New York City Mayor Bill de Blasio speaking at Lincoln Hospital.
New York City Mayor Bill de Blasio speaking at Lincoln Hospital in the South Bronx on Tuesday. Shannon Stapleton/Reuters

Bill de Blasio’s new “health care for all” plan targets the national fight over universal coverage and immigration. But what is the plan, exactly?

All New York City residents, regardless of immigration status, will be eligible for comprehensive health care starting this summer, New York City Mayor Bill de Blasio announced Tuesday morning.

“Health care is a human right,” said de Blasio at a news conference at Lincoln Hospital in the South Bronx. “In this city we’re going to make that a reality.”

The move positions the city as a leader in the national fight over universal health coverage. But is it, really? And what is this plan, exactly? Below, we break it down.

Who would this affect?

Some 8 million New York City residents—the vast majority—are covered by some form of health insurance. This is thanks in part to the Affordable Care Act and NYC’s enrollment efforts, which according to the mayor’s office has shrunk the uninsured rate in New York City to half its 2013 size. Another half a million residents are covered by the city’s existing public health insurance plan, called MetroPlus, which provides free or affordable insurance for residents on Medicaid, Medicare, or who purchase private insurance.

But there are still 600,000 New Yorkers who go uninsured.

Some of them are “young invincibles,” as de Blasio described them on Morning Joe: Low- or middle-income people who think they don’t need health insurance—until they do. Others are people who can’t afford the minimum payments for MetroPlus, or simply don’t know how to access it.

More than half are undocumented immigrants who are not eligible for any of the existing affordable health insurance options. According to an Immigrant Health Task Force Report commissioned for the city in 2015, 63.9 percent of the 540,000-person-strong undocumented NYC population—or 345,000—were uninsured in 2013, and the greatest concentration of uninsured non-citizens live in parts of Queens and Brooklyn.

So are all these people going to get free health insurance?

Not exactly. The plan doesn’t guarantee an insurance plan for all New Yorkers, but it will create some new options to subsidize health coverage for those 600,000 New York City residents without insurance plans, which, according to NYC, will effectively guarantee basic, universal care.

In many ways, the city’s existing Metroplus program was originally designed to do something similar. But it left a few gaps. That’s why part one of de Blasio’s new plan involves strengthening the existing system, by “doubling down” on MetroPlus enrollment outreach, and simplifying customer service. The “young invincibles,” he hopes, will be inspired to come forward; along with anyone else too intimidated to apply.

Some critics have panned this MetroPlus expansion announcement as more about political grandstanding than real revolution.

“Again, [the] city does this already,” wrote Gloria Pazmino, a reporter for Politico NY, on Twitter.

But while MetroPlus is offered to most New Yorkers, it isn’t—and can’t be—accessed by all, including undocumented immigrants and other insurance-ineligible populations.

That’s the population the second prong of the city’s program is meant to serve: The uninsured New Yorkers who are eligible for insurance but who can’t afford a Metroplus plan, and those who are ineligible because they are undocumented.

Dubbed NYC Care, the program, which is unprecedented in scope, will connect anyone without an affordable insurance option in the city with comprehensive care across all NYC Health + Hospitals’ locations. “Like the existing MetroPlus public option, people would need to sign up first to get set up,” a spokesperson for the mayor’s office told CityLab. They’ll be able to do that easily, on the city’s website, or by calling 311.

Once enrolled, NYC Care will offer the same services as Metroplus, like access to primary care physicians, specialty care, and OB-GYNs. The program also emphasizes access to mental health and rehabilitation services. The pricing will be set on a sliding scale, but the city has not yet determined what that range will look like.

After launching NYC Care in the Bronx this summer—where the need for health services is greatest, according to city public health officials—the NYC Care program will expand to all five boroughs by 2021. Metroplus’ improvement timeline is more vague, set to “announce a series of enhancements throughout the year.”

Is New York City the first to try this?

No, but it joins a very small crowd. San Francisco is the only other major city with a comprehensive local health coverage plan. The California city’s version, called Healthy San Francisco, was launched in 2007 under then-mayor (now-California Governor) Gavin Newsom. It, too, targets all uninsured residents of the city, and has reached 148,000 of San Francisco’s uninsured residents since its implementation, the majority of whom stayed in the program for 10 to 12 months. But as of the end of 2017, only 13,615 remained enrolled—giving it a disenrollment rate of 91 percent.

And other states are considering similar measures. Yesterday, in one of his first moves as California Governor, Newsom announced a proposal to expand the state’s Medi-Cal health care plan, after campaigning on a universal healthcare platform. “His announcement on Monday stopped short of the single-payer system demanded by activists that would cover all residents’ healthcare costs,” according to the Los Angeles Times, “but was characterized as the first step down that path.” It would require all consumers to have health insurance, and expands coverage for undocumented immigrants who are up to 26 years old.

Also on Tuesday, Washington Governor Jay Inslee proposed another expansive public health insurance option for the state. There, 800,000 people have gained coverage through the Affordable Care Act—but in 14 counties, consumers have only one provider option, Inslee wrote. If passed, the legislation would create a public option, according to the Seattle Times, which every county across the state would be mandated to carry.

How will New York City pay for it all?

It will cost the city at least $100 million each year to fund the NYC Care plan, and it’s not clear whether that includes the costs to MetroPlus enhancements. Still, de Blasio promises he won’t be raising any new city taxes to pay for it. Instead, he says, the money can come from the funds saved in emergency room costs—which, as they mount, have strained the city’s hospitals. The 2018 budget shortfalls for New York City’s municipal health system, H+H, are projected to be over $156 million in 2018, according to the Independent Budget Office, and could reach $1.8 billion by 2022.

“Going to the emergency room … is the default health care provider for so many people in this country,” de Blasio said on Morning Joe. “We're already paying an exorbitant amount to pay for health care the wrong way when what we should be doing is helping them get the primary care.” If uninsured New Yorkers go to the doctor instead of the ER, the thinking goes, the public hospital system will be more sustainable.

“We'll put the money in to make it work; it's going to save us money down the line,” de Blasio added.

Why now?

De Blasio framed New York City’s progressive health care strategy in the context of a “national reality” on Morning Joe Tuesday morning, taking jabs at the Republicans’ opposition to national health care reform. “The Republicans in Washington have been trying to tear down the universality of health care coverage and get rid of Obamacare,” he said. “We’re doing the opposite.” It’s the latest way the mayor has attempted to set himself up as a liberal foil to President Donald Trump, which some have read as positioning himself for a 2020 presidential bid.

But the announcement is also a more direct challenge to New York State, whose Democrat-majority state legislature is deciding on a statewide universal health insurance plan that has been killed five times by previous, Republican-controlled Senates.

The spate of health care proposals this weekplus the passage of state ballot initiatives that expanded Medicaid in three red states this November—could be an indication that, despite federal inaction, health care is framing local agendas this year.

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