A year into New York's operation of a medical insurance exchange, more than half of the people with new coverage qualified for Medicaid — the federal program for the poor — and many didn't know they were eligible until the push under the Affordable Care Act.
Overall, 370,604 people were enrolled with commercial and nonprofit insurers, 525,283 in Medicaid; and 64,875 in the state's Child Health Plus coverage for families with moderate incomes. That's a total of 960,762.
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With most of the gains coming in Medicaid, here are snapshots of how the first year played out in two of New York's poorer counties:
Out of New York state's 62 counties, the Bronx is dead last when it comes to health. That was the conclusion of a 2011 study by the University of Wisconsin and the Robert Wood Johnson Foundation that measured factors like obesity, smoking and the number of children in poverty.
The study found that there were 8,130 premature deaths per 100,000 people in the Bronx, for example, compared with a statewide average of 5,933.
In the Bronx, 62,404 new enrollees got Medicaid out of a total of 82,613 newly insured people. That's a much higher Medicaid-to-private insurance ratio than any other county, including the four other New York City boroughs.
Bronx resident Elsie Barreto, 60, said she went 12 years without insurance before she signed up for Medicaid under the Affordable Care Act.
"I worried all the time because my mother died of endometrial cancer," Barreto said.
Once she was signed up, Barreto scheduled a colonoscopy. "It has saved my life," she said. "They removed five polyps that would have been cancerous had they been left untreated."
Some new Medicaid enrollees in the Bronx were eligible before but may not have known they were, experts said.
"They're what we call woodwork people," said Elizabeth Lynam, deputy research director of the Citizens Budget Commission, a good government group. "They're called woodwork because they're out there and they were eligible, they just didn't know."
Medicaid eligibility was expanded under the Affordable Care Act but the number of newly eligible recipients was relatively small in New York, which already had generous eligibility requirements compared with most states.
Tina Martinez, director of Medicaid and financial aid at Montefiore Medical Center, recalled one patient, a musician who assumed he wasn't eligible for Medicaid because he had been rejected before. He applied earlier this year, was accepted and got the heart procedure he needed.
Health care providers hope the health of high-poverty areas like the Bronx will improve under the Affordable Care Act, but they note that hundreds of thousands of immigrants without legal residency will remain ineligible for health insurance.
"More people are insured but there remains a population that hasn't been included," said Dr. Steven Safyer, the president of Montefiore. He said that population won't be included "until we have immigration reform."
A total of 877 people signed up for health insurance through New York's health plan marketplace in remote Schuyler County at the lower edge of the Finger Lakes, where 14.1 percent of residents in the small, rural county were uninsured in 2013.
The number of new enrollees represents a little less than 5 percent of the county's population, which stood at 18,460 as of 2013. Of the newly insured, more than half, 467, enrolled in Medicaid and the others were split between Excellus BlueCross BlueShield and Fidelis Care.
"The first thing that strikes me is that comfort level that people have, knowing they have insurance and access to it," Public Health Director Marcia Kasprzyk said.
But more measurable, she said, has been that patients have virtually stopped coming to the weekly free clinic that had been established to serve the uninsured. Instead of the usual 8-10 people arriving with the flu, coughs or in need of a physical for a job, there may be one or two people.
"We're questioning whether we're needed any more because the volume is so low coming through there," Kasprzyk said, "which tells you people have insurance and are going elsewhere."
Another of the five free clinics operated by the Health Ministry of the Southern Tier in neighboring Steuben County closed on Sept. 30, after operators said the Affordable Care Act reduced the number of uninsured seeking services.
"It really is good news," Health Ministries Executive Director Mike Slovak told The (Corning) Leader newspaper just before the closing.
Meanwhile, the percentage of patients seeking charity care at the county's only hospital decreased 24 percent from the previous year, Schuyler Hospital spokeswoman Michelle LaDue Benjamin said, but the number of emergency room visits was unchanged. County officials attribute that to a lack of public transportation and after-hours access to private doctors.
"The population tends to heavily use the local volunteer ambulance services as a transportation option to medical services in the Emergency Department," a 2013 community health assessment concluded.
After moving into the county from South Carolina, Tracey and Eric VanSkiver somewhat reluctantly bought mid-level "silver" health insurance from Fidelis Care through the state marketplace and pay about $680 a month for a plan that provides 70 percent coverage.
"I would have gotten my children covered but if we didn't have to have (insurance), for me and my husband ... I probably wouldn't have with the prices," said Tracey VanSkiver, whose husband is a self-employed contractor with Corning Inc.
The couple's three children, ages 7, 5 and 2, are enrolled in the state's Child Health Plus program for an additional $180 a month, bringing the family's monthly premium payments to nearly $900.
For their money though, the VanSkivers have had no trouble gaining access to primary or specialty care, despite the county's designation by the state as a physician shortage area, Tracey VanSkiver said. They were also relieved not to have to pay the full cost of an unexpected surgery needed by her husband.
"I'm glad that we do have it," she said.