Dick Gottfried

If the New York Health Act were to become law, it would revolutionize health care in the United States. No state has ever successfully implemented a single-payer system at such a scale, but the chairs of the Assembly and state Senate health committees say it can be done. City & State caught up with Assemblyman Richard Gottfried and state Sen. Gustavo Rivera to discuss the bills they are sponsoring in their respective chambers and how they think the proposal can make its way through the Legislature.

A broad coalition of seniors, people with disabilities, caregivers, home care providers and advocates joined the bills’ sponsors, Assemblyman Richard Gottfried and Sen. Gustavo Rivera, as they kicked off a 2019 New York Health Act push at the state Capitol on Monday.

By Harry Cheadle, 12/13/18

Last month, Democrats achieved an historic win in New York, flipping control of the state senate and thus taking control of the entire government, upending a weird status quo during which a group of breakaway Democrats allowed the Republicans to control the legislature’s upper chamber. Now that they actually have the power to pass laws in one of the most Democratic states in the country, the possibilities seem intoxicating for the left: Abortion access could be codified into law, the subways could finally be fixed, the state’s byzantine election laws could be updated, and New York could commit to fighting climate change.

But right near the top of any progressive wish list is the New York Health Act, the state’s version of Medicare for all—which is to say universal, government-provided—health insurance. Single-payer healthcare, as such systems are also called, has been a left-wing lodestar for generations. If the NYHA passed, it would make New York the first state in the union to guarantee free access to healthcare (and freedom from fear of health-related bankruptcy) to all of its residents, including undocumented people. 

If passed and smoothly implemented, NYHA could be not just a way to improve the lives of New Yorkers but a model for the rest of the country as it debates the merits of Medicare for all, a policy backed by Bernie Sanders and many other potential 2020 presidential contenders. But now that Democrats can actually pass the NYHA, single-payer supporters are facing a fight that could pit them against not just the insurance industry but a host of Democratic constituencies and leaders—a preview of the contentious debate over healthcare that might follow victories in 2020.

The foremost obstacle is the powerful medical industry lobby, which will likely deploy the usual counterattacks—think the “death panels” of the Affordable Care Act debate, or the fear-mongering “Harry and Louise” ads that helped scuttle reform in the 90s. Then you have Democratic lawmakers who may hesitate to back a transformative proposal that would raise taxes on a lot of people, a governor who doesn’t seem particularly warm to the idea, a hostile federal government, and potential lawsuits from employers. While the coming NYHA battle represents a possible turning point in the history of healthcare politics, it won’t be a pretty sight.

Yet if single-payer advocates could get past all that, they’d have a roadmap to victory in other states—and a model that could be replicated in DC.

Richard Gottfried, the chair of the New York State Assembly’s Health Committee and the chief architect of the NYHA, recently explained what it would look like. “It would create universal complete health coverage for every New York resident without premiums, deductibles, copays, or restricted provider networks,” he said over the phone. The bill would pay for this by pooling the money the state gets from the federal government for programs like Medicaid and Medicare, and also by raising taxes. “There would be one tax on payroll income, predominantly paid by employers, and a parallel on unearned income like dividends, capital gains,” Gottfried explained.

This would transform the way New Yorkers pay for healthcare—instead of giving premiums to insurers, they’d be getting taxed—and according to a recent studyby the RAND Corporation, overall health spending would drop by $80 billion, or 2 percent, by 2031, even as the roughly 1.2 million currently uninsured New Yorkers gained access to care. Gottfried said he didn’t necessarily agree with RAND’s report (for one thing, his bill as currently written does not specify tax rates, so RAND analysts made assumptions about what those rates would be) but NYHA backers have trumpeted the finding that the bill could drive costs down.

The arguments against the NYHA are echoes of the normal arguments marshaled against single-payer healthcare. Realities of Single Payer, an anti-NYHA organization made up mostly of business and health insurance interests, warns of high taxes, long wait times for care under a government-run system, and job loss in the insurance industry. (Through a spokesperson, Realities of Single Payer said in a statement that “rather than throwing out a functioning system for a very uncertain future, there should be a greater focus on covering the remaining uninsured New Yorkers.”) Katie Robbins, the director of Campaign for New York Health, a coalition of unions, doctors, and left-leaning groups, called these warnings “talking points that are used to create fear” and noted that this year’s election proved single-payer was popular statewide.

“There’s been a longtime narrative, a false narrative in my opinion, that this is an issue that only New York City liberals care about,” Robbins said. “But what we saw reflected in the results is that Senate candidates outside of New York City—Long Island, Hudson Valley, upstate in Syracuse—who ran on the New York Health Act, not just standing on it, but making it a priority of their campaign… handily won their elections.”

Those election results create pressure on Democrats, according to Hank Sheinkopf, a longtime Democratic consultant in the state who has worked for everyone from Andrew Cuomo to Michael Bloomberg to Bill Clinton: “They have to do something.”

The NYHA—which Gottfried has introduced into the Assembly every year since 1992—has passed the lower legislative chamber in each of the past four years. But even with increased support in the Senate, its path to becoming law is tricky to say the least. The top Democrat in the State Senate, Andrea Stewart-Cousins, seemingly embraced the NYHA last year, but after the election said Democrats wouldn’t raise taxes. And while Governor Andrew Cuomo said the NYHA was a good idea “in theory” during a debate against his left-wing primary challenger Cynthia Nixon, he was also skeptical of the cost and said he’d like to see single-payer healthcare be implemented on a federal, rather than state, level. (Neither Stewart Cousins nor Cuomo responded to requests for comment left with their offices.)

Meanwhile, unions remain a powerful force in state politics—especially in New York City—and some might oppose the NYHA because members generally have good insurance they won through negotiations and may not want to replace that with government-provided plans. Other barriers include the Trump administration potentially refusing to grant waivers to New York that some say would be necessary for the plan to be implemented (Gottfried disputed that such waivers would be needed) and potential lawsuits from employers under a federal statute called ERISA that protects employers who choose to pay insurance claims themselves.

It’s also not even clear the NYHA will pass the Assembly when the legislature goes back into session in January. “It’s like starting from scratch because the political dynamics changed so much,” Robbins said. In other words, now that everyone knows the NYHA may actually become law, some Democrats may have second thoughts about voting for it.

Gottfried, for one, seemed confident of the bill’s chances. “I fully expect the Assembly to pass the bill again,” he said. He added that he and NYHA Senate sponsor Gustavo Rivera were talking to stakeholders to flesh out the details of the bill and add “additional provisions” to speed its passage through the Senate. They were also “working to convince” Cuomo that the NYHA was the way to go, Gottfried said.

If Gottfried and his allies can pass the legislation quickly in early 2019, it will put Cuomo on the spot, former Assembly member Richard Brodsky—a frequent Cuomo critic—argued in a recent Albany Times-Union column: “Anything short of immediate support puts him under the same kind of statewide and national pressure, intensified by any presidential ambitions he may have.” It’s safe to say that reticence on Cuomo’s part will spark widespread progressive anger. “If Andrew Cuomo’s first appearance in 2019 is to put a bullet through the head of single-payer, it will have political consequences,” Brodsky said in an interview.

If the dynamics of passing the NYHA seem complicated, welcome to a preview of what national politics may look like in 2021. If Democrats can retake control of the federal government in the 2020 elections, they will have likely done so while promising single-payer healthcare, just as New York Democrats did. But passing a bill through Congress will require selling it to voters in the face of intense opposition from insurance companies and the medical industry, and also navigating the push and pull of other priorities like climate change. Medicare for all can seem like a common-sense solution to the country’s patchwork, inhumane, and overpriced healthcare system when advocates talk about it, and it’s popular in many polls. But history suggests the politics turn thorny when government-provided health insurance becomes a real possibility.

“You’re treading into unknown territory here. There’s no map for how to get this down the road.”
–Richard Brodsky

Recent single-payer pushes have come tantalizingly close in other states, only to fail, sometimes in dramatic fashion. In 2014, Vermont Governor Peter Shumlin pulled the plug on a single-payer bill, saying his state couldn’t pay for it. Two years later, a Colorado ballot measure that would have created a single-payer system was rejected by voters after a confusing election-season scrum—abortion-rights groups opposed the measure because the new system wouldn’t have covered such procedures. Last year, a California single-payer bill was effectively axed by Assembly Speaker Anthony Rendon, who said it was “woefully incomplete” and didn’t describe how the system would be paid for. (Single-payer advocates were so incensed they subsequently attempted to remove Rendon from office.)

Gottfried said that unlike the California bill, the NYHA clearly describes where the funding would come from, and unlike Vermont, New York has enough wealth to make paying for a single-system more practical. But other Democratic factions, including some unions and the governor, may not be persuaded by those arguments, setting up a fight between single-payer advocates and the rest of the party, with lawmakers caught in the middle.

As Robbins pointed out, six of the eight former members of the Independent Democratic Caucus—the rogue Democrats who gave control of the Senate to Republicans—lost primaries to grassroots opponents earlier this year, indicating the same base that is demanding single-payer has some teeth. “I would think that the folks who are in elected office now should really figure out how to deliver what they promised in their campaigns,” she said, “because clearly there is a motivated base with high expectations and now the electoral muscle to make them pay at the polls if they don’t deliver.”

That said, Robbins added that “there’s absolutely no guarantee” the bill will pass, and a lot could depend on pressure from activists. Brodsky suggested NYHA sponsors consider a “toned down” bill that is less costly and helps manage the transition so as to address criticisms about job losses in healthcare. He also said Gottfried had the “political shrewdness” to get it done.

“You’re treading into unknown territory here. There’s no map for how to get this down the road. It’s an enormous challenge,” Brodsky said, adding, “the political climate has changed from roughly unfavorable to roughly favorable. That’s not chopped liver.”

The battle over the NYHA will be a state-level political knife fight, but the stakes could be even higher than the future of healthcare in New York. The hope among advocates is that once a single-payer system gets a foothold in one state, it can be exported around the country. The passage of the NYHA would not be the end point of the movement, but the beginning of a new chapter.

“Social progress in this country historically, usually begins at the state level,” Gottfried said. “Our labor laws, a lot of our consumer protection laws, public support for healthcare for poor people, the child health insurance program—all began at the state level.”

By Rebecca Lewis, 12/9/18

With their new majority in the state Senate, Democrats are finally preparing to pass long-stalled progressive legislation. Perhaps the most expansive and expensive item on the agenda – and among the most controversial – is the New York Health Act, which would establish a single-payer health care system in the state, and one study estimated it would cost $139 billion in 2022. Many incoming lawmakers campaigned on the promise that they would get it done, but even if it does pass, it likely won’t be implemented right away.

The Democratic-controlled Assembly has passed the legislation every year since 2015, but in that time it never came up for a vote in the state Senate thanks to the Republican majority. Now that the chamber will be in Democratic hands, the legislation seems far more likely to pass.

A single-payer health care system means that a single entity covers the cost of all health care, which is still delivered by private or nonprofit providers. Everyone pays into a single plan run by the government, which in turn is the only provider of coverage paying claims. Assemblyman Richard Gottfried’s single-payer bill has proposed one public option and a ban on the sale of private insurance unless it offers additional coverage not included in the state plan.

One major obstacle the New York Health Act must overcome is a less than enthusiastic governor. Although Gov. Andrew Cuomo has expressed support for single-payer health care as a concept, he has repeatedly said that it would be better implemented at the national level. In a recent interview on WCNY, he expressed doubt that the state would be able to finance the $150 billion program, since that would nearly double the state’s budget. “There will be rhetorical desire to do things,” Cuomo said. “Governmentally there will have to be a reality test to get all things to fit in the budget.”

Although this sounds like it could put a serious damper on the future of the legislation, Gottfried called the governor’s stance “a perfectly reasonable position for a governor,” noting that Cuomo is already far more progressive than other governors by simply supporting the concept of single-payer health care. Gottfried said he has been in talks with the administration and expects those conversations to accelerate now that passage is more realistic.

Gottfried said that stakeholders who have remained quiet in the past are coming forward to voice their concerns. Most recently, Gottfried and state Sen. Gustavo Rivera, the bill’s Senate sponsor, have been negotiating with New York City public unions over concerns that union members would pay more or have fewer benefits. “What we’re talking about is modifications just to accommodate concerns that people are raising now that it looks like it can easily pass both chambers this session,” Gottfried told City & State. “People who we haven’t heard from are starting to come forward and say, ‘Gee, could you add this nuts and bolts?’ or ‘Tighten it up here.’’”

Gottfried said making tweaks to the bill will continue at least a couple weeks into the session, which begins in early January. However, Gottfried said that he and Rivera will not make any major structural changes to the bill and said the Assembly is “well positioned” to pass the bill this upcoming session.

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People who we haven’t heard from are starting to come forward and say, ‘Gee, could you add this nuts and bolts?’ or ‘Tighten it up here.’ – Assemblyman Richard Gottfried

Rivera expressed more caution, telling City & State that he feels confident that the chamber will engage in meaningful conversations about the bill, which it has never done before, but did not want to make any promises about a timeline for passage. “This is not a simple thing that we’re trying to do,” Rivera said. “We want to make sure that we don’t put anything up for a vote, to be signed by the governor, unless it’s ready to go.”

Bill Hammond, a health policy expert at the right-leaning Empire Center for Public Policy, argued that no amount of change to the New York Health Act would actually make the legislation viable. “I think (Gottfried and Rivera’s) posture right now is not to acknowledge the sacrifice, it’s to make it even more attractive to whatever interest group thinks they’re going to lose,” Hammond told City & State. He added that any changes would likely add to the already astronomical cost of the bill.

But Gottfried maintained that a single-payer system will lead to lower overall health care spending despite the introduction of a new payroll tax because the average New Yorker would no longer pay insurance premiums and copays. He cited the Rand Corp. study, commissioned by the New York State Health Foundation, which found total health care spending could be lower under the New York Health Act than under the status quo. “To me, the issue is not about where your check goes,” Gottfried said. “What people really care about is how much are they going to have to spend, and how much they will be able to keep under the New York Health Act.”

However, Hammond pointed out that since there is no precedent for the system in the country, the details of the new tax plan have not been worked out yet and it is hard to accurately predict the cost of the program, so the Rand study could be wrong. He added that it also hinges on the federal government providing waivers to in order to divert Affordable Care Act, Medicare and Medicaid funding into the single-payer system, an unlikely prospect with the current administration. “There’s all kind of doubt and uncertainty about who’s going to pay more and who’s going to pay less,” Hammond said.

Rivera dismissed the idea that the New York Health Act depends on receiving those federal waivers, saying they would be helpful, but not necessary. “We believe, both my colleague and myself, believe that there are ways within the system that we could actually extend the New York Health Act as a wraparound service that would ultimately not require waivers,” Rivera said. He added that since the single-payer system would take years to put into place, he remained hopeful that a different, more sympathetic administration would be in the White House by then.

Another sticking point in evaluating and passing the New York Health Act is the fact that the previous legislation contained no specific language on tax rates for the proposed payroll tax, forcing Rand to use a hypothetical tax schedule. Gottfried said no language about tax brackets will be added to the legislation that he and Rivera will introduce and that it will be worked out after the bill’s passage since the program will take years to implement. He added the absence of this information will not pose an impediment to passage and that it could be easily added in if it becomes necessary.

Despite the many obstacles the legislation appears to face, Gottfried said that he and Rivera have learned from their previous mistakes, such as not including a revenue stream, and they remain confident New York will lead the country in single-payer health care. “Anything has to start with somebody,” Gottfried said. “And New York is ideally suited to be the state that begins single-payer coverage.”

By Jonathan Lamantia, 12/7/18

The City Council seems likely to pass a resolution endorsing a state single-payer health care bill after a hearing Thursday in which health committee chair Mark Levine fervently supported such a system and criticized its detractors.

Levine derided the status quo in health care, which costs more per capita in the U.S. than in other developed countries without better outcomes. He said that while he supports a national approach, it is unlikely to be taken up by the Trump administration.

“New York need not and must not stand still in the face of inaction at the federal level,” he said.

The bill would create a statewide public fund to cover all New Yorkers with no out-of-pocket costs. It received broad support at the hearing from nurses, physicians, social workers, immigrant advocates, disability rights activists and community groups.

The New York Health Act has passed the Assembly four consecutive years, and with the Democrats taking control of the Senate in January, there is an increased chance of the bill’s passage next year. Gov. Andrew Cuomo has said he believes the federal government is best positioned to take up the issue.

Assemblyman Richard Gottfried and state Sen. Gustavo Rivera plan to reintroduce the bill in January to address fiscal concerns. One new wrinkle, which Gottfried previewed Thursday, is that it will incorporate long-term care, such as nursing home and home care.

“No New York family will have to wipe out their savings, and no family member will have to give up a career to provide long-term care for a loved one,” he said at the hearing.

A coalition called Realities of Single Payer, which includes the state Health Plan Association, state Conference of Blue Cross and Blue Shield Plans, and the Business Council, said in a statement that the hearing was “nothing more than political theater” and a single-payer system would result in higher taxes and decreased access to care.

An analysis in August by Rand Corp. estimated that the state would need to raise $139 billion more in taxes by 2022 to fund the program, an 156% increase above expected levels. The research organization proposed one possible tax structure, as the current bill lacks one. Under its proposal, households earning up to $290,000 would pay a smaller percentage of their income toward health payments, including the new taxes.

The analysis assumed the state would receive a waiver from the federal government to deliver Medicare and Medicaid benefits through its own program while still receiving federal funds. Centers for Medicare and Medicaid Services Administrator Seema Verma has said she wouldn’t approve such a waiver.

David Rich, executive vice president of the Greater New York Hospital Association, spoke in opposition to the bill at the hearing. He noted the coverage gains New York has made to lower its uninsured rate to 5% from 10% in 2013 and said there were other ways to insure the remaining 5%. He said he worried a single-payer system would provide lower reimbursement to hospitals than the current system.

“Yes, we must cover the remaining 5% of New Yorkers who are uninsured. Yes, we should make health care affordable,” he said. “We can do this without the disruption we think would be caused by a single-payer system.” 

By Sharon Otterman, December 5, 2018

Carolyn Kenyon, left, and Judith Jones, both of Ithaca, N.Y., raised $12,500 and sent it to a debt-forgiveness charity, which then purchased a portfolio of $1.5 million of medical debts on their behalf. Credit Heather Ainsworth for The New York Times

If a slim, yellow envelope with a Rye, N.Y., return address lands in your mailbox this holiday season, don’t throw it out. It’s not junk.

Some 1,300 such envelopes have been sent to New Yorkers around the state, containing the good news that R.I.P. Medical Debt, a New York-based nonprofit organization, has purchased their medical debt — and forgiven it.

Last spring, Judith Jones and Carolyn Kenyon, both of Ithaca, N.Y., heard about R.I.P. Medical Debt, which purchases bundles of past-due medical bills and forgives them to help those in need. So the women decided to start a fund-raising campaign of their own to assist people with medical debt in New York.

Over the summer months, the women raised $12,500 and sent it to the debt-forgiveness charity, which then purchased a portfolio of $1.5 million of medical debts on their behalf, for about half a penny on the dollar.

Ms. Jones, 80, a retired chemist, and Ms. Kenyon, 70, a psychoanalyst, are members of the Finger Lakes chapter of the Campaign for New York Health, which supports universal health coverage through passage of the New York Health Act.

“The way sort of opened,” Ms. Jones said. They cast a wide net for donations, she said, explaining to people that the campaign was only a short-term fix for the larger problem of out-of-control medical costs.

Many people take on extra jobs or hours to afford health care, and 11 percent of Americans have turned to charity for relief from medical debts, according to a 2016 poll conducted by The Times and the Kaiser Family Foundation.

The 1,284 New Yorkers who had their debts forgiven live in 40 of the state’s 62 counties, from Westchester to Chautauqua. The sources of the debt were some 130 hospitals and branches that had provided medical services, R.I.P. Medical Debt said.

“I like doing this much more than I liked doing collecting,” Mr. Antico said.

R.I.P. Medical Debt had its first star turn in 2016, when John Oliver did a segment on his HBO show “Last Week Tonight,” in which he paid $60,000 to forgive $14.9 million in medical debts through the charity. About 9,000 people received the yellow forgiveness envelopes as a result.

Since then, other high-profile efforts to forgive debts through the charity include fund-raisers sponsored by NBC and Telemundo affiliates.

In all, the organization says its donations have forgiven $434 million in medical debt so far, assisting some 250,000 people. That remains only a fraction, though, of the more than $750 billion in past-due medical debt that it says Americans owe.

“It is a drop in the bucket,” Mr. Antico said.

R.I.P. Medical Debt specifically seeks to buy the debts of people who earn less than two times the federal poverty level, those in financial hardship and people facing insolvency.

It purchases the portfolios at a steep discount, a penny or less on the dollar. These bills have typically passed through several collection agencies and months or years of collections. The people, who do not know they have been selected, receive the debt relief as a tax-free gift, and it comes off their credit reports.

Mr. Antico said he thought of his charity as a “resolutionary, not a revolutionary” effort, one that offers people relief, but that cannot solve underlying issues like high medical costs. Through personal data associated with the debt accounts, they are able to target specific classes of people, such as veterans, to relieve their debts.

“I do like the idea that people do not have to ask for help,” he said. “The random act of kindness is kind of a cool thing.”

The envelopes from Ms. Jones and Ms. Kenyon’s gift went out in November, but new letters are going out all the time. And don’t worry. Even if you throw your yellow letter out, your debt is still forgiven. You just might not know about it until the next time you run your credit.

Victor Porcelli, November 14

Though Governor Andrew Cuomo has not expressed support for instituting a single-payer health care system in New York, his fellow Democrats campaigned on the issue as they flipped control of the state Senate, landing all of state government into Democratic hands and providing a significant boost of optimism to the lead sponsors of the New York Health Act, which would create a government-administered single-payer health care system.

The bill has passed the Democrat-dominated state Assembly several times and all the members of Senate Democratic conference signed on as co-sponsors at the end of last legislative session in a unified show of support for the program heading into the election season.

Cuomo has said he supports a Medicare for all-type system at the federal level, but cast doubts on the cost and complexity of doing it in New York, and since their resounding wins on Election Day, the incoming leaders of the Democratic Senate majority have indicated that the massive undertaking of single-payer is not at the top of the agenda.

Still, with Democratic control of the Senate and the Assembly by wide margins, single-payer healthcare could be passed as early as the 2019 session, according to Assemblymember Richard Gottfried, chair of the Assembly Health Committee and lead sponsor of the New York Health Act.

“It was clear in the country and New York that healthcare was the number one issue on voters’ minds,” Gottfried said, before pointing to his legislation. “A solid majority of the new state Senate has either been a cosigner, voted for it in the Assembly, or campaigned on it. So I think we’re on track to get it passed in the Assembly and state Senate.”

The New York Health Act would replace health insurance companies with New York state government as the payer of healthcare costs for all New Yorkers. It has been passed in the Assembly four years running but has yet to be voted on in the Senate, where Republicans have held control. All of the other 30 Democratic senators joined lead sponsor Senator Gustavo Rivera of the Bronx to co-sponsor the legislation, though the Senate Democratic conference is seeing significant turnover due to primary wins by insurgent challengers. But, those challengers have in general been even more vocally supportive of single-payer health care than their more moderate predecessors. These facts give Gottfried confidence that the New York Health Act will pass during the 2019 session, which begins in January.

But the bill still faces an uphill battle, in part because of the massive changes it would institute, and the fact that though it might reduce overall individual and business healthcare costs after implementation, for the state to run the system it would require raising taxes significantly, something many Democrats have promised not to do and Cuomo is vehemently opposed to. It would also drastically impact the state’s private and public hospitals, the health insurance industry, and more. Some of the changes would of course be beneficial to New Yorkers, but the undertaking is complex and the New York Health Act as currently written leaves a lot of detail undetermined, including funding.

The governor has repeatedly opposed single-payer healthcare at the state level, suggesting that it would be more rational and financially feasible if administered by the federal government. Cuomo questioned in the past how a single-payer system could be put in place without doubling the tax burden, and cited California’s and Vermont’s debates over single-payer — which both ended when supporters were not able to answer one question: where would the funding come from? — as paragons of the impracticality of state-level single-payer.

Gottfried, a Manhattan Democrat, is confident that with his fellow lead sponsor Senator Rivera, who is likely to be the Senate health committee chair come January, and other legislators, he will be able to sway Cuomo to support the legislation.

“He’s obviously not on board yet, but he and his staff are very open to working with the Legislature on the issue,” Gottfried said. “I’m convinced we can satisfy their concerns.”

And after a recent study by RAND Corporation concluded that the New York Health Act would result in a reduction of administrative costs, provide all New Yorkers with healthcare, and reduce healthcare costs for most, Gottfried says the financing of the bill will not be a problem.

“New Yorkers are all going to have to think about what they will do with the hundreds of thousands of dollars that will end up in their pockets, and that’s a nice problem to have,” Gottfried said.

The study has a caveat, however, stating in its conclusion that “the estimated effects depend heavily on the assumptions about provider payments, administrative costs and drug prices.” Politico highlighted these assumptions as well as the likely tax increases that have largely been brushed aside by Democrats supporting the legislation. Wealthy people leaving the state, companies restructuring, the cost of hospital expenses rising at a faster rate or the Trump administration not issuing a federal waiver to redirect all healthcare-related funds to the new state entity are all possible events that could result in RAND’s conclusion falling apart.

For it to work, while health care costs drop, taxes would undoubtedly increase significantly for many New Yorkers. As cited by Politico, “a household reporting $150,000 in income would see its state tax rate increase from 6.45 percent in 2017 to 18.3 percent,” under one model scenario. Additionally, those who receive Medicaid or fall under the state’s Essential Plan, which subsidizes health insurance for low-income New Yorkers, have less to gain from the expansion. According to RAND, though, 1.2 million New Yorkers would gain health coverage.

It is likely that funds for New York single-payer health care would partially come from a new payroll tax, which RAND projects to fall largely on employers. However, RAND suggests the health act payroll tax would cost less for businesses already contributing toward employee health insurance and the Medicare payroll tax, estimating decreases in employer costs fairly quickly.

Concerns about businesses and high-income individuals leaving the state persist, with a tax atmosphere in New York that many, including Cuomo, acknowledge is already burdensome and became more so for many taxpayers, especially top earners, under the new federal tax code.

Senator Rivera, aware that cost is the primary argument against single-payer health care, repeatedly emphasized the need to work towards a version of the bill that would reduce the financial strain.

“I will continue working diligently with Assembly Member Gottfried, Senate Majority Leader Stewart-Cousins and the Senate Democratic Conference to make the New York Health Act a bill that is not only fiscally responsible, but that provides comprehensive coverage to all New Yorkers,” Rivera wrote in an email to Gotham Gazette.

The bill and its potential ramifications have been studied closely by Bill Hammond, director of health policy at The Empire Center, a think tank. “Regardless of which party controls the state Senate, the New York Health Act remains a wildly unrealistic idea,” Hammond said by email. “It means putting New York’s entire health-care system — representing one-fifth of the economy — in the hands of the same state government that struggles to run the subways. It requires massive, draconian tax hikes, enough to roughly triple total state revenues.”

“Plus, a true single-payer plan would need federal waivers that the Trump administration has vowed to block,” Hammond continued, also noting a political angle — that if Democrats spend great sums of money and political capital on a health care overhaul of this magnitude, what will they ignore, like fighting climate change or improving mass transit.

“It was easy to cast a symbolic yes vote for a single-payer bill that had no chance of passing,” Hammond said. “Now that that it might actually happen, supporters are going to be forced to confront the practical realities. Then, hopefully, they’ll focus on helping the 6% of New Yorkers who still lack insurance, rather than disrupting coverage for those who already have it.”

Rivera acknowledged that moving to single-payer would not satisfy everyone, especially those who benefit from the current system, and that there are negotiations to come that will likely adjust the bill to make it more palatable to holdouts.

“The biggest challenge will be to reach a consensus among stakeholders that the NY Health Act is feasible [and] fiscally responsible,” Rivera wrote.

Citing “healthcare practitioners, prescription drug companies, healthcare providers, employers, unions and New Yorkers,” as the various groups involved, Rivera also mentioned courting Cuomo as an important step to take in the coming legislative session.

“Our main priority for the next legislative session is to continue shaping the bill so that it is feasible, affordable, that the Governor is willing to sign, and that primarily, provides quality healthcare for everybody,” Rivera wrote. “During the next legislative session, we will focus on making the necessary amendments to the bill so that it truly reflects the different healthcare needs affecting all New Yorkers.”

For now, it is very difficult to imagine Cuomo coming on board, especially given the pains he’s taken to keep state spending increases at around 2 percent per year and to lower taxes. Asked about single-payer health care during a Thursday appearance on The Capitol Pressroom with host Susan Arbetter, Cuomo painted it as unrealistic given budget constraints. He said Democrats are generally in agreement on the concept, but legislators will have to deal with reality in working with him on a state budget next year, while he also said he thinks it’s much more workable on the federal level. “Single-payer health plan, for example,” Cuomo said, “conceptually I think it’s the right way to go in. I believe it’s more feasible financially on the national level. No state has been able to finance the transition costs.”

A variety of factors, including the challenge of getting Cuomo’s support and not wanting to come into power quickly pursuing something as revolutionary as single-payer health care, may be why the likely next Senate majority leader, Andrea Stewart-Cousins, and her likely deputy, Senator Michael Gianaris, have not highlighted it as top priorities for the coming session.

Assemblymember Gottfried noted that state Senators’ public approval of the bill gives him no reason not to “take them at their word,” and said he expects the legislation to move through the Legislature. He knows that private health insurers are certain to vehemently oppose the continued push.

“The insurance industry will be fiercely lobbying against the bill and they have a lot of money, going up against their lobbying will take a lot of work,” Gottfried said. “but I’m convinced with so many senators on the record in support of the bill, we will prevail.”