesiologist, one from the emergency room and, and they just keep coming over and over again. People question themselves, I’m sure I paid this bill. But I don’t want to go to court, so I’m going to pay it again. This is confusing. We think when you go to the hospital, you should get one bill that has all of the cost on it, clearly so that you can read it and understand it. This is what we’re proposing in the Patient Medical Debt Protection Act.
Indigent Care Pool
We’re also working on the Indigent Care Pool, we think that it’s time to take another step and direct that funding to the true safety-net hospitals that serve disproportionate numbers of people who have Medicaid and are uninsured.
Hospital Financial Assistance Law
There’s still work to do on the Hospital Financial Assistance Law, like I said, the law says the hospitals have to tell people about it. But a lot of people aren’t finding out about it, there are still some parts of it that are clunky, and make it difficult for people to apply questions about whether they can look at your assets, they shouldn’t, things like that. We want to fix that up.
Three things that people can do to support policy changes
The first thing is Rate Review in 2010, New York State passed a law that said that if an insurance company wants to raise the rates from one year to the next, they have to apply to the Department of Financial Services, they have to lay out exactly why they deserve to increase your premiums this year.
In many states the health plan must provide consumers 30 days to weigh in on this decision. If you have insurance and your carrier’s trying to raise your rates, you should have gotten a letter from the insurance company saying we want to raise your rates. But you can also go to the Department of Financial Services website.
They have all the information you can just enter your own experiences and regulators at the Department of Financial Services read every one of those comments, and they consider that when they think about that. We also have information about that on the hcfany.org website.
2. A second thing is a Certificate of Need.
In many neighborhoods that are underserved already hospitals are trying to close or buy a hospital that’s not doing very well and then shut it down. Or they’ll say we’re going to close the maternity ward or the emergency room, things like that, that has a huge impact. So when they want to do that they have to go to those state bodies and ask to apply for the Certificate of Need.
They have to get permission to do that, to open a hospital or to add a new ward. What we’re saying in the Senate Bill S1451A legislation, is if a hospital wants to close the hospital, downsize, or open a new one, they should put together a statement of racial equity impact.
We want to know, if you close a hospital, where are patients going to go? Is there another hospital close enough that people can get the same quality of care that they got? If it’s a maternity ward, how are people going to get to the nearest hospital? And how is that going to affect racial disparities in the community?
This passed the assembly and the Senate, the governor has to request them to send it to him, and then he can sign it. We want to get the word to the governor that this is a really important bill, we want this signed, and then the other bill that has passed, and we want to make sure that the governor requests it.
3. The Third bill people can support, Senate Bill S3057A
Senate Bill S3057A would lower the amount of interest associated with consumer debt, which could include medical debt, education, debt, credit card debt if you don’t pay the bill, and you get sued. Once the company, has a judgment against you, right now they can charge up to 9% interest, it lowers it to 2%, which is much more reasonable.
In all of these campaigns, it’s important to ask who’s being affected? Even if it’s not the intended effect? What are the impacts of all of these policies on people and our healthcare system? Who gets access? what’s the quality of care that people get? Not just, getting care, but are they getting the care that they need? And is equitable?
Voice Your Health™, Empowered Patients and Caregivers
Tell your story. That is the most important thing people can do is get the word out. Tell other people in your community, maybe your neighbors or your family members, other people don’t know that this affects you, therefore they think this isn’t a problem. And maybe your legislators think that this isn’t an issue, maybe they think nobody, none of their voters cares about this, therefore they are not going to work on it. We need to get the word out to everybody. This is a problem. This is how it affects people.
Bill A08639A: https://nyassembly.gov/leg/?term=2019&bn=A08639
Bill No: S06757: https://nyassembly.gov/leg/?term=2019&bn=S06757
CSS REPORT FINDS THAT INDIGENT CARE POOL CONTINUES TO PROVIDE WINDFALLS TO NON SAFETY-NET HOSPITALS
Discharged Into Debt: Medical Debt and Racial Disparities in Albany County https://www.cssny.org/news/entry/discharged-into-debt-medical-debt-and-racial-disparities-in-albany-county
Emergency Medicaid in New York State – Limited Medicaid Coverage for Undocumented Immigrants
Hospital Indigent Care Pool
How Structural Inequalities in New York’s Health Care System Exacerbate Health Disparities During the COVID-19 Pandemic: A Call for Equitable Reform https://www.cssny.org/news/entry/structural-inequalities-in-new-yorks-health-care-system
Nearly one million people signed up for Obamacare coverage this spring
New Yorkers Save Billions Under the New York Health Act FAQ. https://d3n8a8pro7vhmx.cloudfront.net/pnhpnymetro/pages/7770/attachments/original/1554325127/New_Yorkers_Save_Billions_Under_the_New_York_Health_Act_FAQ.pdf?1554325127a
Patient Financial Aid Law
Senate Bill 3057A https://www.nysenate.gov/legislation/bills/2021/s3057
Community Health Advocates: https://communityhealthadvocates.org
Community Service Society: https://www.cssny.org/issues/entry/access-to-health-care
Health Care For All New York HCFANY: https://hcfany.org/about/
Navigator Directory: https://info.nystateofhealth.ny.gov/ipanavigatorsitelocations