New York tries to cover 1 million residents in ambitious public and private initiatives

What one national observer describes as "a stealth piece of legislation," quietly adopted by the New York legislature and signed by Gov. George Pataki just before the end of 1999, outlines a bold and ambitious plan to bring health insurance to an estimated 1 million people currently uninsured.

The price tag for three new programs is $1.2 billion in county, state, and federal funds over the next 3½ years and $900 million per year when fully implemented.

"The fact that they think they can cover 1 million uninsured is very interesting," says Trish Riley, executive director of the National Academy for State Health Policy. "And there are some features like the stop-loss for direct pay consumers that we haven’t seen tried before. As with any new program, the devil will be in the details."

In many respects, details of the new initiatives still are to be worked out this year in anticipation of a Jan. 1, 2001, launch. But broad outlines are available.

The biggest of three new programs will be Family Health Plus (FHP), a Medicaid expansion modeled after the current Child Health Plus (CHP). The program is designed to provide comprehensive health insurance at no cost to low-income uninsured adults, according to an analysis by Rima Cohen, vice president for insurance options development of the Greater New York Hospital Association in New York City.

The program is targeted at the working poor whose jobs don’t provide health insurance but provide too high an income to meet conventional Medicaid eligibility.

To qualify for FHP, people will have to be 19 to 65 and ineligible for Medicaid. Those with dependent children may earn up to 150% of the poverty level; those with no dependent children may earn up to 100% of the poverty level. In addition, eligibility is extended to those who meet Medicaid’s definition of a "qualified immigrant," covering most legal immigrants who arrived in the United States before 1996. Immigrants who arrived after 1996 and have lived in this country for at least five years will be eligible.

Federal, state, county funding

Implementation will be in stages. At full implementation in Oct. 1, 2002, the program will cover an estimated 600,000 adults. The anticipated income caps will be $8,300 for an individual and $25,500 for a family of four.

FHP will provide a comprehensive benefits package, established in the law, through managed care plans that contract with the state to offer the program.

Benefits are similar to those offered by CHP, and include inpatient and outpatient hospital care, physician services, lab tests, X-rays, prescription drugs, durable medical equipment, radiation therapy, ambulance and emergency department care, and routine, preventive, and emergency dental, vision, and hearing services.

Funding to pay for FHP is supposed to be divided, with counties and the state each paying 25% and the federal government paying 50% in matching funds. Initially, there had not been much public outcry from the counties, says Ms. Cohen. "The counties know they have a lot of uninsured, but they’d always prefer if someone else pays the bill."

Who picks up the check?

Toward the end of January, however, the counties’ discontent boiled over as Republican members of the General Assembly joined Democrats in saying the state should cover all of local governments’ costs as well as its own.

Senate Majority Leader Joseph L. Bruno said the state could afford to pay the entire share because of a projected budget surplus this year of at least $1 billion. When the Pataki administration reacted coolly to the proposal, even suggesting that the governor would call for cuts in programs important to the legislature to pay for the plan, the stage seemed to be set for the first fight over the new health care package.

Ms. Cohen says enrollment details are still to be developed for the 2001 launch — assuming timely federal approval of the matching funds request. But the state made a commitment to a simple enrollment process that focuses on community-based enrollment, attempting to avoid some of the criticisms that have been voiced over the enrollment problems in the Medicaid managed care rollout in New York City.

Communities get involved

Individuals will be able to sign up through providers, many community-based organizations, and district social service agencies.

Recertification will be conducted annually. Unlike Medicaid, there will be no resources test, and the community-based organizations and providers will be able to conduct enrollment interviews. Funds were identified in the law for an extensive outreach, marketing, and enrollment assistance campaign.

Strength in designing program

New York historically has been better at designing programs than at getting people to enroll in them, says James Fossett, associate professor of public administration and policy at the State University of New York in Albany.

"This is going to be a difficult program to implement," he says, "especially with the new populations. It’s hard to know how to find the families you’re looking for and get them eligible. Another problem is just the scale of the thing.

"Some other states have tried to bring families in, but New York has three times as many people eligible. And they just don’t have a sparkling track record. The logistical problems should not be underestimated," says Mr. Fossett.

Contact Ms. Riley at (207) 874-6524, Mr. Brecher at (212) 998-7449, Mr. Fossett at (518) 443-5846, and Ms. Cohen at (212) 246-7100.