In his State of the City address last month, Mayor Bill de Blasio promised a “guaranteed health care plan” for New York City residents. It’s designed to address the fact that currently roughly one in 10 working-age New Yorkers – some 600,000 adults – is uninsured, a figure derived from the American Community Survey, an annual study conducted by the U.S. Census Bureau. (Virtually all children in New York not covered by private insurance or Medicaid are eligible for State Child Health-Plus coverage.)

Because they are undocumented, half of these adults can’t buy coverage provided through the Federal Affordable Care Act (ACA), and, for the same reason, don’t qualify for Medicaid. Most of the others simply can’t afford the insurance they are offered. The result: Some 7.2% of New Yorkers were uninsured in 2017, a considerably higher percentage than in most other major U.S. cities. In fact, New York ranks 19th among big cities on this scale.

We’ll get to the specifics – and lack of them – in de Blasio’s proposed plan in a minute. Spoiler alert: They may well add up to less than a “guarantee” of health care. But first, let’s review the current status of health care for New York City’s uninsured – and then, to assess the reach of the de Blasio plan, also look at how other local governments have approached the problem of providing for the uninsured.

The reality is that many uninsured New Yorkers already have access to care, most commonly through Health + Hospitals (H+H), the nation’s largest public hospital system. Its most recent data show that the uninsured were 25 percent of adult clinic patients and 29 percent of emergency room users among its 1.2 million unique annual individual patients. By rough calculation, it’s likely that nearly half of uninsured New Yorkers – 250,000 to 300,000 adults – get some care from an H+H doctor.

Most patients, the uninsured included, are obligated to pay something for such care. “H+H Options” is a sliding-scale fee payment plan available to uninsured public hospital and clinic patients. Depending on family income and care received, patients are charged anything from $0 for a clinic visit by a very low-income person up to $1,500 for an inpatient hospital stay for someone from a family of three with an annual household income between $73,000 and $83,000.

(Additionally, since 2012 New York State law has required private hospitals also to offer services on a sliding scale to uninsured patients. But the private hospitals do far less than they should, given their large public benefits and payments.)

Despite this access to care, however, being uninsured has two serious negative consequences. First, it limits your ability to get health care when you need to determine, for example, whether that lump is a cancerous tumor. Second, it increases the stress of everyday life. The uninsured live with fear of a catastrophic illness putting their families in extreme financial jeopardy. For millions of Americans, the ACA ameliorated both anxieties. But it hasn’t reached everyone.

Over the years, local governments have adopted a range of schemes bringing greater health security to their residents. The oldest and most successful are in San Francisco, Washington, DC, and the state of Massachusetts. While they predate the ACA, they continue to augment it. None is a locally run insurance program. But judging by American Community Survey results, enrolled residents in these programs count themselves as insured. Each program has led to reported uninsured rates below four percent.

Healthy San Francisco was launched in 2007. Uninsured residents with household incomes below five times the poverty threshold, regardless of immigration status, were invited to join. The program created a provider network using City facilities, federally funded community health centers, and private hospital systems participating as part of their charitable care obligation. It was financed by the City and Federal governments, member premiums, and substantial fees imposed on businesses (up to $2.83 per employee-hour worked) that did not provide coverage for their workers. In 2015-16, the cost per enrollee was $2,206.

DC Health Alliance pays for uninsured residents to enroll in private managed care plans, purchased for both Medicaid and poor undocumented residents. At its height prior to the ACA it had 55,000 enrollees. Today it provides coverage to about 15,600 otherwise uninsured low-income residents. The average annual cost for 2018 was expected to top $4,100.

Health Safety Net (HSN) in Massachusetts reimburses hospitals and most community health centers for services provided to eligible residents. People with household incomes below 150 percent of the Federal poverty level are entitled to free care; those with incomes up to 300 percent of that level face significant deductibles but can use HSN as either primary or secondary payer. Higher-income residents with very high medical bills may use HSN to pay some of their uncovered expenses. People enroll in HSN through the same web portal used by residents seeking Medicaid, ACA subsidized insurance, or other insurance options. Seamlessly, someone not eligible for insurance is issued an HSN card. In 2017, 288,000 people had some or all their care paid by HSN. HSN also functions as a charity care referee. It distributes uncompensated care contributions from all hospitals to institutions that care for HSN enrollees. If the amount paid in by hospitals doesn’t cover the bill, the State makes up the difference. HSN thus accomplishes two objectives: providing services to the uninsured; and distributing uncompensated care funds based on services delivered rather than losses claimed.

Mayor de Blasio’s proposal is designed to take advantage of New York City’s large public hospital system to offer a different non-insurance option to the uninsured. Probably its most important element is that it reaffirms the commitment to universal access to health care, regardless of income or immigration status, embodied in H+H’s mission statement. Putting the City’s budget where his mouth is, the mayor has increased the City’s contribution to H+H by $1 billion since he took office. Perhaps the mayor’s new pledge to provide guaranteed care, plus his order that all City agencies notify clients of the program, will encourage more uninsured New Yorkers to get the care they need.

Beyond that, the mayor’s plan proposes modest service enhancements for which he has promised a five percent ($100 million) increase in City funding. The changes include: establishing an assigned primary care provider to every participant in the plan (a good idea, but extremely difficult to accomplish in practice); access to a 24/7-member service hotline; and “a dedicated membership card and a welcome packet and education materials.” (Unlike Medicaid, the new card might not be covered by the Trump administration’s proposed expansive new definition of being a “public charge,” making legal status more difficult to attain for uninsured immigrants.) No change in the H+H Options fee schedule is contemplated. Eligibility and enrollment opportunities are not yet set.

As currently presented, the City’s plan won’t buy private insurance like the DC Alliance, doesn’t enlarge the H+H network as Healthy San Francisco did in that city, and won’t reallocate any of the several billion dollars paid into the State’s uncompensated care system as Massachusetts HSN does. It doesn’t require that employers who don’t cover their employees stop “free-riding” on the public system. Nor does it demand that private hospitals do more in return for their expansive tax privileges.

Many foreign-born New Yorkers, even those with green cards, are leery of using public benefits they qualify for in the current political environment. Will a new wallet card, a welcome packet, and a 24/7 phone line be enough to reassure them, and other uninsured New Yorkers, that medical care at an affordable price will be there when needed?

Barbara Caress is a health care consultant with long experience in non-profit, union, and public agency management and administration. She teaches health policy at Baruch College. This article was originally published by Urban Matters