This work was supported by the New York Community Trust
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With the seventh open enrollment period under the Affordable Care Act (ACA) only months away, states are gearing up to set rates and approve products for 2020 in a familiar landscape: one marked by uncertainty. One federal lawsuit working its way through the courts1 seeks to eliminate the ACA in its entirety on constitutional grounds, and another would reverse a ruling blocking the implementation of a Trump administration regulation expanding Association Health Plans2 (which many experts believe would unwind progress in rejuvenated individual markets).3 Despite the uncertainty, New York is approaching the next sign-up period with the wind at its back after a successful 2019 enrollment period. There are many positive signs of the state’s continuing progress.
Positive Signs of Progress
Coverage Rates. One recent survey4 found that the U.S. adult uninsured rate stood at 13.7% at the end of 2018, a four-year high. But a federal survey released in May of 2019 estimated that New York’s uninsured rate had declined to 4.7% overall and 6.8% for adults aged 18 to 64.5
Risk Profile. Federal risk adjustment data from the Centers for Medicare & Medicaid Services (CMS), which provides an assessment of the relative health or sickness of a state’s individual market, found that 16 states had “sicker” individual markets than New York’s in 2018, compared to only 10 states in 2017.6
Individual Enrollment. When Congress and the Trump administration agreed to “zero out” the ACA’s individual responsibility payments (also known as the individual mandate), experts projected a sharp enrollment drop. One 2018 modeling study projected a 37% reduction in individual enrollment in New York because of the mandate repeal.7 A federal tally for exchange enrollment nationally8 found a decline of over 400,000 individuals for the 2019 open enrollment period, although state-based marketplaces performed better than the federal platform. In its 2019 open enrollment report,9 however, New York State of Health (NYSOH) reported higher enrollment in all counties in all programs. The number of individuals purchasing Qualified Health Plans (QHPs) grew by about 7% compared to 2018, the second highest rate in the U.S, according to one report.10 Importantly, roughly the same percentage of enrollees purchased coverage without financial assistance in 2019, as did in 2018. At the same time, rates of renewal and new applications tracked last year’s, and the age distribution was unchanged. The state’s Essential Plan (EP) also grew at the same 7% rate, with enrollment nearing 800,000.
Premiums. While the same actuarial study projecting the sharp enrollment decline projected individual market premiums increasing by a range of 23% to 25% percent, the state Department of Financial Services (DFS) announced11 that, overall, health plans in the individual market will receive a weighted average 6.8% increase for individual coverage in 2020—this is on top of the average 8.6% average increase approved for 2019.12 Many factors affect a state’s average premiums—such as the products selected by individuals—but the CMS risk adjustment data show that 32 states posted higher average premiums than New York’s, compared to 16 states in 2017.13
Affordability. Advanced Premium Tax Credits (APTCs) shield many purchasers of Health QHPs through the NYSOH Marketplace from all or at least some portion of year-to-year premium increases. The maximum premium for the EP—still $20 a month for medical coverage, and $0 for lower-income enrollees—is very attractive to lower-income individuals, as exemplified by the program’s growth. For the 2020 open enrollment period, NYSOH officials tweaked the standard benefit design for the silver plan, the benchmark for APTCs, to reduce the deductible to $1,300.14 But individuals purchasing off the Marketplace or without APTCs have no such affordability protections. Although not a major focus of this report, many analysts are also sounding the alarm about affordability problems in the employer-sponsored insurance (ESI) market as well, but here too New York appears to be bucking the trend (see “Affordability Squeeze,” below).
Affordability Squeeze Is a Growing Concern in ESI Market, But New York Fares Better than Many States
More than 9.6 million New Yorkers have employer-sponsored insurance (ESI), long regarded as the gold standard for health insurance. One national survey, however, found that four in ten people with ESI reported difficulty affording some type of health care or insurance cost, as deductibles and other cost-sharing provisions continue to far outstrip wage growth.15 Another national study estimated that “deductible relief day”—the average annual date that deductibles are paid and policies start paying benefits—doesn’t come until May, with consumers paying out of pocket until then, as if they had no coverage.16
A recent New York survey found that a third of respondents delayed a doctor visit and three-quarters worried about paying for health care in the future because of affordability concerns.17 According to a 2019 federal survey, single and family premiums for private employer insurance in New York are the second highest in the nation.18
Still, New Yorkers may have less of a worry than workers in other states. A May 2019 study found that New York ESI enrollees ranked second-lowest among all states in terms of average household spending for premium payments ($1,300), out-of-pocket medical costs ($500), and combined medical and out-of-pocket costs ($2,320)—well below the national median for these expenses, and trailing only Hawaii.19 Lower costs for workers in these two states may reflect strong union representation; nearly a quarter of workers in both New York and Hawaii were represented by unions—the highest rates in the country—compared to just 3.6% of workers in South Carolina, the lowest-ranking state in union representation.20
18.4 Million Down, 1.1 Million to Go
Despite New York’s progress in increasing coverage and holding the line on ESI costs better than most states, more than a million New Yorkers still lack coverage. The characteristics of the remaining uninsured (Figure 1) show that high numbers are eligible for Medicaid, Child Health Plus, the EP, or premium subsidies for marketplace coverage—about 638,000 people in all. The remaining category also includes many more who are ineligible for help because of income, citizenship status, or an offer of ESI that is unaffordable to them. Recent research by the Urban Institute,21 which has entered the New York health policy lexicon as the “1/3, 1/3, 1/3 problem,” divides the uninsured into three slightly different groups with roughly equivalent numbers of uninsured: 1) noncitizens who are ineligible for public programs or marketplace subsidies; 2) individuals who are eligible for public programs like Medicaid and Child Health Plus (CHP) but not enrolled; and 3) individuals eligible to purchase coverage on the marketplace. Both analyses put a bright line on uninsured populations that would benefit from state actions to bolster the ACA.
While the ACA provided important tools for states like New York that are committed to expanding coverage, it is unlikely that any more federal help will be coming anytime soon. The Medicare for All legislation and several variations22 have generated increased attention and support, but a divided Congress is very unlikely to act on incremental improvements to the ACA, let alone single payer or Medicare expansion legislation. Instead, a bipartisan U.S. Senate package to lower drug costs and protect consumers from surprise bills has the best chance of advancing.23 Meanwhile, the Trump administration continues to chip away at the ACA through rulemaking that reduces APTCs for individuals and increases out-of-pocket costs,24 cuts state funding for the Essential Plan,25 and loosens anti-discrimination provisions.26 That means it will be up to New York policymakers to determine if the current uninsured rate represents a mile marker on the road to universal coverage, or a high-water mark. With this in mind, it is useful to look at actions taken by other jurisdictions around the country, and how they might inform discussions in New York.
Source: Garfield R, et al. June 2018. Estimates of Eligibility for ACA Coverage Among Those Remaining Uninsured as of 2017. Henry J. Kaiser Family Foundation. https://www.kff.org/uninsured/issue-brief/estimates-of-eligibility-for-aca-coverage-among-the-uninsured-in-2016-october-2017-update
The ACA’s individual responsibility provisions were designed to preserve the affordability of coverage by ensuring that the risk pool includes younger, healthier individuals, not just those who purchase coverage because of an immediate medical need. As the looming $0 “penalty” was scheduled to take effect in January 2019, New Jersey and the District of Columbia moved quickly in 2018 to enact local mandates modeled on ACA provisions, with mixed results. The DC Health Link reported a slight drop in individual enrollment,27 but that was likely the result of a shift of enrollees from individual to small group coverage.28 Federal data on New Jersey QHP plan selections show a 7% drop from 2018 to 2019,29 and the total number of individual enrollees declined about 4%, according to state data released for the first quarter of 201930 (about half the decline reported for the previous year). New Jersey announced plans to create its own state exchange for the next open enrollment period,31 and last year it established a reinsurance program with penalty funds earmarked to offset the premium costs of high-claim individuals, which led to a 9.3% premium decrease.32 The new state exchange and lower premium increases stemming from the reinsurance program may boost New Jersey’s enrollment in the future.
In June 2019, California leaders responded to the elimination of the federal penalty by enacting a state one for 2020. The state marketplace, Covered California, reported a 0.5% drop in overall enrollment in 2019 but noted that new signups decreased by almost 25%.33 Data on off-exchange individual market enrollment for 2018 were unavailable, but in 2017, enrollment declined by 87,000.34 With over 2 million enrollees, California’s individual market is giant compared to New York’s—but when a market study projected an increase in individuals without insurance of between 490,000 and 790,000 with the repeal of the individual mandate, lawmakers took note and pitched the idea of the mandate as necessary to keep insurance affordable for all Californians. The enactment of the state individual responsibility provision in California appears to have already had a positive impact on affordability. Covered California recently announced an average rate change of just 0.8% for individual market premiums in 2020, attributing the low rate of increase to the adoption of the mandate and new state premium subsidies, discussed in more detail below. 35
Do New York’s positive enrollment results for 2019 mitigate the need for a state individual responsibility provision? As individuals considered buying or renewing coverage for 2019 without the penalty in effect, certainly the successful EP acted to blunt the impact on low-income New Yorkers maintaining or buying coverage, since the $0 or $20 maximum monthly premium is just a fraction of what similarly situated purchasers of QHPs would pay in other states. But there are some warning signs too. The individual market (Figure 2) has lost over 20% of its membership since 2014. Some of that decline reflects the planned shift of lower-income (and generally younger) QHP enrollees from the exchange to the EP, in order to improve affordability and leverage federal matching funds. QHP enrollment has picked up recently as well. But the off-exchange market—a key component of the overall stability of the individual risk pool—has lost over half of its membership since 2016, a development that has not gone unnoticed by participating health plans.
In filings for 2020 rates,36 health plans cited many reasons for rising rates, including the resumption of the ACA premium tax; rising drug and medical costs; and, in some cases, expanded benefit mandates, such as the elimination of the age limit on fertility coverage. But nearly all plans also noted the loss of the individual mandate penalty as a factor in a “contracting” market and sought modest rate increases as part of their overall increase request, citing a smaller risk pool and increased morbidity. Fidelis Care (Centene), the largest health plan by enrollment, noted an “expected decline in 2020 enrollment leading to a less healthy population due to the elimination of the individual mandate penalty.” Excellus BCBS, a leading upstate plan, noted that “individuals that remain in the pool from one year to the next are about 4 percent more expensive than the overall pool and individuals that exit the pool are about 20 percent less expensive.” National risk adjustment data show that, except for bronze and gold tier plans, off-marketplace purchasers in all remaining metal tiers for coverage are healthier than those purchasing coverage on the marketplace;37 off-exchange purchasers of silver plans, for example, are about 20% healthier than on-exchange buyers. The shrinking individual market, along with steady premium increases for unsubsidized enrollees, should cause some concern. A national estimate of the impact of the mandate repeal by the Congressional Budget Office projected nongroup enrollment would decline by 4 million by 2021, with another 1 million individuals dropping ESI.38 A 2018 state-by-state analysis estimated that had New York adopted an individual mandate for 2019, about 142,000 more individuals would have gained coverage, and individual market premiums would be about 10% lower.39
Source: NYSOH enrollment reports and personal communication with the New York State Department of Financial Services. Data for 2015 not available.
Since the enactment of the ACA, there has been a lively debate about what’s more important to coverage—the mandate or the subsidies, with some academics weighing in on the subsidy side.40 Massachusetts included both elements right from the start and enhanced affordability through its ConnectorCare plans, which layer state-financed subsidies and cost-sharing help on top of federal tax subsidies and cost-sharing reductions for individuals earning less than 300% of the federal poverty level (FPL).41 Unlike the EP, this approach improves affordability for lower-income purchasers but keeps them in the same single risk pool. As part of their budget agreement, California will join Massachusetts in earmarking mandate penalties for a state program that will eliminate premiums for very low-income exchange enrollees and supplement APTCs for those currently eligible, but also extend subsidies to individuals earning between 400 and 600% of the FPL. Covered California estimates that over 900,000 individuals will be eligible for the enhanced subsidies and projects that about 229,000 uninsured Californians will gain coverage.42 Funding for year one of the three-year program is made up of about $300 million in anticipated penalty payments, supplemented by another $135 million in general fund monies.43 The experience of these states shows that in addition to supporting a stable risk pool and lower premiums, individual responsibility payments can make coverage more affordable to individuals for whom federal subsidies fall short. There is also a fairness argument to earmarking the penalties for reinsurance or affordability subsidies. In New York, about 75% of the $201 million in penalties in 2016 came from tax filings by households earning between $10,000 and $75,000,44 two income groups that are likely to include families for whom coverage is still not affordable, even with ACA subsidies.
Coverage for Non-Citizens
Non-citizens ineligible for public programs or the marketplace make up a large share of the uninsured population in New York, accessing sporadic care through a patchwork of federally-qualified health centers, hospital indigent care programs, Emergency Medicaid, and out-of-pocket payments. California, as part of their reform package, will extend Medicaid eligibility to non-citizens up to age 26, providing coverage for an estimated 90,000 eligibles.45 While many California advocates sought coverage for all non-citizens, most regarded the more limited program as a very positive step. And again, there is a useful symmetry in the overall package, as California lawmakers supporting the plan can point to new coverage gains for immigrants, improvements to the Medicaid program, and new and deeper support for middle-income families unreached by ACA subsidies (who face steep premium cliffs beyond 400% of the FPL).
New York City, taking a different tack, is launching a new program known as NYC Care that offers direct access to NYC Health + Hospitals providers; it is aimed at 600,000 uninsured New Yorkers. City officials hope that reaching out to and guiding the uninsured to primary care doctors—along with specialty care, drugs, and mental health care and hospitalization—“will help give all New Yorkers the quality care they need.”46 While NYC Care is not an insurance product (enrollees will continue to pay for care on a sliding scale basis), it will be closely watched to gauge its effectiveness, and to see whether it is replicable in other parts of the state. Starting in the Bronx in August 2019, the program is slated to be expanded citywide by 2021.
Eligible but Uninsured
With the next open enrollment period just months away, New York could move a significant portion of its uninsured to the covered side by finding the key to reaching the remaining eligible but uninsured population. The increase in enrollment in the last open enrollment period suggests that NYSOH’s campaign was well designed and effective.47 Advertising stressed that personal assistance was available and that the uninsured “deserved affordable health care,” an approach that matched findings from a recent UHF report on the uninsured in 16 upstate counties, and seemed to strike the right tone.48 With hundreds of thousands of New Yorkers eligible for Medicaid, Child Health Plus, the EP, or APTCs—but still uninsured—developing and refining messages and strategies in order to finally reach these individuals will be paramount.
An August 2019 regulation finalized by the Trump administration49 will compound the difficulty of this enrollment task. Known as the “public charge” rule, the regulation greatly expands the factors that the federal government will consider in making determinations on applications by noncitizens to become legal permanent residents of the U.S., commonly known as “green cards.” Currently limited to factors such as primary reliance on cash benefits or long-term medical institutionalization, determinations under the new regulation allow consideration of applicants’ age, health status, income, and past use of noncash benefits—such as nutrition programs and Medicaid. According to several analyses,50 the proposed rule could lead to significant disenrollment in Medicaid and Child Health Plus, even among children who are citizens. And one recent study found that the public charge changes are already having a “chilling effect,” with one in seven adults in immigrant families reporting in a December 2018 survey that they had avoided a public benefit program in 2018.51 Although the regulation is scheduled to take effect on October 15, 2019—two weeks before the open enrollment period begins in New York—the first court challenge was filed within a day of its publication. The City of New York, which estimates the regulation will cost its health system over $360 million in the first year,52 suggested possible grounds for the litigation in comments on the proposed regulation filed with the city of Chicago and a number of other cities.53 Those grounds include violations of the Administrative Procedure Act and the Department of Homeland Security’s failure to consider the economic impact of the regulation on states and cities.
Although New York acted in 2019 to improve Medicaid rates for providers and codify ACA provisions in state law, a handful of coverage expansion proposals languished. While supporters hoped for quick passage of comprehensive single-payer legislation54 due to the changeover to a Democratic majority in the state Senate, the sponsors shelved the bill for this year and announced further public hearings. Both houses spurned an Executive Budget proposal to create a commission to study universal access to coverage.55 Proposed legislation56 opening up the Essential Plan to income-eligible noncitizens did not move; nor did a proposal from consumer advocates57 to make coverage more affordable by supplementing ACA tax credits with state funds. Finally, a proposal to increase the income eligibility level for the Essential Plan to 250% of FPL, from its current level of 200% FPL also did not advance, though that approach risks stripping tens of thousands more individuals from the individual market risk pool.
The actions taken by California—a state with a Democratic governor and single-party legislature, which tabled single-payer legislation in 201758—are instructive. On its first day in office, the administration of Governor Gavin Newsom petitioned President Trump and Congressional leaders for federal legislation providing expanded waiver authority for states to implement a single-payer health program.59 It then reached agreement with legislative leaders on the coverage expansion package and rewired an existing study commission to explore other coverage options and transitional steps toward a single-payer system in 2020, and key design considerations for a single-payer system in 2021.60 In fairness, California had an important advantage: while New York faced a deep budget gap in April 2019, California lawmakers were blessed with an “extraordinary” $14 billion budget surplus above and beyond rainy day fund obligations.61
Massachusetts served as the model for the ACA, of course, and provides a good case study on how a state can cobble together financing for coverage initiatives. Health care-related taxes and fees and mandate penalties help support the HealthConnector subsidy program,62 but nearly 50% of the funding in the current fiscal year came from federal matching funds under its Section 1115 Demonstration Program Waiver, renewed in 2018. With New York’s own 1115 Waiver up for renewal soon, that is worth keeping in mind.
There is no shortage of ideas on how to cover the remaining uninsured in New York, but moving the needle will depend on policymakers’ tolerance of the hardships facing large numbers of uninsured going forward (despite the progress made) and identifying resources to support coverage expansion amid many competing demands.
1 Musumeci MB. July 3, 2019. Explaining Texas v. U.S.: A Guide to the 5th Circuit Appeal in the Case Challenging the ACA. Henry J. Kaiser Family Foundation. https://www.kff.org/health-reform/issue-brief/explaining-texas-v-u-s-a-guide-to-the-5th-circuit-appeal-in-the-case-challenging-the-aca/
2 Keith K. May, 28, 2019. ACA Litigation Round-Up: AHPs. Health Affairs Blog.
3 Newell P. June 2018. The Other Shoe Drops: Federal Association Health Plan Regulaton Is Next Threat to Coverage in New York. United Hospital Fund. https://uhfnyc.org/publications/publication/other-shoe-drops-ahp-regulation/
4 Witters D. January 23, 2019. U.S. Uninsured Rate Rises to Four-Year High. Gallup.
5 Cohen RA, EP Terlizzi, and ME Martinez. May 2019. Early Release of Estimates from the National Health Interview Survey, 2018. Centers for Disease Control, National Center for Health Statistics, National Health Interview Survey Early Release Program.
6 Centers for Medicare & Medicaid Services, Center for Consumer Information & Insurance Oversight. June 28, 2019. Summary Report on Permanent Risk Adjustment Transfers for the 2018 Benefit Year. (Interim Summary Report on Risk Adjustment for the 2018 Benefit Year, and Appendix A.) https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/Downloads/Summary-Report-Risk-Adjustment-2018.pdf
7 Rao P, C Ebner, and SA Nowak. 2018. Impacts of the Elimination of the ACA’s Individual Health Insurance Mandate Penalty in the Nongroup Market in New York State. RAND Research Report. https://www.rand.org/pubs/research_reports/RR2579.html
8 Centers for Medicare & Medicaid Services. March 25, 2019. Health Insurance Exchanges 2019 Enrollment Report. Fact Sheet.
9 New York State of Health. May 2019. 2019 Open Enrollment Report. https://info.nystateofhealth.ny.gov/2019openenrollmentreport
10 Cousert C and M Hensley-Quinn. April 1, 2019. Individual Enrollment in Federal and State Health Insurance Marketplaces 2018 and 2019. National Academy for State Health Policy.
11 New York State Department of Financial Services. August 8, 2019. DFS Announces 2020 Premium Rates: Lowers Overall Requested Rates for Individuals and Small Businesses to Protect Consumers and Fuel a Competitive Health Insurance Marketplace. Press Release.
12 New York State Department of Financial Services. August 3, 2018. DFS Takes Action to Ensure a Continued Healthy and Competitive Insurance Market Despite Continued Wrongful Federal Attacks on the Affordable Care Act. Press Release.
13 Centers for Medicare & Medicaid Services, Center for Consumer Information & Insurance Oversight. June 28, 2019. Summary Report on Permanent Risk Adjustment Transfers for the 2018 Benefit Year. (Interim Summary Report on Risk Adjustment for the 2018 Benefit Year, and Appendix A.) https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/Downloads/Summary-Report-Risk-Adjustment-2018.pdf
14 New York State of Health. Standard Benefit Design Cost Sharing Description Chart (04-24-2019). https://info.nystateofhealth.ny.gov/sites/default/files/Attachment%20B%20-%20Standard%20Products%202020%20042419%28Cost%20Sharing%20Chart%29%20%28002%29.pdf
15 Hamel L, C Munana, and M Brodie. May 2019. Kaiser Family Foundation/LA Times Survey of Adults with Employer-Sponsored Insurance. Henry J. Kaiser Family Foundation.
16 Rae M et al. May 15, 2019. Deductible Relief Day: How Rising Deductibles Are Affecting People with Coverage. Peterson-Kaiser Health System Tracker. Issue Brief.
17 Altarum Health Care Value Hub. March 2019. New Yorkers Struggle to Afford High Healthcare Costs; Support a Range of Government Solutions Across Party Lines. Data Brief No. 37. https://www.cssny.org/news/entry/new-statewide-healthcare-affordability-survey
18 Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. 2018 Medical Expenditure Panel Survey (Insurance Component). Tables II.C.1. and II.D.1. https://meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component=2&subcomponent=2&year=2018&tableSeries=-1&tableSubSeries=&searchText=&searchMethod=1&Action=Search
19 Hayes SL, SR Collins, and DC Radley. May 2019. How Much U.S. Households with Employer Insurance Spend in Premiums and Out-of-Pocket Costs: A State-by-State Look. Issue Brief. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2019/may/how-much-us-households-employer-insurance-spend-premiums-out-of-pocket
20 U.S. Department of Labor, Bureau of Labor Statistics. January 18, 2019. Union Members—2018. Press Release USDL-19-0079.
21 Presentation of Donna Frescatore, New York State Medicaid Director. July 18, 2019. United Hospital Fund Annual Medicaid Conference: “Medicaid in New York: A Look Toward the Future.”
22 Henry J. Kaiser Family Foundation. May 15, 2019. Compare Medicare-for-All and Public Plan Proposals.
23 U.S. Senate Committee on Health, Education, Labor, & Pensions. May 19, 2019. Senate Health Committee Leaders Introduce Bipartisan Legislation to Reduce Health Care Costs. Press Release. U.S. Senator Lamar Alexander and U.S. Senator Patty Murray. https://www.help.senate.gov/chair/newsroom/press/senate-health-committee-leaders-introduce-bipartisan-legislation-to-reduce-health-care-costs
24 Aron-Dine A and M Broaddus. April 26, 2019. Change to Insurance Payment Formulas Will Raise Costs for Millions with Marketplace or Employer Plans. Center on Budget and Policy Priorities.
25 Curran E. April 25, 2019. Proposed Rule on Basic Health Program Impedes States’ Progress. Center on Health Insurance Reforms.
26 Keith K. May 25, 2019. HHS Proposed to Strip Gender Identity, Language Access Protections from ACA Anti-Discrimination Rule. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20190525.831858/full/
27 Centers for Medicare & Medicaid Services. 2019 Marketplace Open Enrollment Period Public Use Files. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2019_Open_Enrollment.html; Centers for Medicare & Medicaid Services. 2018 Marketplace Open Enrollment Periods Public Use Files. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2018_Open_Enrollment.html
28 Cousert C and M Hensley-Quinn. April 1, 2019. Individual Enrollment in Federal and State Health Insurance Maketplaces 2018 and 2019. National Academy for State Health Policy.
29 Centers for Medicare & Medicaid Services. 2019 Marketplace Open Enrollment Period Public Use Files. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2019_Open_Enrollment.html; Centers for Medicare & Medicaid Services. 2018 Marketplace Open Enrollment Periods Public Use Files. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2018_Open_Enrollment.html
30 New Jersey Department of Banking & Insurance. June 18, 2009. NJ Department of Banking and Insurance Releases Health Insurance Enrollment Figures for First Quarter of 2019. Press Release. https://www.nj.gov/dobi/pressreleases/pr190618.html Enrollment Data, 1st Quarter 2019. https://www.state.nj.us/dobi/division_insurance/ihcseh/ihcsehenroll.html
31 State of New Jersey, Office of the Governor. June 27, 2019. Governor Murphy Signs Legislation to Establish State-Based Health Exchange in New Jersey. Press Release. https://www.nj.gov/governor/news/news/562019/approved/20190628a.shtml
32 State of New Jersey. New Jersey Health Insurance Market Preservation Act. https://nj.gov/treasury/njhealthinsurancemandate/index.shtml; Office of the Governor, State of New Jersey. September 7, 2018. Press Release. Governor Murphy Announces Impact of New Jersey’s Actions to Stabilize Health Insurance Individual Market. https://nj.gov/governor/news/news/562018/approved/20180907a.shtml
33 Covered California. January 30, 2019. Covered California 2019 Open Enrollment Early Observations and Analysis.
34 Wilson K. June 28, 2019. State Releases Data on California 2018 Health Insurance Enrollment. CHCF BLOG. California Health Care Foundation. https://www.chcf.org/blog/state-data-2018-health-insurance-enrollment/#related-links-and-downloads
35 Covered California. July 9, 2019. California’s Initiatives Will Lead to Hundreds of Thousands Gaining Health Care with Lower Premiums and New Financial Help. Press Release. https://www.coveredca.com/newsroom/news-releases/2019/07/09/californias-initiatives-will-lead-to-hundreds-of-thousands-gaining-health-care-coverage-with-lower-premiums-and-new-financial-help/. Rhode Island also adopted a state coverage mandate for 2020, and is awaiting federal approval of a Section 1332 waiver for a reinsurance program, which is also expected to reduce individual market premiums. For a summary, see Keith K. July 18, 2019. New 1332 Resources; Rhode Island Waiver Deemed Complete. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20190718.732965/full
36 New York State Department of Financial Services. Rate Applications by Company.
37 Centers for Medicare & Medicaid Services, Center for Consumer Information & Insurance Oversight. June 28, 2019. Summary Report on Permanent Risk Adjustment Transfers for the 2018 Benefit Year. (Interim Summary Report on Risk Adjustment for the 2018 Benefit Year, and Appendix A.) https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/Downloads/Summary-Report-Risk-Adjustment-2018.pdf
38 Congress of the United States, Congressional Budget Office. May 2019. Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2019 to 2029. https://www.cbo.gov/publication/55085
39 Blumberg L, M Buettgens, and J Holahan. July 2018. How Would State-Based Individual Mandates Affect Health Insurance Coverage and Premium Costs? Urban Institute and the Commonwealth Fund. https://www.urban.org/research/publication/how-would-state-based-individual-mandates-affect-health-insurance-coverage-and-premium-costs
40 Frean M, J Gruber and DB Sommers. March 6, 2017. Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the Affordable Care Act. Journal of Health Economics 53(2017) 72-86. https://doi.org/10.1016/j.jhealeco.2017.02.004
41 Massachusetts Health Connector. ConnectorCare Health Plans.
42 Covered California. July 9, 2019. Projected Impacts of State Laws Affecting Health Care Consumers and Covered California in 2020. Fact Sheet. https://www.coveredca.com/news/pdfs/State_Subsidy_and_Mandate_Fact_Sheet.pdf
43 Health Access California has several informative publications on the California budget agreement, including a budget scorecard updated on June 10, 2019; a fact sheet from June 25, 2019; and a blog post. A California Senate Budget Committee summary provides additional information on the spending agreement.
44 Newell P and M Miller. October 8, 2018. 2019 Shaping Up as a Watershed Year for New York’s Individual Market as Federal Challenges and Uncertainty Continue. United Hospital Fund. https://uhfnyc.org/publications/publication/NY-individual-market-federal-challenges-2019/
45 Ibarra AB. June 25, 2019. New Budget Boosts Health Coverage for Low-Income Californians. Kaiser Health News.
46 Office of the Mayor, City of New York. January 8, 2019. Mayor de Blasio Announces Plan to Guarantee Health Care for all New Yorkers. Press Release. https://www1.nyc.gov/office-of-the-mayor/news/017-19/mayor-de-blasio-plan-guarantee-health-care-all-new-yorkers#/0
47 See NYSOH 2019 Open Enrollment Report for a summary of open enrollment period strategy and activities.
48 Newell P. April 23, 2019. Reaching the Five Percent: A Profile of Western and Central New Yorkers Without Health Coverage. United Hospital Fund. https://uhfnyc.org/publications/publication/uninsured-in-western-and-central-ny/
49 U.S. Citizenship and Immigration Services, Department of Homeland Security. August 14, 2018. Inadmissibility on Public Charge Grounds. https://www.federalregister.gov/documents/2019/08/14/2019-17142/inadmissibility-on-public-charge-grounds
50 Artiga A, R Garfield, and A Damico. October 2018. Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid. Issue Brief. Henry J. Kaiser Family Foundation. https://www.kff.org/disparities-policy/issue-brief/estimated-impacts-of-the-proposed-public-charge-rule-on-immigrants-and-medicaid/; Artiga S, A Damico, and R Garfield. May 2018. Potential Effects of Public Charge Changes on Health Coverage for Citizen Children. Issue Brief. Henry J. Kaiser Foundation.
51 Bernstein J et al. May 2019. One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018. Urban Institute. https://www.urban.org/sites/default/files/publication/100270/one_in_seven_adults_in_immigrant_families_reported_avoiding_publi_2.pdf
52 Comment submitted by Kimberly Conway. City of New York and NYC Health + Hospitals. December 10, 2018.
53 Comment of City of New York and Chicago. December 10, 2018. https://www.regulations.gov/document?D=USCIS-2010-0012-62861
54 The New York Health Act, A.5248/S.3577. https://www.nysenate.gov/legislation/bills/2019/s3577
55 FY 2020 Executive Budget, Health and Mental Hygiene Article VII bill, Part N.
56 A.3900/S5974. https://www.nysenate.gov/legislation/bills/2019/s3900
57 Health Care for All New York. 2019 Policy Agenda. http://hcfany.org/wp/wp-content/uploads/2018/12/HCFANY-2019-Policy-Agenda.pdf
58 Chang C. June 30, 2017. What Killed Single-Payer in California? The New Republic.
59 State of California, Office of the Governor. January 7, 2019. Letter from Governor Newsom to President Trump and Congressional Leaders. https://www.gov.ca.gov/wp-content/uploads/2019/01/1.7.19-Letter-to-the-White-House-and-Congress.pdf
60 State of California, Department of Finance. Healthy California Commission.
61 Taylor M. November 14, 2018. The 2019-20 Budget: California’s Fiscal Outlook. California Legislative Analyst’s Office.
62 Personal communication with staff of the Massachusetts Health Connector. May 2019.