The President continues his unprecedented blizzard of executive orders (now numbering at least 129). One of interest last week was an executive order designed to reduce the cost of care for seniors. Primarily focused on the cost of prescription drugs, deep inside the order was a proposal to limit “a shift in drug administration volume away from less costly physician office settings to more expensive hospital outpatient departments.”

The order touches on a growing debate over the pricing of health care and the effort to establish “site neutral” health care payments. 

Here is the background: The amount charged for medical procedures or services can depend as much on where they are performed as on the type of procedure or service provided.  All else being equal, a procedure in a hospital is much more expensive than that same procedure done in a freestanding facility like a physician’s office or a clinic. The higher cost is meant to support a hospital’s more complex infrastructure, staffing and other expenses. 

However, these higher prices are being charged for services provided at non-hospital locations, which often operate at less expense.  That’s in large part because hospitals are buying up private practices, clinics, imaging centers and labs, using them effectively as a “cash cow” to charge more.  Once acquired, these facilities often begin using the hospital billing code to charge hospital prices for services that were previously less expensive.  When acquired by a hospital, physician practices charge about 14 percent more than when they were independent. That means patients and insurers begin to pay more for the same services. The only difference is that the non-hospital facility is owned by a hospital and begins to use the hospital billing code. And over half of physicians now work for hospitals and health systems. 

As a result, patients, Medicare, and health insurance companies are paying higher prices for care than they otherwise would. For example, Medicare pays twice as much for procedures done in hospital-owned facilities as they would for those done in independent physicians’ offices. And for many patients, high deductibles and co-insurance policies mean that they may face a financial hit as well.

The “site neutral” approach requires that Medicare procedures and services are delivered at the same price regardless of the location, whether it’s a hospital, doctor’s office, imaging center or clinic.  This would result in significant savings for consumers, employers and taxpayers. Decreased Medicare spending as a result of “site neutral” policies could save taxpayers $150 billion.

Saving that much money could help the Congress address its budget plans. The potential savings drove the House of Representatives to approve legislation that contained a “site neutral” provision. In the U.S. Senate, Republican Senator Cassidy and Democratic Senator Hassan have released a legislative framework for a “site neutral” payment policy.  The President’s more limited proposal could trigger the making of a deal on the issue.

Here in New York, a similar approach is gaining steam.

The Fair Pricing Act has been introduced to advance a “site-neutral” approach to commercial health plans. The Act requires that low complexity, routine, medical procedures would have their prices capped at no more than 150% of Medicare to lower health benefit expenses for payers while making healthcare more affordable for
patients. By reducing the cost disparities between hospitals and independent facilities, patients won’t be financially penalized for where they receive care, and employers and taxpayers will face less expense.

For patients paying significant out-of-pocket medical costs—like the uninsured, the underinsured, and others with coinsurance or high-deductible expenses—the Act limits their financial exposure. Onerous facility
fees including any additional charges for routine office visits, basic diagnostic tests, or minor outpatient procedures, would also be prohibited under the bill. Transparency through data reporting and public availability of hospital-pricing information will further ensure patients make informed decisions on healthcare for themselves and their
families. Publicly accessible pricing data allows patients to compare the costs of procedures and services across hospitals, independent clinics, and other providers. This helps ensure they can choose care options that best fit their financial situation and medical needs.

Every patient deserves fair priced care and has the right to be protected from sticker shock for medical services such as clinic visits, vaccines, and imaging procedures. These are among the many routine procedures New Yorkers experience every day that are threatened by unsustainable increases in healthcare costs. “Site-neutral” pricing ensures that patients will not be burdened by unsustainable pricing disparities. It’s time for federal and state policymakers to act.

Governor Hochul and state lawmakers continued to haggle over a state budget, now two weeks overdue, and ended up approving a fourth budget extender last week. Albany’s sleepwalking approach to budget-making stood in stark contrast to the flurry of action from the Trump Administration.

By the end of last week, President Trump had signed 116 executive orders, a record for a new president. Many were no more than press releases seemingly designed to impact the media cycle. One that puts a bullseye on New York was issued last week.

In a sweeping broadside statement, the President ordered the U.S. Attorney to “stop the enforcement of State laws” on climate change that the administration says are unconstitutional, unenforceable or preempted by federal laws.

It directs the U.S. Attorney General to target state laws on carbon taxes and fees, as well as state laws mentioning terms like “environmental justice” and “greenhouse gas emissions.” The order directs the AG to “expeditiously take all appropriate action to stop the enforcement of State laws and continuation of civil actions … that the Attorney General determines to be illegal.”

Within 60 days, the order says, the Attorney General will report on the actions taken against state climate laws and recommend other actions from the president or Congress.

The executive order clearly goes after state programs designed to combat climate change and it was merely one of the Administration’s efforts to undermine science-based policies. The Administration cut funding and staff for Flagship Climate Report, which examines the growing climate disaster and its report is required by Congress. The Administration also announced a plan for deep cuts to the E.P.A.’s Greenhouse Gas Reporting Program, which requires disclosures by large companies that emit air pollution.

All of these feverish actions ignore science. Let’s start with the obvious: The planet is heating up and 2024 was the world’s hottest year in recorded history. The world’s climate scientists have agreed that “Human activities, principally through emissions of greenhouse gases, have unequivocally caused global warming” and that “limiting human-caused global warming requires net zero CO₂ emissions.”

The state policies targeted by the Administration are designed to follow the best science on mitigating a worsening human-induced catastrophe. As we all know, the President thinks otherwise. He’s long dismissed climate change as a hoax.

But, despite his belief, science tells us that global greenhouse gas emissions have continued to increase and with that the heating up of the planet.

Legal experts have dismissed the Administration’s executive order as unconstitutional. Governor Hochul agreed and joined her co-leader of the U.S. Climate Alliance in a joint statement saying, “The federal government cannot unilaterally strip states’ independent constitutional authority” and that “We are a nation of states — and laws — and we will not be deterred.”

Among the many targets of the Trump Administration’s executive order is that it attempts to torpedo New York’s landmark Climate Change Superfund Act.  The Act was approved to mitigate the costs to state taxpayers resulting from the damage caused by the ongoing climate catastrophe.

New York’s recently enacted Climate Superfund is crafted to ensure that state and local taxpayers are not on the financial hook for 100% of the damages caused by severe storms, rising sea levels, and hotter temperatures.  Currently, New Yorkers are paying billions in climate-related damages.  There is zero doubt that those costs will continue to rise for the foreseeable future.

The costs will be staggering, yet they are costs that must be paid.  The Climate Superfund requires the largest oil companies – those most responsible for greenhouse gas emissions – to pay New York $3 billion annually for each of the next 25 years to offset these costs. And it does so in a way that ensures that the companies cannot pass these costs on to the public. 

If the Trump Administration’s executive order is successful, that annual $3 billion assessment will be borne by state and local taxpayers – either through increases in taxes or draconian cuts to government-provided services. Since these climate costs have to be paid, the question is should the public pay all of the costs?  New York’s law says polluters should pay their fair share.

Given the narrow House majority in the U.S. Congress, the seven New York Republican Representatives can play a key role in deciding the fate of the state’s efforts to follow climate science and protect taxpayers. They can urge the president to lay off New York’s climate policies, including the Climate Superfund. Whether they choose to do so, only time will tell.

With spring and lawn care season right around the corner, New Yorkers aren’t only preparing for warmer weather and enjoying the great outdoors: They’re steeling themselves for the irritating ramp up of loud, dirty gas-powered lawn equipment.

That’s because it doesn’t matter if you live on Long Island or Buffalo, we’ve all had the jarring experience of having a peaceful day interrupted by an obnoxiously loud gas-powered leaf blower or other lawn equipment that’s spewing fumes from its engine.

These machines are not only staggeringly loud, but they also produce a shocking amount of air pollution. That makes them more than a Saturday morning annoyance – they’re also a health hazard.

Nationwide, New York State ranks third in the nation for fine particulate pollution and fourth for global warming pollution from dirty gas-powered lawn equipment. Pollution from gas-powered lawn equipment contributes to ground-level ozone and fine particulate pollution (PM 2.5) and emits high levels of carcinogens like benzene, along with other toxic compounds.

Even short-term exposure to these pollutants can cause or contribute to asthma, heart attacks, cardiovascular disease, premature death and more.

For its small size, gas powered lawn equipment packs a big punch when it comes to air pollution. Incredibly, studies show that operating a gas-powered leaf blower for just one hour produces as much smog-forming pollution as driving a car 1,100 miles – the distance from Albany to Jacksonville, Florida.

These devices also make it harder to address climate change. It’s estimated that gas-powered lawn equipment in New York alone produced almost 1.4 million tons of global warming pollution in 2020 – equal to the climate emissions released by more than 300,000 cars.

And then there’s the noise. This too is more than just annoying – it poses a significant health threat as well. Most gas-powered leaf blowers exceed 70 decibels measured at 50 feet, which is considered dangerous to hearing. Additionally, this noise impacts the immune system, causes adverse cardiovascular effects, and impairs the learning, hearing, sleep, and language development of children. Acoustic research also shows that gas-powered leaf blower’s distinctive low frequency noise penetrates further than other machine-generated sound waves, even through solid walls.

But cleaner air is within grasp for New Yorkers: a group of New York legislators have put forth a proposal to help lawn care companies and local government maintenance crews switch from dirty gas-powered lawn equipment to cleaner, quieter electric tools.

State Senator Liz Krueger (Manhattan) and state Assemblyman Steven Otis (Port Chester and New Rochelle) have introduced bills S1574 and A2657, which would create an electric landscaping equipment rebate program. This would go a long way towards reducing global warming pollution, improving air quality and reducing noise pollution from gas-powered leaf blowers and lawn equipment by promoting the adoption of quieter, zero-emission landscaping equipment.

This legislation has already garnered bipartisan votes of support in the state Senate, which `has already approved it. The bill is also broadly supported by a diverse set of constituencies and interests, including over one hundred public health, environmental and community groups, lawn equipment manufacturers, and equipment retailers like Home Depot.

With support from unusual allies like this, it will hopefully send a clear message to members of the New York Assembly to join their Senate colleagues and take action to quickly to pass A2657 and then send it to Governor Hochul’s desk for her signature.

Electric lawn equipment is generally cleaner, quieter and easier to use. These electric alternatives are often just as capable as their fossil fuel-powered counterparts and, over a lifetime of use, cost less to operate.

It’s time to join the call for cleaner, quieter lawn equipment in New York. Hopefully, Albany will join the call.

April 1^st is the first day of New York’s fiscal year, meaning that it is the day when a new state budget should be in place. Yet April 1, 2025 will come and go, without a new state budget on the books.

While late budgets are nothing new, this year’s faces a huge uncertainty: whether the Congress will approve a federal spending plan that blows a big hole in New York’s budget.

First some background. Under New York State’s Constitution, the executive branch is required to submit a balanced budget to the Legislature, usually in January. In contrast to other states, New York’s fiscal year starts on April 1^st – the earliest in the nation. While that gives lawmakers only three short months to cobble together a state budget, for the vast majority of the decades that the requirement has been in place, budgets were set more or less on time. It wasn’t until the mid-1980s that the fiscal “wheels” started to come off, with one budget being adopted 133 days after the beginning of the fiscal year! New York’s court system changed that with a decision in 2004 that gave the governor far more control over the budget process. Since then, delays in producing a final budget have been much shorter.

Add this year to the list of late budgets.

This year’s budget delay is tied to significant differences – some financial and some not – between the executive and legislative budget plans. For example, the governor and the Legislature have offered their own financial plans that spend different amounts, with the governor proposing a $252 billion budget, the Assembly at $257 billion, and the Senate’s budget at $259 billion. Negotiating those differences is a key step in getting the budget done. Another major spending item to figure out: how to fund the Metropolitan Transportation Authority (MTA); all agree on spending $3 billion, but there is no agreement on how.

It’s not just about the numbers though. Policy differences can derail budget negotiations. Two years ago, it was Governor Hochul’s demands in the area of public safety that jammed up the budget process. Last year, housing policy was a sticking point.

This year, reportedly there are four major policy differences among the three leaders: a restriction on wearing masks in public, a ban on cellphone use in K-12 schools, and two issues dealing with public safety.

None of those proposals have a significant financial impact on the state. But the governor is using budget negotiations to advance her policy initiatives.

Looming in the background is the impact that the Trump Administration and the Congress may have on the state’s finances.

The House of Representatives has advanced a budget plan that contemplates big cuts to federal programs and the extension of a massive tax cut. The U.S. Senate has adopted a budget plan that is significantly at odds with the House. With both houses having advanced their own plans, efforts to reconcile their differences are ramping up.

Given the narrow House majority, the seven New York State Republican Representatives can play a key role in deciding whether New York’s budget suffers devastating cuts at the hands of Congress. Whether they choose to do so, only time will tell, but the difficulties facing the Congressional Republicans make it clear that New York Representatives can play an outsized role in protecting the state.

Which brings us back to Albany. Despite the uncertainties surrounding discussed federal cuts in spending – no one knows for sure how much will be cut – state lawmakers must cobble together a plan of their own. And they need to do so quickly.

State budget makers are well aware of the danger, but they simply cannot predict what Congress will do. So, the game plan has been to pass a state budget and then return to address any shortfalls once the dust settles in Washington.

For Governor Hochul and state lawmakers, they have once again failed to deliver an on-time budget, a job that they were elected to do. Not only is the state’s fiscal plan overdue, but it may get seriously more complicated once Congress finally acts. In this three-dimensional chess match, the first move is Albany’s. But it’s late and the clock is ticking loudly.

While the Capitol continued to buzz about progress on budget deliberations, a state court decision garnered a lot of attention from lawmakers. The decision from a state Supreme Court judge in Suffolk County found a state law limiting the outside income of lawmakers constitutional. The law limits the amount of money that a lawmaker can make outside of his or her legislative salary to no more than $35,000 annually.

The law was to have gone into effect on January 1^st of this year, but had been blocked by a lawsuit brought by Republican lawmakers and their constituents. The lawsuit asserted that the law’s limit on outside income was unconstitutional. The judge’s decision is the latest in a five-year effort to limit the outside income of lawmakers.

First some background on the tortured path to impose such a restriction. In 2018, a state commission reviewing the salaries of top members of the executive branch and the state Legislature issued a report that called for a dramatic increase in lawmakers’ salaries.

From the period 1999 through 2019, lawmakers hadn’t seen a raise in their base legislative pay. The creation of the commission was a way for the governor and legislative leaders to circumvent the way in which pay has historically been raised. Previously pay raises were approved like any other piece of legislation – being introduced, considered in committee, and then voted on the floor before being sent to the governor for final approval.

But even under those rules pay raises for lawmakers were a difficult vote to cast, one that challengers could use as a political weapon to great effect in future campaigns. Pay raises for lawmakers is a political loser in many parts of the state. That’s why two decades had passed since the last one.

Establishing a commission to determine the appropriate level of compensation for lawmakers and top members of the executive branch was a way to get around taking a tough vote — or at least allow them to point to the compensation determination having been made by an outside entity.

The commission decided, among other compensation-related issues, to approve pay raises in three phases. The first was to go into effect on January 1, 2019 with an increase in lawmakers’ base salaries from $79,500 to $110,000. The following year, the salary would go up to $120,000. Finally, one year later there was a jump to $130,000. That salary would have put New York not only far above the national average, but the highest in the nation.

That earlier limit on outside income was challenged in court, with the final ruling that the salary boosts could go into effect, but the outside income restriction could not. As a result, lawmakers in December 2022 passed a new law, one in which they took the tough vote to place a limit of $35,000 on outside income; but they threw in a sweetener: Legislative salaries would be increased to $142,000, far-and-away the highest in the nation.

New York’s new law raised salaries immediately, but delayed the new outside limit restriction until January 1, 2025 since lawmakers who ran for the 2023-24 legislative session did not know of the new restriction. Thus, waiting until January 2025 for the outside income restriction to go into effect would give lawmakers and challengers a better understanding of the compensation structure when deciding whether to stand for election for the 2025-2026 term.

In mid-2024, some lawmakers sued again and got a preliminary court action to stop the restriction on outside income. The final decision came down earlier this month and opponents of a limit on outside income lost. The restriction is going into effect. Warning of “chaos,” opponents now are asking for a postponement of the decision and have said that they will appeal it – which they are, of course, entitled to do.

The legal back-and-forth ignores the rationale for the restriction in the first place. The 2018 commission report joined with reformers when it clearly stated that it “determined to limit outside earned income to ensure that Legislators devote the appropriate time and energy to fulfilling their Constitutional obligations and to also minimize the possibility and perception of conflicts.” The concern is not theoretical: New York has seen its share of scandals in which lawmakers have used their public positions to enrich themselves personally.

The five-year-long foot-dragging needs to come to an end. When lawmakers first accepted those gigantic pay increases starting five years ago, they knew that it came with some strings attached. One of those strings was that if you wanted the highest legislative pay in the nation, you must forgo significant outside income.

For most lawmakers, this is no big deal. The vast majority of lawmakers have no significant outside income. Media reports state that perhaps as many as 38 of the 213 legislators would be impacted by the law.

Those who ran in 2022 and then in 2024 knew that there was a distinct possibility that if they won, they would face a limit on outside income. Five years of delays are long enough. New Yorkers deserve state lawmakers who serve only one “master”: the public that they are sworn to serve.