Title: What Options for Essential Plan Coverage?

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Amina Srna: It's The Brian Lehrer Show. I'm producer Amina Srna, filling in for Brian today. Let's talk now about another sticking point in the New York State budget negotiations. On April 1st, some 450,000 New Yorkers were sent notices that they would no longer be eligible for zero-premium health insurance coverage through the state program called the Essential Plan. That will start July 1st. This was brought on by what's called the One Big Beautiful Act, or H.R. 1, passed by Congress last summer. There are proposals for mitigating these changes as part of the state budget, but no agreement on that yet.

To talk about what federal bill changed and how the state is responding, we're joined by my colleague Caroline Lewis, healthcare reporter for WNYC and Gothamist, and by Elisabeth Benjamin, vice president of health initiatives at the Community Service Society and co-founder of the Health Care for All New York campaign, who issued a final report offering some options for expanded eligibility and helped craft one of the proposals under consideration in the legislature. Welcome back to the show, Caroline Lewis and Elisabeth Benjamin.

Caroline Lewis: Awesome. Thanks for having us.

Amina Srna: All right. Let's start with who's currently eligible for the Essential Plan. Elisabeth, you want to take that one?

Elisabeth Benjamin: Sure. The Essential Plan covers all immigrants who are ineligible for federal Medicaid funding and advanced premium tax credit funding, as well as citizens with incomes-- That's up to 250% of the federal poverty level. It's also available to citizens who are ineligible for Medicaid, so that's between 138% and 250% of poverty. The bottom line is that people who earn up to $39,000 a year, who are ineligible for federal Medicaid, can enroll in the Essential Plan.

Amina Srna: Elisabeth, how many people are currently enrolled?

Elisabeth Benjamin: Currently, there is around 1.7 million people enrolled, and that is expected to decline by around 0.5 million people starting July 1st, and then on January 1st, a small tranche of people will become ineligible. Lawful immigrants, like asylees and refugees, will be ineligible for tax credits, financial assistance, if you will, to purchase coverage on the marketplace. The fix that's before Albany is to protect two groups of legal immigrants who currently are eligible for coverage but will no longer be eligible, and about 80% of the whole population is also citizens who are going to lose financial eligibility because the Essential Plan is going to go back down to having an income cap of around $30,000 a year.

Amina Srna: Caroline, the Essential Plan is for people who make too much money to qualify for Medicaid but who would still struggle to purchase insurance on the state insurance marketplace and don't get insurance through their jobs. Is that right?

Caroline Lewis: Yes, exactly. Like Elizabeth said, there's some people who are on there because they have a certain immigration status that might prevent them from getting traditional Medicaid. I think that a lot of the people on there are people who are earning too much to qualify for Medicaid but would struggle to purchase insurance on the marketplace, like you said. Now there's going to be a lot of cuts to this health plan that has become very popular in New York. Those are some of the people who are going to be affected.

Amina Srna: Listeners, are you one of the New Yorkers facing being dropped from the Essential Plan? Those notices, as we've been talking about, went out at the beginning of this month. Did you receive one? What are your alternatives for health insurance? Have you come up with a plan? Call or text us at 212-433-WNYC, that's 212-433-9692. The state's proposal for dealing with the federal cut in funding is to cap the threshold for the Essential Plan at 200% of the poverty rate. Elisabeth, that leaves 450,000 people across the state no longer eligible. Is that right?

Elisabeth Benjamin: That's right. People making $31,000 a year and $39,000 a year who currently have coverage are now going to be thrown off the Essential Plan. I just want to mention how much it would cost for them to buy a Marketplace plan. They'd have to come up with as much as $250 a month for the privilege of purchasing a plan that has a $2,500-plus deductible.

Someone making $32,000 a year would be expected to pay $5,500 before being able to physically use their health insurance plan for anything besides their annual physical. It's just not a value proposition for someone making $32,000 a year. They can't afford those premiums, even with the now meager financial assistance, because, of course, the Congress did not renew the enhanced premium assistance tax credits by December 31st. The financial assistance is much skimpier than it used to be.

Amina Srna: Caroline, it might be a little or maybe a lot in the weeds, but what did that big H.R. 1 bill actually cut?

Caroline Lewis: We should take a step back. Last July, this H.R. 1 came out, this big spending bill, and it basically said the federal government is no longer going to fund health insurance coverage for certain groups of legally present immigrants. Those groups make up a significant share of the people on the Essential Plan, and so it would mean that we're losing $7.5 billion in federal funding for this program, or about half of the funding for the Essential Plan.

The state said we can either shut the Essential Plan down altogether and just provide state-funded coverage for just the groups we legally absolutely have to cover, or we can try to revert back to a previous version of the program with a lower income limit, which would also allow us to access this trust fund that was attached to the program. We did ultimately get federal approval to do that.

That is what Governor Hochul has framed as the best-case scenario: that we are preserving coverage for most of the people on here just by lowering the income limit, but that best-case scenario that the governor has laid out still leaves, like we said, almost 0.5 million people without coverage because now they're going to be making too much money to qualify.

Amina Srna: Elisabeth, what would it cost the state to keep things as they are now and to pick up the full cost?

Elisabeth Benjamin: There's policy choices. For this fiscal year, we can offer coverage to people for a premium of $50 a month, which is quite reasonable at these income levels, and cover the legal immigrants that we were discussing, who are ineligible for everything. These are people who are like dreamers, refugees, asylees. We can do all that for $393 million.

That's in this fiscal year, as little as that. Or we could continue the free coverage, keeping it exactly the same in this fiscal year for $1.5 billion.

Those sound like big numbers, but the governor, with a great foresight, put $2.4 billion aside in case the basic in her budget proposal, in case the federal approval didn't come through for preserving coverage at the lower income cut, but that approval came through. I guess our point is, what else are you going to do with that $2.4 billion that should be put into a coverage lockbox? They even allocated $3 billion in the out years. We can keep these people have really good and viable options on coverage for as little as about $400 million a year in this fiscal year, because this is like a three-quarters issue, and then in the next out years at $600 and around $650 million.

We think this is a really reasonable proposal and are delighted that all but 2 of the Democratic members of the New York State Senate have signed on and co-sponsored this proposal, and 40 members of the Assembly likewise have co-sponsored the proposal. There's incredible appetite to keep people and maintain people in coverage. I don't think anyone wants to see 0.5 million people lose coverage when healthcare is the number one affordability problem for New Yorkers.

Amina Srna: Caroline, before we move into some alternatives on the table, in your Gothamist article earlier this month, you quoted the governor as saying in a statement, "From the beginning, I sounded the alarm about the devastating impact H.R. 1 would have on our hospitals and healthcare system and made clear that no state can fully backfill cuts this severe." Can you parse that for us? Does she not see fully funding it as an option?

Caroline Lewis: I think she's been saying that from the beginning, as we've seen a lot of federal healthcare cuts on the table. Even when it comes to imposing work requirements for Medicaid, which is coming next year, we're going to be seeing a lot of federal healthcare cuts. I think she wanted to level set and say, "Don't expect us to fill in all the gaps. That's not possible." She still has not committed to fill in the gaps for the Essential Plan. She might still decide to do that, but I feel like her baseline is, "Don't assume that we're going to be able to fill in all these cuts."

Amina Srna: This is The Brian Lehrer Show on WNYC. I'm producer Amina Srna, filling in for Brian today. We're talking about the eligibility changes to New York State's Essential Plan for health insurance coverage sparked by H.R. 1, a.k.a. the Republicans' One Big Beautiful Act, with WNYC and Gothamist reporter Caroline Lewis and with Elisabeth Benjamin, co-founder of the Health Care for All New York campaign at CSS. Let's take a call. Amber in Brooklyn, you're on WNYC. Hi, Amber.

Amber: Hi. Thanks for taking my call, and thanks so much for doing this segment. I got this notice in the mail. I'm on the Essential Plan for New York State. I'm a 51-year-old woman, and I work 37 hours a week, and I make over the 200% of the national poverty line. That's what the notice said. If you make 200% more than the national poverty line, which is about $15,600, then you're not going to be eligible for this plan anymore.

I just want to point out that to have the privilege of having this Essential Plan, it's taking me three and a half weeks to even find a doctor that takes my insurance. Even if you have it, it's incredibly hard to actually find care. Imagining having to pay for this out of pocket, it just wouldn't be possible. As I'm getting a little bit older, these are things that I'm really worrying about. I'm looking for a job. I've been looking for a job in my field for over two years now. Can't find anything. It's really frightening. If anybody's voting on what to do with the Essential Plan, I suggest that they be on it for about a year and see how it feels.

Amina Srna: Amber, thank you so much for your call and sharing your story with us. Caroline, is that reflective of a lot of what you're hearing of people who are getting dropped?

Caroline Lewis: I think it probably depends on, you know, what type of care you're looking for, whether you can easily find doctors who take it. From what I've heard from some people on the Essential Plan is that they feel like it's really good coverage for the most part. I think the idea that you have minimal copays when you go to the doctor and that you're paying nothing out of pocket each month is really extraordinary in the current insurance marketplace.

I definitely hear from people who have different employment situations. A lot of people might be gig workers or freelancers or have different types of employment where they are employed, but they just are not able to access employer insurance or their income's a little less predictable. I think for those people, this idea of now having to purchase coverage on the marketplace is really daunting, and people are questioning, "Do I manage other expenses in a different way and try to do it, or am I going to go uninsured?"

Amina Srna: Let's go to another caller who is also being dropped from the Essential Plan. Alison in Manhattan, you're on WNYC. Hi, Alison.

Alison: Hi. Again, thank you, as the last caller said, for doing the segment. I'm a 63-year-old woman, gig worker, and the Essential Plan, exactly as your guest had just said, for me has been wonderful. I've had terrific. My doctor was on it. Everything through Weill Cornell. It really has been a godsend to me, and I'm panicking now. What am I going to do?

Amina Srna: Alison, thank you so much for sharing your story with us. I'm sorry to hear what you're going through. Elisabeth, you wanted to give out a number for people who need a little bit of help. Do you have that at your fingertips?

Elisabeth Benjamin: I sure do. I have it memorized, in fact. For the first caller, if they're having a hard time finding a doctor, definitely give us a call. We're at 888-614-5400. Then for anybody who's in this predicament, first of all, I would say call the three leaders on our Health Care for All New York campaign website. There's a policy priority tab, and one of it says "protecting health coverage." There's a thing, a call to action link, where it will just direct you straight through to the three leaders' phone numbers.

You can make a call today and then tell them that this fix must be in our state budget. If we can't get this fixed in the state budget, and we really are going to go down the road of throwing 0.5 million people out of coverage, and you want help trying to find an affordable health plan, you can call that same number, 888-614-5400. The plan selections will open on May 16th if the legislature and the governor do not fix this problem.

I'm not giving up. Make a call today. Call Speaker Heastie. He's out of the Bronx. Call the majority leader, Andrea Stewart-Cousins, if you live in Westchester, and call the governor. These are our three leaders, and they can save coverage for 0.5 million people by enacting the bills that are really, really popular in both the state assembly and Senate.

Amina Srna: To that point, we're getting several callers who are texting about the popularity of the Essential Plan, who are disagreeing with the first caller, or I guess had a different experience than the first caller, saying that they love their Essential Plan and hoping that something will be done to preserve it.

Elisabeth Benjamin: Most people do. I think the first caller just maybe didn't pick-- There's 12 plans to choose from, and not all plans are created equal. That's why it's really helpful to use one of our navigators that can make sure that your doctor is in network or the hospital you want to use or the prescription drug formulary that you need is all in network.

Enrolling into health insurance is not for the faint of heart. That's why we have in-person assisters called navigators. We're really fortunate in New York State that we have a robust health insurance enrollment network called navigators. 888-614-5400, but please, please think about calling the governor, calling Majority Leader Stewart-Cousins, and Speaker Heastie. We can save this program. We really can.

Amina Srna: Elisabeth, another question, I think, maybe for you. "Is the income test for people on the Essential Plan based on income from this year?" I will still qualify through most of this year, beyond July, but I wanted to know if I can just show my W-2 forms from my employers, or if that is tracked automatically. Do you have an answer for that?

Elisabeth Benjamin: Yes. This is what's so cool about our New York State of Health website is that it will do income verification. If you go to a navigator, especially for gig workers, because they often have multiple W-2s and any income data, the enrollment is based on what you think your best guess is for your income for the current year. If you guess wrong, right now, there's no penalty for guessing wrong.

No one actually, especially with gig workers, can forecast if they're going to have a big job mid-year or not. Typically, the marketplace looks at your last year's income. It does do Department of Labor matches, so it can kind of tell what you've done in the first quarter of this year. It's a very elegant system. If, say, you had a job for the first quarter, but you're not going to have for the second quarter, with your navigator, you can make the case that, "No, I'm still income eligible for this insurance product."

Amina Srna: Elisabeth, let's talk about some of the other alternatives, including going from $0 premium to $50 a month. What are those numbers like?

Elisabeth Benjamin: We estimate that if the 444,000 people that are going to lose coverage on July 1st were offered the same product, so no deductible, really low-cost sharing, with a $50 premium, we think about 25% of the population would be able to do that. Some people just won't be able to do it at all. That means we can basically cover 134,000 people for $393 million this year.

If we do free coverage, it's going to be more expensive. To cover all 465,000 people that are losing eligibility, it'd be $1.5 billion a year. All of that is doable, given that the governor and the Division of Budget put $2.4 billion in this fiscal year and $3 billion in the out years to make up for the One Big Beautiful Bill losses to keep people covered. I think it's just extremely important to know that we can fix this, we can afford this fix, and please make those calls.

Amina Srna: Another option I see is to cut the amount doctors and hospitals are reimbursed for healthcare back to the same levels as for Medicaid. What does that do?

Elisabeth Benjamin: That's actually not the proposal. It would be to pay the health plans and the doctors and hospitals 125% of Medicaid, which is like the Medicare rate. That's a fair rate. My numbers are making those calculations assuming we ran our Essential Plan program for the first five, eight years of the program with those reimbursement rates for the health insurance companies, 125% of Medicaid. That's how we were very prudent and able to build up that huge trust fund that we're now going to be able to access.

I think our paper kind of toggles the rate. We say, "Well, what if we offered to go back to baseline and do 125% of Medicaid or the Medicare rate? What if we do 150% of Medicaid? What if we go all the way up to 220% of Medicaid?" Right now, we've doubled the amount that we're spending on health insurance premiums for the Essential Plan, basically, to support and strengthen our healthcare industry, both the insurance companies and the provider rates, but we don't have to.

We run a 6 million-person Medicaid program at the Medicaid rates, already lower than 125% of Medicaid. I'm not saying it's the best rate in the world, but it's certainly doable, and of course, the Medicare rate, which is equivalent to 125% of Medicaid, is doable. That's why the federal government sets the rates.

Amina Srna: In the introduction of this interview, Elisabeth, I mentioned that you helped to draft one of those options. Which one did you draft and why?

Elisabeth Benjamin: What we did in our paper is set out a list of policy options. I think most of the policy options that are being considered, you could cut the insurance premium rates that are paid to the carriers, which obviously are quite wealthy, down to 125%, and then you can toggle it up to 220% of Medicaid. I think it's really for policymakers to decide how much they want to pay the healthcare industry.

If their bottom line is, we must keep it at these top dollar premiums of 220%of Medicaid, and that means we can't afford this, and so we're going to throw 0.5 million people off of coverage, I think that's the wrong policy choice. I think we can definitely afford it if we play around with these health insurance premiums that are paid to the carriers and to providers. You want to know the numbers, we can tell you the numbers at every single reimbursement rate option. We model five different rate settings. It's all about how you set prices, which is an important policy lever. We just need to understand it and make these choices.

Amina Srna: Oh.

Elisabeth Benjamin: Go ahead, please, Caroline?

Caroline Lewis: I was just going to jump in and say I think in general, we are expecting a lot of people to lose insurance coverage because of federal cuts. Even if we don't have people losing coverage because of the Essential Plan, we're expecting people to lose coverage once the federal Medicaid work requirements go into effect. All of that also pulls funding from healthcare providers.

When you're uninsured, you're either not going to the hospital, or you're going, and you don't have a way to pay for it. I think ultimately that also pulls funding from hospitals, and they would be advocating for the state to fill in those gaps. I feel like if you can put that funding back into play and also insure people and prevent them from losing coverage, I think that puts it into perspective.

Elisabeth Benjamin: Caroline says it so well. It's what I call a win, win, win. If we keep the Essential Plan, health plans get money for their members. Hospitals and doctors get money for seeing people as opposed to just having uncompensated care. The government saves the day for 0.5 million people and has already done so for 1.3 million people. We're so grateful for that. Patients get to keep being able to see doctors. These are just policy choices, and we really hope our state policymakers make the right one and save this plan.

Amina Srna: Elisabeth, did the end of the ACA subsidies play into these decisions?

Elisabeth Benjamin: They didn't exactly. They got cut radically. The Faustian bargain that was originally crafted in 2010, because the Democrats were going by the rules, which the Republican budget makers don't really follow, which is that you have to pay for any kind of new spending. They made the subsidies not as generous as they could be. While the ACA really improved New York state's individual marketplace, when we enacted the ACA, there was only 19,000 people that could afford $1,000 a month to pay for coverage. Now we have 206,000 people in that marketplace.

Earlier, when we had these enhanced premium tax credits, which unfortunately Congress let expire in the first budget shutdown, that was what the fight was all about in the fall. They got their vote, but unfortunately, the vote failed. We basically have really radically cut those ACA subsidies back down. They were expanded during the COVID period. They were called enhanced premium tax credits, and those enhanced premium tax credits went away. They were quite beneficial for people. People basically have to pay almost twice as much out of pocket.

Amina Srna: We're getting a lot of calls and texts about the New York Health Act. Let's take one caller to represent a few of those people. We have former State Assemblymember Richard Gottfried on the line. Hi, Former Assembly Member. We only have about 30 seconds for you. I'm so sorry, but I bet you could do it real fast.

Richard Gottfried: Good morning. What Elisabeth Benjamin is proposing is really essential, pardon the pun, to fill the gap for the next couple of years. What we really need is the New York Health Act, which would produce permanent coverage for every New Yorker, funded not by taking money away from other state programs, but basically by using the savings, the tens of billions in savings we get by taking insurance companies out of the picture.

Amina Srna: Thank you so much for your call. Caroline, is the New York Health Act in play at all?

Caroline Lewis: Not really. I would say the New York Health Act is basically the state version of universal insurance, and so it would be like the New York version of Medicare for All. I think that there's been a resurgence in interest because of these federal cuts, absolutely, that has made people feel like this is more urgent, including some people who were not previously involved in advocating for insurance at all, people who are just seeing that this is happening and saying, "What's the solution?" There's a resurgence of interest, but I think in the past, there's been some feeling that this isn't necessarily doable at the state level. I don't know how true that is, but I think it would take a big leap to get there.

Amina Srna: Elisabeth, final question to you. A listener asks, "Please give the way to call the governor again."

Elisabeth Benjamin: Oh, sure. You go onto the World Wide Web and go to Health Care for All New York campaign website. On that website, there is a dropdown that says "policy priorities," and there's a tab that says "protecting health coverage." You can just click on that, and it has a link, and it'll place the calls for you. It has a little script that you can say. It makes it so easy. All you have to do is click on that, and you're off to the races.

Please, please, thank you for asking about it. We can save this. I just really feel we can do this if we all put our minds together. As Assemblymember Gottfried said, this is an important fix for the next couple of years, but at the end of the day, we really have to rethink how we're running our healthcare system because it isn't working for people.

Amina Srna: Elisabeth Benjamin is vice president of health initiatives at the Community Service Society and co-founder of the Health Care for All New York campaign, who is advocating for expanding coverage. Caroline Lewis is my colleague in the WNYC and Gothamist newsroom, health reporter for us here. Thank you both so much.

Caroline Lewis: Thanks.

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