II.A. Overview of the State
As of 2018, New York State (NYS) has the fourth largest population after California, Texas and Florida, with a population of 19.8 million. NYS is a diverse state with a substantial portion of its population being members of racial and ethnic minorities. Compared to the national population, in 2018, a larger percentage of NYS’s population is Black (15.66% NYS: 13.4% US); Asian (8.35% NYS: 5.8% US); and Hispanic (19.2% NYS: 18.1% US). NYS also has a significantly larger foreign-born population (22.7% NYS: 13.7% US-2013-2017 data), and larger population speaking a language other than English at home (30.6% NYS: 21.3% US-2013-2017 data). NYS’s cultural diversity is both a strength and challenge. Racial and ethnic minorities often face more obstacles accessing quality healthcare services than white Americans, even when they have insurance. A priority for NYS is to ensure that health care systems meet the needs of diverse populations to promote equity in health care and eliminate disparities in health access and outcomes. Throughout this application, NYS’s commitment to health equity, especially focused on addressing the significant disparity in maternal mortality, will be evident.
In 2013-17, the percent of New Yorkers who graduated from high school was slightly below the national level (86.1% NYS: 87.3% US), while the percentage with a bachelor’s degree or higher was higher at 35.3% versus 30.9%. NYS’s per capita income in the past 12 months (2017 dollars – 2013-17) was higher than the national average ($35,752 NYS: $31,177 US), and NYS’s median household income for 2013-17 was also higher ($62,765 NYS: $57,652 US). However, NYS’s percentage of persons in poverty was higher than the national percentage (14.1% NYS: 12.3% US). Educational attainment has a major impact on income and is a significant factor in access to quality health care. Poverty is also associated with poor health outcomes, especially for women and children. Racial and ethnic minorities are significantly impacted by lower educational attainment and poverty in NYS.
NYS’s population is dense; in 2018 there were 421 persons per square mile in NYS, ranking 12th out of 56 US states and territories. New Yorkers are more likely to live in urban areas than residents of other states—64% of NYS’s population live in the NY Metropolitan area, 43% in New York City (NYC) alone. NYC remains the most populous incorporated place in the US with 8.5 million people (2015). NYS is also geographically diverse; population density varies widely, from 27,000 persons per square mile in Manhattan to only three persons per square mile in Hamilton County in the Adirondack Mountain Range. NYC is 104 times more densely populated than the rest of the state. Population density often determines the number and types of health services in an area.
NYS has a rich health care system. In 2017, NYS had the third-highest ratio of physicians to residents in the nation, with approximately 365 physicians per 100,000 residents, compared to a national average of 271 per 100,000. NYS also has 111 active primary care physicians per 100,000 residents, and 10 general surgeons per 100,000, with rankings of the seventh highest ratio and 15th in the nation, respectively. NYS is home to more than 2,500 outpatient hospital and free-standing health clinics. This includes 47 Article 28 sponsoring facilities with approximately 262 school-based health centers (SBHC) of which 160 are Federally Qualified Health Centers (FQHC). To increase access to dental care, there is a system of 52 Article 28 sponsoring facilities which operate 1,940 SBHC-dental clinic sites across NYS. There is also a network of 172 family planning clinic sites. In addition, NYS has over 220 hospitals including 120 perinatal hospitals and 3 free-standing birthing centers. Despite the substantial health care resources, many areas of the state lack access to needed services due to a maldistribution of resources. As of January 2019, there were 150 primary care Health Professional Shortage Areas (HPSAs), 103 dental HPSAs; and 145 mental health HPSAs. Of the total HPSAs, about 37% of HPSAs are in metropolitan areas; 63% are in rural or mostly rural (non-metropolitan) areas. More than 4 million New Yorkers live in a primary care HPSA.
The redesign of NYS’s Medicaid program to improve health care outcomes while containing costs continues as a priority. At the inception of the Medicaid Redesign efforts, NYS’s Medicaid (MA) Program, once the nation’s largest, was spending nearly $59 billion to serve 6.3 million people, which was twice the national average when compared on a per recipient basis. Since its inception in 2011, the Medicaid Redesign Team’s (MRT) reforms have generated $8 billion in federal savings, which were reinvested through a 2014 Federal-state waiver in NYS’s Delivery System Reform Incentive Payment program (DSRIP), currently in its fifth year. DSRIP led to a network of Performing Provider Systems (PPS) comprised of hospitals, individual providers, and community-based organizations, who collaborated to provide patients with community-based, higher quality, coordinated care. Through community-level collaborations and a focus on system reform, the ultimate goal of these projects is to achieve a 25% reduction in avoidable hospital use over 5 years. As of the second quarter of year three, the halfway mark of this initiative, PPS earned over $3 Billion in DSRIP funding with over 3 million patient engagements. PPS also successfully met all state and/or PPS implementation requirements for a total number of 44 completed projects. The focus on DSRIP in this last year is to build community services and decrease unnecessary hospitalizations, implement Value Based Payments (VBP) to ensure the reimbursement follows improved outcomes and to ensure these systems that have been supported and developed since the inception of DSRIP are integrated into the community and continue to support improved health outcomes for all New Yorkers.
In July 2017, Medicaid announced a new focus for Medicaid Redesign in NY: The First 1,000 Days on Medicaid initiative, recognizing that a child´s first three years are the most crucial years of their development. This effort ensures that NYS’s Medicaid program is working with health, education and other system stakeholders to maximize outcomes and deliver results for the children served. The First 1,000 Days aims to improve lifelong educational and health outcomes by focusing on early childhood development. The ten initiatives being piloted by the NYS Department of Health (DOH) under its First 1,000 Days are:
- Create a Preventive Pediatric Care Clinical Advisory Group
- Increase early literacy by expanding the Reach Out and Read program and supplying books to families of young children at primary-care doctor visits
- Expand Centering Pregnancy, an evidence-based group prenatal care model in communities with poor birth outcomes
- Develop a NYS Developmental Inventory Upon Kindergarten Entry to assess school readiness
- Ensure sustainability of maternal infant home-visiting in three high-risk perinatal communities
- Require Managed Care Plans to have a Kids Quality Agenda
- Develop a "hub-and-spoke" data system for cross-sector health care referrals in three communities
- Explore Braided Funding for Early Childhood Mental Health Consultants
- Support Parent/Caregiver Diagnosis as Eligibility Criteria for Dyadic Therapy
- Launch peer family navigator services at five sites across NYS that help hard-to-reach families connect to early childhood health resources.
The collaborative approach of the MRT serves as an example of how public agencies can partner with stakeholders to develop innovative solutions. The efforts of the MRT benefit Medicaid members, health care providers, community-based organizations and other stakeholders, through efforts to improve quality care and reduce costs. It is anticipated that savings from MRT reforms will continue to grow in future years as key structural reforms are implemented. In March 2018, NYS’s MRT was awarded this year's Public Service Innovation Award from the Citizens Budget Commission recognizing the MRT for transforming NYS’s Medicaid program into a national model by cutting costs and putting patients first. NYS’s Title V program works closely with the Office of Health Insurance Program (OHIP) that oversees NYS’s Medicaid program.
NYS’s Population Health Improvement Program (PHIP) complements DSRIP and advances the Prevention Agenda (PA, discussed below) and the State Health Insurance Program (SHIP). Priorities include integrating behavioral health into primary care as well as addressing broad social determinants of health. This planning and integration also include Value Based Payments (VBP) - a method to directly tie payment to providers with quality of care and health outcomes to incentivize providers through shared savings and financial risk. By DSRIP Year 5 (2020) all Managed Care Organizations must employ VBP methodologies that reward value over volume for at least 80-90% of their provider payments. Broad representation is included in VBP workgroups to ensure the standards and guidelines for these payments reflect broad input. Title V staff are members of the Maternity Care and the Children’s Clinical Advisory Groups convened to develop and update the quality measure sets used for the VBP contracting on an annual basis.
In addition to DSRIP, the federal waiver amendment allows for comprehensive primary care transformation and commercial health plan multi-payer engagement through a Center for Medicare and Medicaid Innovation (CMMI)-funded State Innovation Model (SIM) grant. The goal is to build a highly functioning primary care model that includes behavioral and population health and is complemented by a strong workforce and engaged consumers, with supportive payment and common metrics. NYS has built a state aligned NYS Patient-Centered Medical Home (PCMH) model to achieve these goals. There are currently 2,400 practices and about 9,100 physicians recognized under the model and about 750 practices currently undergoing a transformation. The specific outcomes for this initiative include:
- Instituting a state-wide program of regionally-based primary care practice transformation to help practices across NY, adopt and use the NYS PCMH model
- Expand the use of VBP so that 80% of primary care is paid by value-based contracts 2020
- Expand the use of high-value primary care so that 80% of New Yorkers are receiving services in an advanced primary care setting by 2020
- Support performance improvement and capacity expansion in primary care by expanding NYS’s primary care workforce through innovations in professional education and training
- Integrate NYS PCMH with population health through Public Health Consultants funded to work with regional PHIP contractors
- Develop a common scorecard, shared quality metrics, and enhanced analytics to assure that delivery system and payment models support three-part aim objectives.
- Provide state-funded health information technology, including greatly enhanced capacities to exchange clinical data and an all-payer database.
Further commitment to improving the health of all New Yorkers is evident in the PA that was developed in conjunction with the Public Health Committee of the NYS Public Health and Health Planning Council (PHHPC), and in partnership with more than 140 organizations across the state. The PA focuses on eliminating the profound health disparities across all priority areas including: preventing chronic diseases; promoting a healthy and safe environment; promoting healthy women, infants and children; promoting wellbeing and preventing mental and substance use disorders; and, preventing communicable diseases. Title V staff directed the update in the PA 2019 – 2024 related to Promoting Healthy Women, Infants and Children and worked to ensure the alignment with NYS’s Title V State Action Plan. The vision for the 2019-2024 PA highlights a Health in All Policies approach and a focus on healthy aging.
Regardless of the efforts to improve NYS’s health care system, without health care coverage, New Yorkers are unable to access care. Expanding access to health care by making affordable health insurance available is one of the critical accomplishments of the Governor’s health care agenda. The NY State of Health (NYSOH), the state’s official health plan marketplace, was created to assist New Yorkers to gain access to quality affordable health care coverage. As of January 2019, more than 4.7 million New Yorkers were enrolled in health care coverage, an increase of 435,000 people from 2018. Of those enrolled, nearly 272,000 enrolled in private qualified health plans (QHPs); 790,000 enrolled in the state’s Essential Plan (described below), a 9% increase in QHP and Essential Plan from 2017-2018; 418,000 enrolled in Child Health Plus (CHP); and, 3.2 million enrolled in Medicaid. NYS’s uninsured rate fell to 5% in 2018 - its lowest point in decades.
Individuals, families and small businesses can use the marketplace to compare insurance options, calculate costs and select coverage online, in-person, over the phone or by mail. New Yorkers may obtain MA and CHP coverage through the Marketplace. NYSOH has certified more than 9,500 navigators, brokers, and Certified Application Counselors to provide free, in-person enrollment assistance to apply for coverage in 44 languages. NYSOH features a state-of-the-art website where New Yorkers can shop and enroll in coverage and a customer service center to answer questions and enroll people into coverage.
While QHP enrollment is only available year round to applicants who experience a qualifying event, Native Americans can enroll in QHPs year-round. Applicants who are eligible for the Essential Plan, Medicaid, or CHP can also enroll at any point in the year. Under federal ACA rules, a baby’s birth triggers a qualifying event, but pregnancy does not. Legislation was enacted in NYS in January 2016 that makes pregnancy a qualifying event through the state-run exchange, making NYS the first state in the nation where the commencement of pregnancy allows a woman to enroll in a plan through the exchange. With the availability of the NYSOH marketplace, the uninsured rate for rural New Yorkers has declined by almost half, with many gaining insurance coverage for the first time.
The Governor continues to support significant legal, economic and health efforts that will have a positive impact upon the MCH population. The Governor established the NYS Council on Women and Girls in 2018 to recognize and advance women’s rights within NYS. The Council provides a coordinated State response to issues that particularly impact the lives of women and girls, focusing on nine areas of impact. These include education, economic opportunity, workforce development, leadership, health care, child care, safety, STEM and intersectionality. Over the past year, the Governor continued to promote efforts in support of women and families by launching the 2019 Women’s Justice Agenda found at https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/WomensReport021919.pdf. It reflects Governor Cuomo’s continued advocacy and support for equal rights for all New York’s women. The comprehensive proposals included in the agenda take steps forward to improve access to reproductive healthcare, deliver justice to domestic violence survivors, close the pay gap, and ensure reproductive, economic and social justice for all NY women.
In January 2019 Governor Cuomo signed into law the Reproductive Health Act that codified Roe v. Wade into NYS law, clarified who can provide abortion care and removed abortion from the penal code, placing it in public health code. This law ensures that individuals have the ability to access the care they need to protect their health. NYS has always demonstrated a strong commitment to protect access to reproductive health options. In addition, the Governor advanced an aggressive strategy to ensure that all new mothers have access to screening and treatment for maternal depression, including insurance coverage for depression screening by both adult and pediatric primary care providers and launching an awareness campaign to provide information on symptoms and treatment options.
NYS’s application reflects a strong commitment to promoting health equity and particularly focuses on addressing those factors that result in maternal mortality. For nearly eight years, the DOH has conducted a Maternal Mortality Review of all maternal deaths in NYS. While there have been modest improvements, more work remains, particularly since Black New Yorkers remain almost two to three times more likely to die in childbirth than white women.
Recognizing this significant disparity, in April 2018 the Governor announced a comprehensive plan to target maternal mortality and reduce racial disparities in maternal health outcomes. The multi-pronged initiative includes efforts to address maternal mortality with a focus on racial disparities, expanding community outreach and taking new actions to increase access to perinatal care. These efforts include:
- Create the Taskforce on Maternal Mortality and Disparate Racial Outcomes: The Taskforce, consisting of experts in the field and key stakeholders, was formed to provide expert policy advice and develop recommendations to improve maternal outcomes, addressing racial and economic disparities and reduce the frequency of maternal mortality and morbidity in NYS.
- Establish the Maternal Mortality Review Board (MMRB): At the recommendation of the Governor's Council on Women and Girls, the Governor directed the DOH to establish the MMRB comprised of health professionals who serve and/or are representative of the diversity of women and mothers across the state, to work in collaboration with the American College of Obstetricians and Gynecologists (ACOG) District II and NYS to review maternal deaths in NYS. The MMRB will also be tasked with making policy recommendations to the DOH to improve maternal outcomes by reducing maternal mortalities and morbidities, and recommendations will specifically contemplate racial and economic disparities and enhance the efforts of the DOH's Maternal Mortality Review Committee, established in 2010, that conducts a comprehensive, population-based examination of maternal mortality, to determine trends over time.
- Launch the Best Practice Summit with Hospitals and Obstetricians-Gynecologists (OB/GYNs): The Governor sponsored a summit in November 2018 with Greater New York Hospital Association, Healthcare Association of NYS, ACOG District II, and other stakeholders to discuss the issue of maternal mortality and morbidity, including racial disparities. The Summit addressed maternal mortality and morbidity statistics, as well as best practices to improve birth outcomes, community awareness of maternal mortality and disparities, current medical school curricula, graduate medical education and continuing education for physicians, with the goal of implementing immediate measures and identifying future action items to improve maternal care and management.
- Pilot the Expansion of Medicaid Coverage for Doulas: The DOH is piloting the expansion of Medicaid coverage for doulas that are non-medical birth coaches who support a pregnant person before, during or after childbirth, if needed. Certified doulas have been shown to increase positive health outcomes, including reducing birth complications.
- Support CenteringPregnancy Demonstration Projects: NYS increased support for CenteringPregnancy, a group prenatal care model designed to enhance pregnancy outcomes through a combination of prenatal education and social support and has been associated with reduced incidence of preterm birth and low birth weight, lower incidence of gestational diabetes and postnatal depression, higher breastfeeding rates and better inter-pregnancy spacing. It also been shown to narrow the disparity in preterm birth rates between black and white women.
- Require Continuing Medical Education and Curriculum Development: The Governor called on the State Board for Medicine to require appropriate practitioners to participate in continuing medical education on maternal mortalities and morbidities and disparate racial outcomes. Additionally, the DOH will work with medical schools, including the State University of New York's four medical schools, to incorporate information on maternal mortality and disparate racial outcomes into their medical school curriculum, graduate medical education and training for practicing physicians.
- Expand the New York State Perinatal Quality Collaborative: NYS expanded its collaboration with hospitals across NYS to review best practices to address hemorrhage and implement new clinical guidelines to reduce maternal mortality. Currently, over 80 hospitals are engaged voluntarily in this effort.
- Launch Commissioner Listening Sessions: Health Commissioner Zucker partnered with community activists to visit high-risk areas across the state to listen to local stakeholders, including pregnant women, to explore the barriers they face when pregnant or as new mothers. Information from these sessions will be used to enhance and support efforts to improve birth outcomes specifically related to women of color.
The Governor‘s Taskforce on Maternal Mortality and Disparate Racial Outcomes met three times and made a series of recommendations to the State; the top recommendations were included in the State Budget and include: resources to support the MMRB, the development and implementation of implicit bias training for health care providers, expansion of the Community Health Worker Program, the development of a data warehouse for perinatal care and the formation of an expert panel to make recommendations around post-partum care. Additional information regarding these efforts are detailed under the Domain sections of this application. Title V staff are working closely with the Governor’s Office and other key stakeholders and partners to improve birth outcomes, regardless of race, ethnicity and geographic location in NYS. Governor Cuomo remains strong in his support of NYS’s MCH population directly aligned with the purpose and mission of Title V.
In January 2019, the Governor signed into law the Gender Expression Non-Discrimination Act, landmark legislation that protects the rights of LGBTQ people. This legislation bans the practice of conversion therapy. The law also prohibits employers, educational institutions, landlords, creditors, and others from discriminating against individuals based on gender identity or expression and make offenses committed on the basis of gender identity or expression, hate crimes under NYS law. Strong partnerships continue to bolster NYS’s efforts in MCH.
NYS’s Public Health Law (PHL) provides a strong legal foundation for DOH’s efforts to promote and protect the health of individuals. The functions, powers and duties the Commissioner of Health and other DOH officers and employees are detailed in PHL Article 2 and include: supervision and funding of local health activities; the ability to receive and expend funds for public health purposes; reporting and control of disease; control and supervision of abatement of nuisances affecting public health; and to serve as the single state agency for the federal Title XIX (MA) program. Article 2 also provides that DOH shall exercise all functions that, “…hereafter may be conferred and imposed on it by law.”
Law governing the organization and operation of NYS’s local public health infrastructure, which includes the health departments of 57 counties and the City of NY, is contained in PHL Article 3, Local Health Organization. Local health departments are supported by millions of state local assistance dollars, which the DOH administers under the provisions of PHL Article VI, State Aid to Cities and Counties, providing further support for services targeting NYS’s MCH population.
A key determinant of DOH’s capacity to serve individuals is PHL Article 7, Federal Grants-in-Aid, which specifically authorizes DOH to “…administer the provisions of the federal social security act or any other act of Congress which relate to maternal and child health services, the care of children with physical disabilities and other public health work and to co-operate with the duly constituted federal authorities charged with the administration thereof.” This provision not only empowers DOH to obtain and distribute Title V funds, but also those from Title X of the PHS Act, WIC, and other federal resources essential to the health of the MCH population.
The comprehensive tobacco control capacities of DOH are specified in PHL Article 13-E, regulation of smoking in certain public areas, which enables DOH to reduce environmental exposure to tobacco smoke by prohibiting smoking in most indoor public places; PHL Article 13-F, regulation of tobacco products and herbal cigarettes; distribution to minors, which defines the State tobacco use prevention and control program, prohibits free distribution of promotional tobacco and herbal cigarette products, and which prohibits sale of such items to minors.
PHL Article 21, Control of Acute Communicable Diseases, details the role of local health officials in control efforts, and specifies reporting requirements and patient commitment procedures and provides control requirements for specific diseases, including HIV, rabies, typhoid fever, poliomyelitis and Hepatitis C. PHL Article 23, Control of Sexually Transmissible Diseases, outlines the roles of state and local health officials in the identification, care and treatment of persons with a sexually transmissible disease specified by the Commissioner.
Direct reference to the duties of the Commissioner regarding the health needs for mothers, infants and children is made in PHL Article 25, Maternal and Child Health. Succeeding sections in PHL Article 25 authorize the Commissioner to, among other important activities, screen newborns for inherited metabolic diseases and critical congenital heart disease (§2500-a), HIV (§2500-f) and hearing problems (§2500-g). NYS’s Child Health Insurance Plan is detailed in PHL §2510 – 2511. The Commissioner’s powers to affect prenatal care are enumerated in PHL §2522 – 2528-364-i and 365-k of Social Service Law. An important asset to DOH efforts to monitor and improve patient care and outcomes is provided by PHL §2500-h, which authorizes development and maintenance of a statewide perinatal data system and sharing of information among perinatal centers.
DOH’s Early Intervention (EI) Program, for children who may experience a developmental delay or disability is authorized by PHL §§2540 – 2559-b, while programming to provide medical services for the treatment and rehabilitation of children with physical disabilities is authorized by PHL §2580 – 2584.
Nutrition programming conducted on behalf of children in day care settings is authorized by PHL §2585 – 2589, while PHL §2595 – 2599 establishes the nutrition outreach and education program to promote utilization of nutrition education throughout the state. The operation of NYS’s Obesity Prevention Program is detailed in PHL§2599-a – 2599-d.
The ability of NYS to regulate hospitals, including ambulatory health facilities, is conferred by PHL Article 28, Hospitals, and is a prime determinant of DOH’s capacity to protect the health of individuals. Among the specific provisions relating to hospitals is the NYS Health Care Reform Act (HCRA), which is codified as PHL §2807-j – 2807-t. A major component of NYS Health Care financing laws, HCRA governs hospital reimbursement methodologies and targets funding for a multitude of health care initiatives. The law also requires that certain third-party payers and providers of health care services participate in the funding of these initiatives through the submission of authorized surcharges and assessments. Similarly, DOH has been given broad powers to regulate home health care agencies and health maintenance organizations through PHL Article 36 and PHL Article 44, respectively. Since a majority of MA-eligible mothers and children are enrolled in MA managed care plans, DOH relies on its delegated powers to ensure the quality of care rendered to them.
The broad authority provided through these and other state laws empowers the DOH to implement and oversee programs focused on improving the health of the MCH population.
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