From Strategy to Reality: The Enactment of New York's Family Health Plus Program

Less than a week before Christmas in 1999, Governor George Pataki and the leaders of the New York State Legislature basked in the spotlight after announcing that they had agreed to back a new entitlement program, Family Health Plus (FHP), that would offer fully subsidized health insurance to 600,000 low-income, working adults in New York State. Passage of this bold new program, along with its financing mechanism--a near doubling of the state's cigarette tax plus proceeds from the national tobacco settlement--would place New York ahead of most of the nation in extending publicly funded health coverage to adults, and would make the state's cigarette tax the highest in the nation.

This news surprised even the most seasoned political observers. Few had predicted that Governor Pataki and Senate Majority Leader Joseph Bruno, both Republicans and fiscal conservatives who prided themselves on their record of tax cutting and prudent health care spending, would join forces with Assembly Speaker Sheldon Silver, a Democrat, to enact the biggest single health insurance expansion in the state since the creation of Medicare and Medicaid. Even fewer expected these leaders to agree to hike cigarette taxes to fund this initiative.

While governors across the country were expanding health insurance programs for low-income children, only a handful of states had taken advantage of a relatively new federal option to extend their Medicaid programs to cover more low-income parents. Even fewer states were willing to cover childless adults--a more expensive and less politically sympathetic population than either children or parents. The media, health care advocates, and political pundits alike heralded New York's achievement.

I greeted the news of this historic agreement with perhaps less shock than many, since I had a front row seat to the events leading to the passage of this legislation and knew that negotiators had been close to an agreement in the weeks before Christmas. Nevertheless, some of the program's details surprised me and, on a personal note, I was relieved that two years of work to ensure enactment of a health insurance expansion had finally borne fruit.

In 1997, I left my job in Washington, DC, to work at the Greater New York Hospital Association (GNYHA), which represents 175 public and not-for-profit hospitals and nursing homes in the New York City area, to head a project called "Insurance Options for the Uninsured" (IOU). My sole mission as IOU's director was to devise and implement strategies for expanding health insurance coverage in New York State.

This position was, in some respects, a natural progression from my work in Washington, where I was the senior health policy advisor to the Senate Democratic Leader, Tom Daschle. For over a decade, I advised Daschle on health care matters before the Senate and helped him shape the health agenda of the Democratic Caucus. Many of my efforts were focused on advancing health insurance expansions, though, toward that end, I was involved in far more legislative defeats than successes. From the Medicare Catastrophic Health Insurance bill, which was enacted and repealed during my first two years working in the Senate, to the failed Clinton health plan in 1994, I had played a part in some of the most high-profile--but ultimately unsuccessful--health legislation Washington had produced in the past ten years. My last year on Capitol Hill, Congress did pass the Title XXI State Children's Health Insurance Program (SCHIP), a significant expansion of health coverage for children, but the political climate in Washington made me pessimistic that broader national health reform measures would originate there in the coming years. Rather, I expected the states to take the lead on this issue, and moving to New York offered me a unique opportunity to participate in...