Every dollar of premium you, your employer, your school district or your town pays goes first to an insurance company. Here is what the six largest did with it in 2025, from their own annual reports.

Excellus is a nonprofit, and it did lose money on operations in 2025 — $108 million — because claims rose 16%, the biggest jump in nearly twenty years, with prescription-drug claims up 35%.²¹ That is the honest picture: even the nonprofit insurer in our market is a $7.5-billion-a-year toll booth whose costs are set by drug companies and hospital systems it cannot control, so the bill lands on you. Its 2026 individual rates rose 20.7% and small-group rates 15%; for 2027 the state approved another 12.2% and 13.5%.^{22 8} Statewide, insurers asked for 20.6% and 23.7% increases for 2027; regulators cut them to 6.0% and 8.0% and held the profit line to one percent — which tells you how much room was in the request.^{23 24}

The paperwork is not an accident; it is the product. Every insurer has its own forms, networks, formularies and prior-authorization rules, and every hospital and doctor's office hires people to fight them. Medicare Advantage plans handled 53 million prior-authorization requests in 2024 and denied 4.1 million; only 11.5% of denials were appealed, and 81% of those appeals won — meaning most denials were wrong, and most patients never found out.²⁷ In 2025 the denial rate on standard requests was 12% in Medicare Advantage, 14% in Medicaid managed care and 18% in marketplace plans, with two-thirds overturned on appeal.²⁸ A federal inspector general found that 13% of Medicare Advantage denials were for care that met Medicare's own rules.²⁹ New York hospitals report more than $3 billion in insurer denials outstanding.³⁰

A denial is the purest form of cost externalization: the insurer keeps the premium and makes someone else — you, the hospital, the county — pay for what it did not want to cover. Privatized gains, socialized losses, one claim at a time.

Coverage is going the wrong way. The federal budget law passed in July 2025 cut Medicaid and marketplace funding; the Governor's office projected 1.5 million New Yorkers would become uninsured and hospitals would lose $8 billion a year (the Empire Center argues the state's headline figure was partly double-counted and the first-year budget hit is closer to $2.6 billion — the coverage losses are not in dispute).^{33 34} On July 1, 2026 about 450,000 New Yorkers lost Essential Plan eligibility; replacement coverage runs about $250 a month with a $2,500 deductible.^{31 35} The enhanced federal premium credits expired at the end of 2025, and 50,000 fewer New Yorkers are getting help with premiums this year.^{36 37}

Even for the insured, the plan is thinner every year: nationally 23% of working-age adults are underinsured — covered, but with deductibles they cannot afford — and 30% are paying off medical debt.³⁸ New York has done more than any state to stop hospitals from suing patients (lawsuits fell from 13,886 in 2019 to 105 in 2025) and to keep medical debt off credit reports; that is worth celebrating, and it does not lower a single premium.^{39 40 41} Medical bills are GoFundMe's most common fundraiser, and the average campaign raises about 40% of what it asks.⁴² A GoFundMe is the market's answer to a denied claim.

In Wayne County the numbers are these: 91,250 people, nearly a quarter over 65, median household income $74,506, about 6.8% uninsured, one in five on Medicaid.^{43 44 45} A family plan at $27,000 is more than a third of that median income.

Wayne County once had four hospitals. The state's own list of closed hospitals records one on Lake Avenue in Wolcott and the Lyons Community Hospital — both gone so long ago that the Health Department has "no information available" on where their records went.⁴⁶ Sodus had Myers: opened in 1900 by Dr. John F. Myers, sold in 1955 to a nonprofit membership corporation, the Myers Community Hospital Foundation, and moved to a new building on Middle Road that the community paid for.⁴⁷ By the 1990s a small nonprofit hospital could not survive on its own: grants were harder to get and insurers paid less for a small population. In 1998 Myers joined ViaHealth, the Rochester system that already owned Newark-Wayne.⁴⁸ In November 2002 ViaHealth announced the closure — Myers was down to six inpatient beds and one admission a day, the system had absorbed $9.2 million in losses over five years, and its 80 staff would be "reassigned"; a ViaHealth administrator said it would "work with local real estate developers to market the Myers Hospital building."⁴⁹ ViaHealth became Rochester General Health System in 2008 and Rochester Regional Health in 2014.⁴⁸ The Sodus campus today is an outpatient site.⁵⁰

Newark is following the same script. Newark-Wayne Community Hospital, opened in 1921 and part of the Rochester system since 1991, is the county's last hospital: 1,500 jobs, $68 million in payroll, 5,100 admissions and 24,000 emergency visits a year, and 78% of its patients on Medicare or Medicaid.^{51 48} In January 2025 it took six medical-surgical beds offline and told the county it had "no plans to close."⁵² In May 2026 Rochester Regional announced it would close the Marshall Birthing Center — more than seventy years old — sending deliveries to Rochester General.^{53 54} Births had fallen from 670 in 2019 to 380 in 2025; 37 staff were affected; the stated reason was recruiting physicians, "not a financial issue."^{55 56} The entire Wayne County Board of Supervisors and Senator Helming wrote to the Governor; fifty people came to the state hearing; the Health Department approved it anyway. The last baby was delivered August 31 and the unit closed September 3, 2026.^{57 58 59} A week later the same executive listed the real pressures on rural hospitals: "low reimbursements, staffing difficulties, aging populations, declining birth rates and falling inpatient volumes."⁶⁰ Low reimbursement is a money problem. Residents at the September meeting asked the obvious next question: is the emergency room next?⁶¹

This is what "the market has spoken" means in a rural county. More than fifty New York hospitals have closed since 1996; 116 rural hospitals nationally have stopped delivering babies since the end of 2020, and only 41% still do.^{64 65} A market pays for volume; a county of 91,000 people spread over 600 square miles does not produce volume. So the market closes the small hospital, keeps the specialists in the city, and hands the drive to the mother in labor. Every closure is cost externalization — the system's loss becomes the family's gas money, missed work and risk — and every one leaves the very rich untouched, because they were never going to deliver in Newark anyway. Privatized gains, socialized losses.

The New York Health Act — A.1466 in the Assembly, S.3425 in the Senate — has been introduced every session since 1991 and passed the Assembly five times, most recently in 2018. Since the Senate changed hands in 2019 it has not left committee in either house; leadership has not brought it to the floor.^{66 67 68 69} What the bill text says it does:¹³

What you stop paying: the $6,850 from your paycheck, the employer's $20,000 you never saw, the deductible, the copay, the bill for the out-of-network anesthesiologist, the county's Medicaid share on your tax bill, and the 20 cents on the dollar the insurer kept. What replaces it is one tax you can see on one line, that goes up with income instead of with age or illness.

In 2018 the New York State Health Foundation hired the RAND Corporation — a research institution founded to advise the Air Force, not a health care advocacy group — to model the New York Health Act. RAND ran the numbers for 2022 and 2031 against the status quo.^{11 72} Its headline: "a single-payer plan in New York does not have to increase the amount of money spent overall on health care in the state, but it would substantially change who pays for health care."⁷³

That is where "nine in ten" comes from: RAND found that households below the 90th percentile — roughly nine of every ten New Yorkers — would pay less on average, households in the 90th-to-95th percentile about $1,700 more per person, and the top 5% substantially more.¹² Rivera and Gottfried's summary of the same study put the net employment effect at about 150,000 more jobs and the annual saving at $15 billion by 2031.⁷⁴ The Campaign for New York Health rounds it to "over 90% spend less"; a 2015 study by UMass economist Gerald Friedman said 98% — that figure is Friedman's, not RAND's, and this brief uses RAND's.^{75 76}

What RAND assumed — say it first

RAND's estimate depends on three assumptions, and an honest campaign states them before an opponent does. First, every federal waiver is granted: "Key assumptions of our modeling analysis include the following: Federal waivers for Medicaid, Medicare, and ACA requirements are approved."¹² Without waivers, federal Medicare and Medicaid money keeps flowing through federal programs and the state plan wraps around them — still possible, but a different bill. Second, administration costs 6% of spending — three times Medicare's rate, half the private insurers' — and provider payments grow at the public-program rate. Third, nobody moves: RAND warns that "even a small tax migration or avoidance effect could influence the state's ability to finance the program." RAND's own range runs from 15% lower spending (if drug prices reach Medicaid levels and administration is lean) to 12% higher (if provider rates and administration both run high).¹² The taxes are large because they replace premiums: about $139 billion in new state revenue in 2022, rising to $210 billion — money households and employers are already spending on premiums, deductibles and copays, collected differently.¹²

The critics' numbers, so you have them: the Empire Center says 31% of New Yorkers would pay more, mostly people on Medicaid or the Essential Plan who pay nothing today and would owe a small payroll tax; the Business Council calls it "the largest tax increase in New York history"; the insurer-funded Realities of Single Payer coalition says "$250 billion in new taxes" and "160,000 lost jobs."^{77 78 72 79} Every one of those numbers is a way of describing the same thing RAND described: the premium becomes a tax, and the people who pay more are the ones with the most.

Here is the part of the health care money that shows up in an envelope from the town every January. New York's school districts spend about $7 billion a year on health insurance for employees, their families and retirees — $6,813 per pupil in benefits against $3,143 nationally — and it has been the fastest-growing line in the school budget for two decades.¹⁴ Towns, villages and the county pay the same premiums for highway crews, clerks and deputies, and carry hundreds of billions in promised retiree coverage statewide that no one has funded.⁸⁰ On top of that, Wayne County sends its share of Medicaid to Albany every year — the local share averages 8.6% of county budgets outside New York City — and that money comes almost entirely from the property tax.^{81 71}

The New York Health Act reduces what your school district and town pay for employee health coverage, and every dollar of that comes straight off the property-tax levy. Under the bill a public employer stops paying premiums and pays the payroll tax instead; RAND found employers that offer coverage today would pay $200 to $800 less per worker, and the New York City Comptroller estimated the City could spend about $3 billion less a year on active-employee coverage.^{12 82} The county Medicaid share ends outright.¹³ This brief does not put a percentage on your school levy, because the honest number depends on the tax rates the Legislature sets in the revenue bill and on each district's contract. What is not in doubt is the direction: the health line in the school budget goes down, the county's Medicaid line goes to zero, and the levy follows.

The nurses' union, NYSNA, "strongly advocates" the New York Health Act and sent members to Albany for it again in May 2026; its president, Nancy Hagans: "I have seen patients suffer because they didn't have health insurance … It's time to pass the New York Health Act!"^{83 84} 1199SEIU, the health care workers' union, CWA, RWDSU and the Doctors Council SEIU support it.^{70 85} The United Auto Workers' 2026 statement of its issues says: "Our union has always maintained that health care must be a human right, not simply a privilege for the wealthy." "We need a single-payer system that guarantees quality, comprehensive health care for all and that puts patients above profits."⁸⁶ The UAW's New York region put "passing the NY Health Act" on its state legislative agenda, and the UAW International is an endorsing organization of Medicare for All in Congress alongside SEIU, the National Education Association, National Nurses United and the Mine Workers.^{87 88}

Why would a union that already bargains good coverage want this? Because every contract fight for twenty years has been a fight over health care: the raise that went to the premium instead of the paycheck, the strike over the deductible, the plant that moved to a country where the employer does not carry the health bill. The UAW's case is that single payer is good for its members and good for their communities — the laid-off worker, the retiree, the neighbor with no union — because the cost stops following the job. Not every union agrees: NYSUT and DC 37 withdrew their support in 2023 over whether members would keep contract-quality benefits, the UFT wants financial assurances, and the building trades have been wary; the 2023 amendments guaranteeing public employees benefits at least as good as their contracts were written to answer them.^{70 85 89} That is the work of coalition, and it is not finished.

We were told the immigrant took your health care, the family on Medicaid, the guy who won't work. Look at the receipts. The federal law that pushed 450,000 New Yorkers off the Essential Plan this July was sold as cutting coverage for "illegals"; the people who lost it were lawfully present — green-card holders, refugees, people here on work visas who pay the same taxes you do.^{33 31} In the same year, UnitedHealth made $12 billion, its CEO $61 million, and the six national insurers together spent $25 billion on buybacks and dividends.^{2 3 6} The health insurers' trade association spent $17.2 million lobbying Washington in 2025, UnitedHealth another $12.5 million; in Albany, the hospital association was the fourth-largest lobbying client at $3.1 million and gave $942,000 to the Governor's last campaign.^{90 91 92 93} The coalition running the ads against the New York Health Act — "Realities of Single Payer" — is the Health Plan Association, the Blue Cross conference, the Business Council and the chambers of commerce, including Rochester's.⁹⁴ Nobody on Medicaid wrote a lobbying check. This is not about capitalism; a farmer selling apples is a capitalist. It is about a specific industry that collects a toll on care and spends part of it making sure the toll stays. The gains are privatized; the losses — the denied claim, the closed birthing center, the GoFundMe — are socialized.

The market closed Myers and is closing Newark one unit at a time. The answer is the one Sodus found in 1955: a nonprofit the community owns. The path is for local nonprofits — a hospital foundation, a federally qualified health center, a cooperative of the towns — to buy Newark-Wayne from Rochester Regional and buy back the Myers campus, and reopen them as community hospitals sized for what a rural county actually needs: a birthing center, an emergency room that stays open, urgent care, primary care, rehabilitation and long-term care, with specialists visiting from the city instead of patients driving to it. Carl Fitzsimmons will work with whatever local groups decide this is what they will do for our communities, and put the state's money and law behind them.

It has been done. In Troy, a year-long community campaign and $5 million in state funding got Trinity Health to reverse the closure of the Burdett Birth Center — with a Democratic Assemblymember and Republican county officials on the same side.⁹⁸ In Madera, California, a hospital that closed in 2022 reopened in 2025 with a $57 million state distressed-hospital loan and 497 employees.⁹⁹ In Martin County, North Carolina, the county is reopening its closed hospital as a federal Rural Emergency Hospital.¹⁰⁰ Cuba Memorial in Allegany County was ten days from closing, converted to critical-access status, restructured its debt and is still open.¹⁰¹ And Clifton-Fine Hospital in St. Lawrence County is pursuing the federal Rural Emergency Hospital designation — a model New York allows — that pays a hospital a fixed monthly federal payment to keep an emergency room and outpatient services open without inpatient beds.¹⁰²

The money exists. New York's Statewide Health Care Facility Transformation Program put out nearly $300 million in its latest round; the federal Rural Health Transformation Program is sending New York more than $212 million in its first year and just awarded $76 million to 56 rural organizations; USDA Community Facilities loans finance rural hospitals directly; and Senator Helming's bill to pay critical-access hospitals 101% of cost is sitting in committee waiting for an Assembly partner.^{103 104 105 106} The honest caveats: Myers closed with six beds and one admission a day, so a reopened Sodus is a birthing center, urgent care and rehabilitation campus, not a 1955 hospital; Massena's town took on $9.3 million in pension liabilities when it handed its hospital to a system, so the deal terms matter; and none of it is stable on today's reimbursement — which is why the hospital plan and the New York Health Act are one plan.^{49 107} A single public payer that pays one adequate rate for a delivery in Newark is what keeps the lights on in Newark.

Street power gets the county resolution and the hearing. People power builds the coalition — nurses, autoworkers, school boards, mothers who drove to Rochester in a snowstorm — that outlasts one session. Electoral power puts a vote in the Assembly that an insurer cannot buy. Together, we can get this on the Governor's desk the first year.