Lessons from COVID 19: Examining the History and Context of the 2024 New York Health Equity Reform Waiver Amendment

The Affordable Care Act (ACA), passed in 2010 by the Obama administration, is a landmark law that has improved health equity in the United States. It expanded health resources for women, families, children, the elderly, the disabled, communities of color, and the LGBTQ+ community. This has come through the required plans that cover women’s preventative health services, the establishment of the Pregnancy Assistance Fund (PAF), and an $11 billion funding contribution to community health centers, among many other initiatives [1]. In addition to these initiatives, the ACA also brought significant reforms to longstanding programs like Medicare and Medicaid, enhancing their reach and effectiveness. While the ACA did not create Medicare and Medicaid—both established in 1965—it created substantial reforms to these programs. Medicare and Medicaid are both health insurance programs that provide health coverage to people 65 and older and people with low incomes, respectively. Out of the two programs, the amendment to which this paper is dedicated focuses specifically on Medicaid, which is a state-federal partnership that is administered and funded by both.  Hence, the 2024 New York Health Equity Reform (NYHER) 1115 Waiver Amendment significantly impacts Medicaid for its residents, more so than Medicare, which is solely a federal program thus having a far less direct individual impact.

The Affordable Care Act has lasted for 14 years to date and has withstood two administrations since its birth under the Obama administration. The ACA has expanded over the years on both federal and state levels. Namely, through voting in South Dakota and North Carolina, legislative action with the International Revenue Service (IRS) was taken to fix the ACA’s  “family glitch” that made healthcare more expensive for families with children [1]. While these changes make the program even better, states still have a crucial role to play in improving their healthcare equity through state-level action. As the relevant state-level action in New York seeks to improve the social determinants of health for their residents, so does the United States for their citizens. The precedent set in place by the ACA has significantly reduced both ethnic and racial disparities in receiving healthcare in the forms of insurance and physical access. This is supported by the data collected before and after the 2013 provision of the ACA.  Before 2013, families ineligible for Medicaid and uninsured among different populations were as follows: 24.4% of the Hispanic population, 24.4% of the Black population, and 14.5% of the White population. After implementation, these numbers dropped to 24.5%, 13.5%, and 8.2%, respectively [2], demonstrating a large increase in Medicaid eligibility among all groups.  However, despite this improvement, millions of uninsured Americans still lack coverage.  Many states do not have a plan to expand Medicaid, leaving many with no hope of obtaining health care coverage in the future. Further motivation for this amendment waiver stems from COVID-19, which had profound negative effects on susceptible populations like low-wage workers, children, and people of color. Data from the Centers for Medicare & Medicaid Services (CMS) revealed significantly higher levels of COVID-19-related hospitalizations and mortality rates exhibited among Black and Latino populations compared to white individuals. This difference is largely attributed by systematic factors affecting people of color, including a higher prevalence of chronic illness, overrepresentation in frontline jobs, and increased likelihood of having multigenerational or multifamily housing [9]. Such disparities continue to highlight the need to address social determinants of health and make healthcare more equitable.

New York’s most recent addition before the NYHER Waiver Amendment to Medicaid was through the ACA Medicaid Expansion. The ACA Medicaid expansion was initially a mandatory expansion created by the federal government that would expand Medicaid eligibility to non-elderly adults with incomes up to 133% of the federal poverty level.  However, in a 2012 Supreme Court decision, National Federation of Independent Business v. Sebelius ruled that the federal government could not hold payment for a state's Medicaid program if they did not implement the ACA Medicaid expansion, which made the expansion optional for states [7].  New York State implemented this in January 2014 making it one of 41 states to adopt the Medicaid expansion as of 2024, while 10 states have yet to accept [3]. The changes made by adopting this expansion increased the income eligibility threshold for pregnant women from 200% to 223% of the Federal Poverty Level, which had a statistically significant impact on reducing severe maternal morbidity for low-income women during delivery hospitalizations compared to high-income women [8]. The NYHER Waiver Amendment seeks to make similar changes to the ACA Medicaid expansion and also target more social determinants of health.  This amendment is one of the most recent changes in New York's healthcare access, but the state has been active in improving healthcare access and reducing the disparities caused by the social determinants of health. One example is the Doula Services Benefit, a state-wide Medicaid Executive Budget enactment in the 2023-2024 year [4]. This enactment became effective in March 2024 and allows all New York State Medicaid Members to receive doula service at no cost during and up to 12 months after pregnancy. This is effective regardless of the outcome of the pregnancy, and members can receive up to eight doula visits before and after pregnancy.

The NYHER Waiver Amendment continues on the same path as previous New York legislation to expand access and reach of Medicaid. To pass this amendment, there was over a year of negotiation between the CMS and the New York State Department of Health (DOH).  These efforts began on March 31, 2020, after the Delivery System Reform Incentive Payment Program (DSRIP) expiration, which reduced avoidable hospitalizations by 25% over five years [5]. The process to pass this amendment began with the Concept Paper, released in August 2021, which outlines the four goals of the amendment. These include “Goal #1: Building a more resilient, flexible and integrated delivery system that reduces racial disparities, promotes health equity, and supports the delivery of social care”. This works towards investing in regional planning, Social Determinant of Health Networks (SDHN) development and performance, Advanced Value-Based Purchasing (VBP) arrangements, Capacity building and training, and ensuring access for populations impacted by the justice system [9]. The first goal’s initiative  covers several different groups of different income statuses and criminal records. The goal directly reduces the negative effects of social determinants of health by reducing the negative impact one’s society or community can have towards receiving equitable healthcare.  The following three goals include Goal #2: Developing Supportive Housing and Alternatives to Institutions for the Long-Term Care Population. Goal #3: Redesign and Strengthen Health and Behavioral Health System Capabilities to Provide Optimal Response to Future Pandemics & Natural Disasters. Goal #4: Creating Statewide Digital Health and Telehealth Infrastructure” [9]. These goals continue to contribute towards reducing social determinants of health that negatively impact people of color's healthcare quality and access. 

Following the concept paper, New York submitted a formal waiver application to CMS on September 2, 2022. This led to a series of negotiations between CMS and DOH regarding the 1115(a) waiver and the eventual passing of the waiver amendment. This waiver amendment to section 1115(a) was passed in other states before the approval of NYHER; these states include Arkansas, Arizona, California, Massachusetts, New Jersey, Oregon, and Washington. The final waiver amendment passed in New York State was then able to draw upon the waiver amendments passed in the aforementioned states and improve the realm of effectiveness in improving health equity, long-term program stability, and general design of the legislative work.  

[1]  In Depth: How the Affordable Care Act Changed America.  The Barack Obama Foundation

[2]  Mandler, The Affordable Care Act Has Significantly Reduced Racial Disparities in Health Care Access

[3] Status of State Medicaid Expansion Decisions, KFF

[4] Family Planning Benefit Program, Medicaid Program Information, 2024

[5]  Friedman,, et al., CMS Approves Groundbreaking 1115 Waiver Amendment for New York State Medicaid Program

[6] Social Determinants of Health,  Healthy People

[7] Mitchell, Overview of the ACA Medicaid Expansion

[8] Study Examines Value of Medicaid Expansion in New York, Columbia University Mailman School of Public Health

[9] Friedman, New York Health Equity Reform (NYHER)

Works Cited

“Family Planning Benefit Program.” Medicaid Program Information, 2024. https://www.health.ny.gov/health_care/medicaid/program/longterm/familyplanbenprog.htm.

Friedman, Brett R, Drew M Clary, Stephanie A Webster, David O Ault, and Timothy Rozier-Byrd. “CMS Approves Groundbreaking and Innovative 1115 Waiver Amendment for New York State Medicaid Program: Insights: Ropes & Gray LLP.” Insights | Ropes & Gray LLP, January 16, 2024. https://www.ropesgray.com/en/insights/alerts/2024/01/cms-approves-groundbreaking-and-innovative-1115-waiver-amendment-for-new-york-state-medicaid-program.

Friedman, Brett. “New York Health Equity Reform (NYHER).” New York State Department of Health, 2022. https://www.health.ny.gov/health_care/medicaid/redesign/med_waiver_1115/docs/2022-09-02_final_amend_request.pdf. 

“In Depth: How the Affordable Care Act Changed America.” The Barack Obama Foundation, 2023. https://www.obama.org/stories/13-years-aca/

Mandler, C. “The Affordable Care Act Has Significantly Reduced Racial Disparities in Health Care Access, Report Says.” CBS News, March 22, 2023. https://www.cbsnews.com/news/affordable-care-act-obamacare-reduced-racial-and-ethnic-disparities-healthcare/.

Mitchell, Alison. “Overview of the ACA Medicaid Expansion - CRS Reports.” Congressional Research Service, June 9, 2021. https://crsreports.congress.gov/product/pdf/IF/IF10399.

“Social Determinants of Health.” Healthy People 2030, 2021. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health.

“Status of State Medicaid Expansion Decisions.” KFF, November 12, 2024. https://www.kff.org/affordable-care-act/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/#:~:text=On%20March%2027%2C%202023%2C%20Governor,budget%20by%20June%2030%2C%202024.

“Study Examines Value of Medicaid Expansion in New York.” Columbia University Mailman School of Public Health, October 3, 2022. https://www.publichealth.columbia.edu/news/study-examines-value-medicaid-expansion-new-york#:~:text=The%202014%20New%20York%20State,of%20the%20Federal%20Poverty%20Level.