Russell Cordeiro doesn’t have health insurance because it is too expensive. Jason Fullmer and his family avoid traditional insurance in favor of cost-sharing. Recent master’s graduate Mrinalini Nayak was overwhelmed with all of the paperwork and hasn’t gotten around to re-enrolling, despite her best intentions.
Fourteen years after the Affordable Care Act (A.C.A.) passed, opening up insurance possibilities to those who were previously uninsured, there are still scores of people who aren’t insured. New York is ranked as one of the top states when it comes to keeping families and children enrolled: 1.5 million New Yorkers were covered by state-sponsored plans known as Essential Plans or Qualified Health Plans, for those not eligible for Medicaid, as of April 2024.
The state has also managed to re-enroll over 80 percent of people who were on New York State Medicaid, Child Health Plus, and the Essential Plan when automatic renewals — which started during the COVID pandemic — ended in summer 2023.
And yet, there are still people who are falling through the cracks or intentionally choosing not to enroll. The calculus has changed since 2018, when the A.C.A. ended its penalty for not having minimum essential coverage.
So who are the uninsured? And what’s their thinking? In the New York area, here are a few examples of people living without coverage.
Paperwork galore
Mrinalini Nayak, a native of India, was in her final semester of graduate school at CUNY when she was notified that her Healthfirst insurance – part of the state’s Medicaid offerings – was ending. When Nayak went to re-enroll, she was told she would need to chase down an official letter from her prior employer – what she thought was just a formality. Knee-deep in assignments, the task fell off her radar.
Months later, the 28-year-old was under the impression that she was still enrolled when she got an email informing her that her coverage had ended. She logged onto the state portal expecting to find a simple form. Instead, she realized she’d have to go digging for all of her past addresses, provide a history of previous medical issues, and more. Fed up with the requirements and the portal’s clunky format, she once again put enrollment on the back burner. Months later, she’s still without coverage.
“I’d much rather live on the edge of life than go through this paperwork,” she said in a phone interview.
Nayak is not an exception. Chris Palmedo, an associate professor at the CUNY School of Public Health who conducted a 2018 study on barriers to students getting insurance, said that bureaucracy has always been an issue. People think “I’m going through this complicated process to end up paying money out of my own pocket for something where the return is unclear,” he said.
Luckily there are groups like Public Health Solutions (P.H.S.) to help New Yorkers get insurance with as little hassle as possible. The nonprofit organization, one of several that assists with enrollment, serves around 15,000 clients a year – primarily people from low-income and immigrant backgrounds.
Michelle Honan, Director of Community Health and Nutrition Access at P.H.S., agrees that the complicated enrollment process can deter people from getting coverage, especially if English is not their first language. Undocumented immigrants are probably the largest group of uninsured in the city, added Honan. P.H.S. provides services in 10 languages to accommodate them and others who may struggle with language barriers.
Even with outside assistance from groups like P.H.S., enrollees are still required to track down a number of items to get coverage — household information, tax returns, proof of income, and a Social Security card — which can be rather time-consuming.
Some people might think, “forget it. This is too much to understand,” said Wen Qing Wang, senior program manager at P.H.S.
Just plain too expensive
There’s bureaucracy and then there’s cost. Living in New York, which is ranked as the most expensive city to live in in the United States, doesn’t make things any easier.
“Combining rent with healthcare with just a simple cost of living, something’s gotta give,” said Russell Cordeiro, a 46-year-old hair stylist who lives in Brooklyn.
Cordeiro has been living without insurance since he moved to New York more than 20 years ago. He says his income is too high for Medicaid and too low to afford a state-sponsored plan, leaving him trapped in insurance purgatory. He looks at the marketplace every year to see how the prices have changed, but is never satisfied with the options. The last time he checked, he said the cheapest option was a plan with a monthly payment of $480 and a $6,500 deductible.
Even small charges like $10 could be off-putting to certain people, said Wang from P.H.S. When taken together, all of the costs — copays, coinsurance, and deductibles — could be the final factor in someone’s decision not to enroll.
Being uninsured in his twenties didn’t faze Cordeiro much. After all, he was relatively healthy. But as he gets older and more health issues crop up, he can’t ignore the writing on the wall.
In his early thirties, Cordeiro was diagnosed with Bell’s Palsy, a condition that causes muscle weakness on one side of the face. He was able to get affordable care and treatment from a clinic called Callen-Lorde, which provides care “free of judgment and regardless of ability to pay.” Cordeiro remembers paying somewhere in the ballpark of $100.
In another instance, he had to go to the hospital after he was assaulted on the street. The thought of having to pay upwards of $6,000 for the ambulance and stitches he received terrified him. But in another stroke of luck, the city footed the hospital bill after Cordeiro filed a police report and submitted a plea to a caseworker.
“I don’t find myself often getting emotional, but quite honestly at that moment when the police came to look at me and were like, we’re definitely calling you an ambulance, I was like, ‘oh shit,’” he said.
Cordeiro has always dealt with health issues on a case-by-case basis, but he knows the time may come when he’s stuck with a bill he can’t afford or an illness he can’t treat. He and his wife have considered moving to New Jersey for cheaper coverage — the state has lower healthcare costs than New York. But for now, he’s sticking it out here, hoping he can maintain his healthy streak.
“There’s definitely been a few times where I probably should have gone to the doctor but when you’re in this type of situation, you end up having kind of the mentality of, well, if I wait long enough it’ll either go away or it’ll kill me,” he said. “So I’m just going to wait and see what happens.”
Lifestyle decisions
Cost is also one of the main reasons Jason Fullmer, 37, of Brooklyn, doesn’t have insurance. But it’s not the only one – his choice is a personal one.
The self-employed entrepreneur and his family have sought out alternative forms of care more in line with their focus on holistic health. They’ve always been very “health-focused” Fullmer said, especially given that his wife works as a holistic health coach. The two have a 16-month-old toddler.
Fullmer doesn’t consider being uninsured a loss, given they would be paying out of pocket for the type of care they want regardless. Plus, what they don’t pay in insurance they make up for with their grocery bill. Fullmer said the family eats only unprocessed foods, which can be more expensive.
Still, the family has found other ways to get the care they need. Through Knew Health, they practice a concept known as medical cost sharing. Every time someone in the family suffers from “a catastrophic event,” they are liable for up to $2,500. Luckily, they’ve never had to use it.
Fullmer previously paid monthly membership to a clinic called Parsley Health, which provides five “in-depth” medical visits and five visits with a healthcare coach per person a year, according to the company website. Fullmer paid $199 a month for the “Complete Care” plan his first year then downgraded to the “Essential Care” plan for $99 a month, before eventually canceling his membership altogether to save money. His wife still pays $99 a month for the “Essential Care” plan – which comes out to $1,188 a year.
Even with these checkered safeguards in place, Fullmer recognizes that their choice to go without insurance is a risky one. His approach is to take everything in stride and tackle issues as they arise.
“Just yesterday my wife had a bit of a scare where it’s like I don’t even know where we would turn to to get this analyzed,” he said. “But you figure it out and you deal with it.”
