New York City’s New 'Universal' Healthcare Program and Its Implications for America

Screen Shot 2019-01-24 at 10.46.18 AM.png

As the largest municipality in America, it comes as no surprise that New York City leans very much to the left, with nearly 68 percent of its voters enrolled as Democrats as of Nov. 2018. New York City has also long been an immigration hub. Its ports of entry, such as the famous Elis Island, have been responsible for a massive influx of immigrants, more than three million of which now call the city their home. These progressive leanings and the proportionally large non-citizen population has made the city a bulwark against the policies of incumbent President Donald Trump, himself a former New Yorker. 

On Jan. 8, Mayor Bill de Blasio reaffirmed his jurisdiction’s commitment to progressive ideals by announcing that the city would dramatically increase its provision of healthcare to all its inhabitants regardless of immigration status, emphatically stating that “everyone is guaranteed the right to healthcare.” The program, slated to cost $100 million annually, will ensure the provision of healthcare to all New Yorkers currently unable to access or afford it. The New York City move is significant because it signifies a shift in the application of federalism and acts as a vehicle for opposition to the current Administration’s agenda, namely, the evisceration of the Affordable Care Act and the oftentimes brutal crackdown on illegal immigration.

The NYC Healthcare Program Overhaul

Unique to American Federalism is that states and (by extension) municipalities are given a degree of control over their internal affairs in matters that do not conflict with explicit federal prerogatives. As such, many cities and states have implemented laws that go beyond those emanating from Washington D.C., such as the legalization of cannabis. New York City’s new project is emblematic of federalism as it is designed to compensate where the federal government is ostensibly lacking. With the central government has now positioned itself against public healthcare schemes, New York City is utilizing its constitutional entitlements to implement universal healthcare style regulations.

De Blasio’s new proposal is meant to reduce the level of uninsured as well as the necessity of low-income individuals to resort to using the emergency room for otherwise benign and preventable healthcare concerns. To this end, the program consists of two parts. The first can be described as an outreach and marketing campaign designed to increase enrollment in the city’s publicly subsidized low-cost insurance plan MetroPlus, a not-for-profit private-public insurer that provides affordable coverage for the city’s residents with funding from the state’s Medicaid program. Built around the city’s robust public hospital network, MetroPlus currently services over half a million New Yorkers and is easily accessible for those who qualify. However, lack of public awareness of this program has led to calls for greater outreach efforts such as those stipulated in the new healthcare proposal.

The second pillar of the new healthcare proposal is the creation of a new program called NYC Care. While not a universal healthcare plan, NYC Care is designed to provide New York City’s estimated six-hundred thousand uninsured with access to preventive care at any of the city’s public hospitals. Specifically, the program is not an insurance plan and simply guarantees that NYC Care cardholders (available to those who apply via the city’s enrollment program) are to be matched with a primary care physician operating out of one of the city’s eleven public hospitals. Once received by a PCP, card members will face lower out of pocket costs determined on a sliding scale (i.e., based on income) which could potentially amount to $0.

In order to make this program a reality, de Blasio has suggested $100 million be spent on expanding public hospitals and retrofitting them to allow PCPs to better receive patients for preventative care visits. Since New York City is statutorily required to balance its budget, and since the mayor has promised that no new taxes would be associated with the initiative, the funds will have to be reallocated from other areas of the municipal budget. While not universally supported among New Yorkers who reject de Blasio’s effort as political grandstanding, the reallocation of funds is meant to better equip NYC Health + Hospitals (the organization in charge of the city’s network of public hospitals) in order to cope with the increased demand for preventative care visits. By doing so, the mayor’s office anticipates that substantial savings will be gained by fewer emergency room visits, where federal law prohibits service discrimination based on ability to pay and immigration status, and the cost of which is borne by the city.

Nexus with Immigration and Inherent Opposition to Trump

Important to the city’s new healthcare direction is that it is to be accessible to all of the city’s residents, including those that are undocumented. Childless illegal immigrants with low incomes are often barred from receiving government health benefits such as Medicaid due to their undocumented status. As such, those that do not receive such benefits from their employers usually remain uninsured and are hampered by cultural and linguistic barriers when attempting to enroll in private plans. New York City’s large non-citizen population of 1.43 million, nearly 38 percent of which are estimated to be illegal immigrants, makes this an acute issue for New York City and has contributed to the disproportionate rate of uninsured among undocumented immigrants, whose rate is nearly six times higher than the overall rate.

Perhaps more significant than the progressive push to cover all inhabitants of the city is the fact that the inclusion of illegal immigrants can be understood as a stab to Trump from the city’s liberal government. New York City has a rich history of immigration, has some of the most diverse immigrant communities in the nation and has repeatedly reaffirmed its commitment to being immigrant friendly (e.g., through its designation as a sanctuary city). Due to these urban characteristics, New York City has been a thorn in Donald Trump’s side since his inauguration, a day that saw over four-hundred thousand people congregate to Manhattan in order to engage in the first annual Women’s March. By explicitly including the provision of government-subsidized healthcare to undocumented individuals, the program reflects trends among liberal dominated localities attempting to better integrate their immigrant populations and places the city in direct opposition with the President.

Implications for Federalism and Healthcare Around the Country

The decision of New York to drastically increase coverage to the lowest-earners and to those undocumented residents is a significant move for a locality to make. First, it shows a dramatic shift in the use of federalist prerogatives by the various states and local governments. Whereas during Obama (and before) the most significant state challenges to federal authority came from conservative-leaning states with the intention to halt perceived central government encroachment, the trend in the Trump era seems to have reversed. Liberal states are becoming increasingly more militant in passing regulations (e.g. environmental) aimed to compensate for federal government shortcomings, thereby altering the traditional conception of federalism as a means to limit government influence. By doing so, states are taking a more active role in policy making, restoring their mantle as “laboratories of democracy” and providing useful examples for ideologically similar counterparts.

Second, the implementation of a prototype universal healthcare scheme reflects a trend in liberal states to unilaterally move forward with universal healthcare or single payer schemes. Already larger than all but a dozen states by population, New York City is a good model for a universal healthcare program for states both small and large (i.e., possessing many large cities). Should the city’s new program succeed and demonstrate that accessible preventative care is able to improve health while reducing municipal expenditure on emergency room visits, it is likely that such a program will become a model for others across the nation. While New York City’s initiative is by no means a novel idea, in fact, it is closely modeled after San Francisco’s “Healthy San Francisco” program launched in 2007, it is the largest ever undertaken in the U.S. and its success or failure will likely affect expectations for lawmakers around the nation.