When you are not feeling well, the decision to see a doctor or other health care provider should not be a complicated one. But it often is, fraught with a variety of concerns, starting with the most basic one: physical access to providers, which can include lack of primary care doctors or specialists in the area and transportation problems or work schedules that can make it difficult to make it to appointments. Other concerns include the quality of care and, even for those with health insurance, its affordability, which carries a plethora of sub-concerns. Is the service covered? If so, is pre authorization required? Have you met any deductibles? How much is the co-pay? Is the doctor in-network? The hospital? Will you be hit with a surprise medical bill for some unforeseen out-of-network provider or test? Unfortunately, the fragmented structure of our healthcare system, with doctors, insurers and patients all seemingly driven by amoral economic forces, does not generate a collective sense of confidence that every person, regardless of income and geography, will receive the appropriate medical care that promotes their well-being.
NJ Appleseed seeks to change that reality. Our mission is to impact public policy to secure quality health care services for all, regardless of income, social status, race or ethnicity. In particular, we provide a legal voice to communities and organizations seeking to establish health care as a social right by advocating on behalf of those who lack the economic or political resources to obtain such services through the private market, and by striving to assure that such services are effective, affordable and designed to promote well-being. Our principal goals and focus are:
- to preserve vital community health care assets by policing corporate restructurings, including the conversion of health care entities from nonprofit to profit-making, and other changes in their mission that might adversely impact access to care;
- to provide education and technical assistance to hospitals, neighborhood health centers and other nonprofit health service organization boards, state officials and nonprofit insurance companies regarding their fiduciary obligations, and to assist community residents in holding such nonprofit organizations accountable;
- to advocate for pro-consumer regulations that promote accessible, affordable and quality health services regardless of income, social status, race or ethnicity; and
- to promote coordinated efforts among healthcare providers to ensure the equitable and effective delivery of health care services to historically under-served communities, and in particular, to diminish the racial disparities in the health status of Newark residents.
Community Health Assets Protection Project
NJ Appleseed represents community organizations and residents in administrative and court proceedings to ensure that hospital and other health-related nonprofit boards satisfy their fiduciary duties to the public when seeking to merge or sell their charitable healthcare assets to a for-profit entity or another nonprofit with a different mission.
We have acted to help ensure compliance with the Community Healthcare Assets Protection Act, (CHAPA), P. L. 2000, c. 143 (N.J.S.A. 26:2H-7.10 et seq.), enacted in response to the late 1990’s trend by many non-profit hospitals around the country to convert to for-profit status. CHAPA was based on model legislation proposed by the National Association for State Attorneys General to govern the conversion process. It also covered mergers between nonprofit hospitals.
CHAPA requires prior review by the Attorney General’s office in consultation with the Commissioner of Health and Senior Services for any transaction in which a nonprofit hospital is to be acquired by an entity other than a charity licensed in New Jersey, to determine if the acquisition is in the public interest. That determination can only be made based on a finding that “appropriate steps have been taken to safeguard the value of the charitable assets of the hospital and to ensure that any proceeds from the proposed acquisition are irrevocably dedicated for appropriate charitable health care purposes” and that the proposed transaction is “not likely to result in the deterioration of the quality, availability or accessibility of health care services in the affected communities.” Public notice must be provided via newspaper advertising, the public can submit written comments during the Attorney General review and at least one public hearing must be held, with at least two weeks’ notice, at which any person may comment in writing or in person. Following review, the application must be submitted to a state Chancery judge for approval, a proceeding in which any person who filed a written comment or appeared and made a statement at the public hearing is deemed a party, including consumers or community groups representing the citizens of the State.
Since enactment of CHAPA, NJ Appleseed has taken an active role in trying to protect the public’s interests during conversions and transactions between nonprofit and religious hospitals. In all the matters listed below, we have submitted detailed comments to the Attorney General and Department of Health and Senior Services and, in some cases, made submissions to the Chancery Court overseeing these transactions. Closures are not covered under CHAPA unless assets of the hospital are sold to another entity, although a Certificate of Need (CN) must always be secured from the Department of Health prior to the closure of an acute care facility.
Conversion of Nonprofit to For-profit
In January 2014, NJ Appleseed Executive Director Renée Steinhagen wrote an op-ed in the Star Ledger concerning the problematic trend of non-profit hospitals in New Jersey being converted to for-profit ones, in which the profit motive can drive up the cost of health care for patients and undermine the focus on community needs that is central to the charitable mission of nonprofit entities.
East Orange Hospital
Sold to Prospect Medical Properties, Docket No. ESX-C-214-15 (Feb. 24, 2016).
June 3, 2015 Letter to Attorney General.
October 21, 2015 Letter to Court with attachments.
NJ Appleseed Public Comments.
St. Clare’s Health System (Denville)
Sold to Prime Healthcare Services, LLC.
Certain dedicated assets were transferred to the New Jersey Community Foundation, Docket No. MOR-C-100-16 (2014).
Prime Healthcare’s acquisition of St. Clare’s was originally intended to include Franciscan Oaks, a more than 300-bed continuing care retirement community in Denville that was part of the St. Clare’s system. NJ Appleseed wrote to the Attorney General on behalf of Concerned Residents of Franciscan Oaks alleging fiduciary duty violations. As a result, Prime pulled out of that part of the transaction. (Sept. 12, 2014).
St. Michael’s Medical Center (Newark)
Sold to Prime Healthcare Services, LLC, Docket No. ESX-C-57-16 (April 7, 2016).
In the Matter of Saint Michael’s Foundation, Inc., Docket No. ESX-C-253-16 (Jan. 17, 2017).
December 23, 2012 Letter to Department of Health.
NJ Appleseed Comments at Public Hearing.
November 2015 Op-ed Urging Governor Christie to Save St. Michael’s.
January 15, 2016 Letter to Department of Health and Attorney General.
March 28, 2016 Letter to Court.
Saint Mary’s Hospital (Passaic)
Sold to Prime Healthcare Services, LLC, Docket No. PAS-C-57-14 (2014).
NJ Appleseed Comments at January 15, 2014 Public Hearing.
January 22, 2014 Letter to Department of Health and Attorney General.
Christ Hospital (Jersey City)
Post-bankruptcy sale of Christ Hospital to Hudson Hospital Opco LLC and Hudson Hospital Propco, LLC, dba CarePoint Health, Docket No. HUD-C-104-12.
Bankruptcy Court, Case No. 12-2906 (MS).
May 23, 2012 CN Comments.
May 29, 2012 Letter to DHSS and Attorney General.
June 25, 2012 Letter to Court.
Hoboken University Medical Center
Application by Hoboken Municipal Authority to sell Hoboken University Medical Center to HUMC Holdco, LLC (2011).
March 2, 2011 Letter to Mayor and City Council Requesting Public Hearing on Ordinance.
June 23, 2011 Letter to City Council Requesting CHAPA Hearing.
NJ Appleseed CN Comments.
Meadowlands Hospital (Secaucus)
Sold to Meadowlands Hospital Acquisition, LLC, Docket No. HUD-C-175-10 (November 2010).
Subsequently, representing HPAE (Health Professionals and Allied Employees) Union, we wrote to the Department of Health and Senior Services in 2013, asking it to enforce its CN Order that was incorporated in the Court’s CHAPA judgment.
July 2010 Appraisal of Meadowlands Hospital.
NJ Appleseed Public Comments.
September 30, 2010 Letter to State Health Planning Board.
April 30, 2010 Letter to Attorney General.
August 2, 2011 Letter to Health Commissioner.
October 28, 2013 Letter to Health Commissioner.
Bayonne Medical Center
Post-bankruptcy sale of Bayonne Medical Center to a consortium of investors, IJKG LLC. It has since been acquired by CarePoint and has a reputation for high billing rates, consistent with our objections to the sale.
Docket No. HUD-C-8-08 (January 2008).
NJ Appleseed Public Comments.
Mountainside Hospital (Glen Ridge)
Sold to Merit Health Systems, Docket No. ESX-C-153-07 (May 30, 2007).
Submission to Department of Health regarding proposed sale.
NJ Appleseed Comments at March 29, 2007 Public Hearing.
April 4, 2007 Letter to Attorney General.
April 10, 2007 Letter to Health Commissioner requesting health care monitor.
Memorial Hospital of Salem County (City of Salem)
Sold to Community Health Systems, Docket No. SAL-C-15-02 (2002).
NJ Appleseed Comments on Proposed Sale pursuant to CHAPA.
Bergen Pines Hospital (Paramus)
Prior to enactment of CHAPA, NJ Appleseed challenged the planned privatization of Bergen Pines Hospital, which was owned and operated by Bergen County. In 1998, Bergen County transferred its county hospital, Bergen Pines, to the Bergen County Improvement Authority, who in turn leased the hospital to Solomon Health Group, a for-profit company. At this point, the facility was renamed Bergen Regional Medical Center. Pursuant to this transaction, the license remained in public hands and the hospital received tax exemptions and reimbursement rates consistent with public ownership, but to the enrichment of a private entity. Indeed, Solomon was not even required to make capital improvements. Finally, after many challenges and wide-spread public discontent, the County decided not to renew the lease and instead signed a contract for it to be run jointly by two nonprofits, Care Plus Bergen and Integrity House, a Newark-based drug treatment center. Now known as New Bridge Medical Center, it is the state’s largest hospital, with 1,000 beds.
Health Professionals and Allied Employees v. County of Bergen, A-4277-97 (1998).
Amicus Brief filed with Appellate Division by NJ Appleseed, together with NJ Public Health Association, Citizens for Public Health, NJ Citizen Action and Gray Panthers of Northern New Jersey.
Raritan Bay Medical Center (Old Bridge and Perth Amboy)
In response to an effort by Prospect Medical Holdings, a California for-profit hospital chain, to buy Raritan Bay Medical Center in 2013, we requested documents directly from the hospital and raised questions regarding the alleged need to sell the hospital for financial reasons. As a result of the issues we raised publicly, along with opposition to the sale from within the hospital, the Board of Trustees decided not to approve the sale as requested by Raritan Bay’s CEO.
June 10, 2013 Letter to Attorney General and Commissioner of Health.
NJ Appleseed Comments on Proposed Sale.
Secular, Nonprofit to Catholic Hospital or Out-of State-Nonprofit
St. Michael’s Medical Center (Newark)
The Archdiocese of Newark sought approval to sell its three hospitals, including St. Michael’s Medical Center, to local affiliates of Catholic Healthcare East, a 24-hospital system based in Newtown, PA. The sale of St. Michael’s was conditioned upon the closure of the St. James and Columbus Hospitals.
In the Matter of Application of Cathedral Health Services, Inc., Docket No. ESX-C-101-08 (2008).
NJ Appleseed Comments.
Court Order approving sale
Passaic Beth Israel Medical Center
Sale of Passaic Beth Israel Regional Medical Center (which resulted from the merger of former Passaic Beth Israel and Passaic General Hospitals) to Saint Mary’s Hospital in 2006. NJ Appleseed intervened to protect reproductive services. Subsequently, in 2014, St. Mary’s was acquired by Prime Healthcare Services and it is now known as St. Mary’s General Hospital.
September 2006 “Dear Colleague” Outreach Letter re Pending Sale.
NJ Appleseed Public January 2017 Public Comments.
January 31, 2007 Letter to State Health Planning Board.
February 2, 2007 Letter from Attorney General to Court approving sale.
Rancocas Hospital (Willingboro)
The sale of Rancocas Hospital was part of the larger bankruptcy of Alleghany Hospitals filed in Pennsylvania. NJ Appleseed, Planned Parenthood of Camden County, and the ACLU-NJ intervened in the state hearing concerning several dedicated funds to compel the creation of a charitable trust to pay for the reproductive services that Rancocas would no longer provide. The Court denied us standing in July 2002. The hospital is now known as Lourdes Medical Center of Burlington County.
Sale of Rancocas Hospital to Our Lady of Lourdes Health Services, Docket No. BUR-L-3541-98.
Wayne General Hospital
Purchase of Wayne General Hospital from The Barnabas Health System by St. Joseph’s University Medical Center in 2001. As a result of negotiations between Barnabas and NJ Appleseed, Planned Parenthood of Metropolitan New Jersey received a $2 million grant from the St. Barnabas system to provide the reproductive health services that Wayne General would no longer provide as a Catholic hospital. It is now known as St. Joseph’s Wayne Medical Center.
Christ Hospital (Jersey City)
Christ Hospital, affiliated with the Episcopal Diocese of Newark, was purchased by Bon Secours Health System in 2001. It retained its religious identity but continued to offer sterilization and contraception. Following targeted advocacy by NJ Appleseed with the NJ-ACLU, the hospital created a women’s health center six blocks away that provided abortions under a different parent corporation. It is now part of the for-profit organization Hudson Hospital Opco, which does business as Care Point Health.
Elizabeth General Hospital
In 2000, Elizabeth General Hospital, a secular institution, was merged with St. Elizabeth Hospital, a Catholic one, to form Trinitas Regional Medical Center, which discontinued certain reproductive services, including abortion, in accordance with Catholic doctrine. Representing the head of the gynecology department and some of his patients, we went to court and obtained an order compelling the set-aside of a charitable trust. The fund was to be held and administered by Morristown Planned Parenthood, which was required to make funds available to Elizabeth and Newark residents who had been or would have received certain reproductive services at Elizabeth General that had been discontinued. We received attorneys’ fees, since we had preserved a “fund in court.”
In the Matter of the Application of Elizabeth General Medical Center and St. Elizabeth Hospital for Consolidation, Docket No. UNN-C-97-99.
Preventing Closure and Improving Services
University Hospital (Newark)
NJ Appleseed is part of the Newark Coalition of Concerned Citizens, which is working to preserve University Hospital as an effective public hospital that provides quality, affordable services to all residents located in the Greater Newark area. In particular, we are trying to reinvigorate and improve the community oversight of the hospital by seeking changes to the board’s governance structure and its current advisory board to enhance the participation of residents at the same time as ensuring that the hospital remains responsive to their healthcare needs. In support of that effort, the Coalition launched a petition in June 2019.
Another threat to University Hospital, home to Rutgers New Jersey Medical School, arose in 2020 with a proposal to merge the Medical School with Robert Wood Johnson Medical School in New Brunswick. On July 27, 2020, NJ Appleseed wrote to Governor Murphy expressing concerns about the merger–that it would undermine University Hospital, the City of Newark and the predominantly low-income minority population the Hospital serves by shifting resources to New Brunswick and the privately-owned RWJ/Barnabas Health System. That would violate the State’s commitment to University Hospital, NJ’s only public hospital, and also the State’s commitment to the Newark community embodied in the 1968 Newark Accords. We are also troubled by the lack of transparency and legislative oversight for the proposed merger. Our letter demanded that NJ continue to honor its commitments to Newark and urged swift passage of legislation or rules that would restrict Rutgers from unilaterally moving or displacing residents, interns and fellows, clinical services and faculty to other hospitals regardless of financial motivations for doing so. We further urged that University Hospital be part of the decision-making process and have a vote on any move that involves its workforce in order to protect the integrity of the Newark campus and its relationship to the New Jersey Medical School.
St. James Hospital (Newark)
Closed as a result of purchase by Catholic Healthcare East (2008).
NJ Appleseed Comments re CN Review.
Outline of CHAPA Issues.
Columbus Hospital (Newark)
Closed as a result of purchase by Catholic Healthcare East (2008).
NJ Appleseed Comments re CN Review.
Muhlenberg Regional Medical Center (Plainfield)
NJ Appleseed submitted a series of letters to the Department of Health and Human Services in 2008, regarding the request by Solaris Health Services to obtain a Certificate of Need so that it could close Muhlenberg Regional Medical Center, an acute care facility in Plainfield, and sell it to JFK Medical Center, based in Edison. We requested a Community Impact Study and failing that, to condition closure on Solaris providing certain non-acute care services at the site for at least eight years and appointing a health care monitor to conduct a full community needs assessment, among other conditions. We also asked the Health Commissioner to consider her obligation to eliminate health disparities in vulnerable racial and ethnic communities.
In July 2008, the Commissioner approved the closure subject to a number of conditions, including procedures for proving notice of the closure to community and other providers, operation of a satellite emergency department at the Muhlenberg location for at least five years, provision of transport services to JFK and other providers, financial support for midwifery services in Plainfield and provision of primary care services at Muhlenberg or another Plainfield location. Further, Solaris was also not allowed to terminate a lease to a dialysis company unless the company secured an alternate site in the same area. As of 2019, JFK is still operating the satellite emergency department and leasing to the dialysis provider.
In 2018, JFK merged into Hackensack Meridian Health and sold part of the Muhlenberg campus for $3 million to an affiliate of Community Health Associates (CHA) in Bloomfield. CHA, which also owns Salem Medical Center in Salem (formerly Memorial Hospital of Salem County), plans to develop a medical arts complex on the property and also build a 120-unit luxury apartment building. The deed of sale included restrictions barring for 10 years uses such as facilities for emergency care center, imaging and dialysis, and a nursing school that would compete with JFK’s activities on the rest of the property.
During the pandemic of 2020, there were plans to put the development on hold so that the Army Corps of Engineers could convert the gutted interior into a space holding 200 temporary hospital beds for the care of COVID-19 patients. The plan was dropped when it was discovered that it would take too much time and money given the deterioration in the condition of the building since the closure.
CN Letter–May 5, 2008.
CN Letter–June 12, 2008.
CN Letter–June 25, 2008.
Barnert Hospital (Passaic)
Chapter 11 Bankruptcy petition, Docket No. 07-bk-21631 (DHS) (D.N.J. Aug. 15, 2007).
September 28, 2007 Letter to Attorney General and Health Commissioner.
April 14, 2008 Letter to Attorney General and Health Commissioner.
Pascack Valley Hospital (Westwood)
Closed due to Bankruptcy in 2007.
Chapter 11 Bankruptcy petition, Docket No. 07-bk-23686 (D.N.J. Sept. 24, 2007).
Union Hospital (Township of Union)
Closed in 2007. The site is currently used as a satellite location for the emergency department of Overlook Medical Center in Summit.
Hospital Center at Orange
Closed in 2004.
December 19, 2003 Letter to Attorney General.
Other Nonprofit Healthcare Conversion Work
Lawsuit against State Over Hospital Tax Exemption
On August 10, 2021, we filed papers on behalf of NJ Citizen Action, the American Federation of Teachers NJ and several individuals seeking to intervene in support of the plaintiffs in Colacitti v. Murphy, a suit brought by several municipalities that challenges a law allowing non-profit hospitals to retain their charitable exemption from real estate taxes, even when some aspects of their operations are conducted for profit. The law, A-1135, enacted Feb. 22, 2021 as P.L. 2020, c. 17, was meant to overturn AHS Hospital Corp. v Morristown, a precedential 2015 Tax Court decision. It held that Morristown Medical Center was not entitled to tax exemption on almost all of its property because non-profit and for-profit activities were significantly commingled, to the substantial benefit of for-profit entities, including an insurance company, investment company and various “captive P.C.” for-profit physician practices owned by the hospital. The law was channged to allow non-profit hospitals to shelter for-profit partners and ventures on their campuses tax-free, retroactive to 2014. In some instances, they would have to pay the municipality a “Community service contribution” instead. The new law also prohibits taxpayers from challenging the assessment or tax-exempt status of any other property in the county, as they were previously allowed to do. We took on the case because we believe that it makes it more likely that hospitals will contract out entire departments and even nursing staff, moving us further toward the privatization of health care, which increases cost and lowers quality. It is also likely to hurt education by reducing the local tax revenues that are used to pay for it and unfairly burden taxpayers who might have to make up the shortfall or face cuts in services.
Notice of Motion
Certification by Renée Steinhagen
The court denied our request for interevention so we submitted an amicus brief instead, which we filed on Nov. 5, 2021.
In addition, we filed a separate lawsuit on September 28, 2021, on behalf of NJ Citizen Action and the AFT-NJ and individual taxpayers. Our lawsuit, NJ Citizen Action v. Murphy, challenged those aspects of the law which prohibited third-party tax appeals. The state moved to dismiss and in March 2022, we responded and filed a cross motion for summary judgment. Our Reply Brief was filed on April 27, 2022.
The court dismissed the main lawsuit challenging the tax exemption on July 22, 2022, and subsequently, on September 28, 2022, dismissed our lawsuit as moot and nonjusticiable because the state had conceded that, despite the language and intent of the statute to eliminate all third-party appeals, it barred only administrative appeals given that the Legislature did not have the power to override the state constitutional right of prerogative writ to challenge government actions in court. We decided to appeal because the language of the statute and the understanding when it was passed was that it would bar all third-party tax appeals. Thus, a delaration from the court that the right to bring third-party tax appeals in court still exists is necessary to avoid confusion among the public. It would also prevent the state from backtracking on its concession and trying in the future to bar all third-party appeals based on the plain language of the statute. We filed our Appeal Brief and Appendix on February 22, 2023.
Horizon Blue Cross Blue Shield (1996-1997)
NJ Appleseed opposed a 1996 attempt by Horizon Blue Cross Blue Shield of New Jersey, the state’s largest health insurer, to merge with a for-profit company, Anthem Insurance, and change from a nonprofit to a for-profit entity. We submitted a memorandum to then-Attorney General Peter Verniero on Dec. 11, 1996, and subsequently intervened in a case initiated by BCBS against the state, In the Matter of the Application of BCBS, Inc. for Conversion to a Domestic Mutual Insurer, Docket No. ESX-L-1591-97, and then heard by the Appellate Division, No. A-4505-96 (App. Div. 1997). The trial and appellate courts ruled that Horizon BCBS is a charitable and benevolent institution and, as such, was obliged to preserve its assets for charitable purposes. The state Supreme Court denied review. Horizon BCBS abandoned the plan in 1997.
Motion to Intervene.
Brief in Response to Horizon Motion for Summary Judgment.
Litigation Related to Conversion of Health Insurance Plan (HIP) of NJ (1998)
NJ Appleseed participated in HIP conversion disclosure litigation, HIP of New Jersey, Inc. v. NJ Department of Banking and Insurance, 309 N.J. Super. 538 (App. Div. 1998), which the company initiated to block the disclosure of documents to NJ Appleseed that would reveal the terms of the sale of the company to a for-profit entity. One year later, HIP went into liquidation. Acting on behalf of NJ Citizen Action and consumer members of HIP, we intervened in the receivership seeking an independent investigation of the events leading to HIP’s financial collapse. We also asserted a charitable trust lien, on behalf of HIP’s members and the public. The court, however, found that we did not prove that the company had value at the time of sale.
In the matter of the Liquidation of HIP of NJ, Docket No. MID-C-275-98.
Legislation Protecting Public Interest in Charitable Assets On Conversion to For-Profit (2001)
NJ Appleseed gave testimony in support of legislation to allow conversion of a nonprofit health service corporation to a domestic stock health service corporation under certain circumstances. It requires approval from the Commissioner of Banking and Insurance and conveyance of stock worth 100 percent of the fair market value of the original corporation into a charitable foundation established by the state to promote the health of the state’s residents. The bill, A-2739/S-1581, was signed into law in June 2001, as P.L. 2001, c.131 (N.J.S.A. 17:48E-45 et al.) by Governor Donald DiFrancesco.
Forum on Protecting Public Interest on Restructuring of Nonprofit Health Insurer (2006)
In June 2006, NJ Appleseed joined with Consumers Union to sponsor a public forum on “The Role of Nonprofit Health Insurance in New Jersey: Protecting the Public Interest in an Era of Health Restructuring.” The forum, held in Trenton, emphasized nonprofit health insurance in the state of New Jersey, while also addressing the role and performance of nonprofit health care across the United States. The panelists were: Howard Berman, chairman of the Alliance for Advancing Nonprofit Healthcare; William J. Marino, president and CEO of Horizon Blue Cross Blue Shield, New Jersey’s largest health insurer; Mark Schlesinger, professor in the Division of Health Policy and Administration at Yale University School of Public Health; and Deborah Chollet, a senior fellow at Mathematica Policy Research, in Washington, D.C., an eminent researcher and scholar on health care delivery and financing issues.
Horizon Blue Cross Blue Shield (2008)
Subsequently, in 2008, Horizon BCBS once again began taking steps toward conversion. In response, NJ Appleseed developed principles to protect the public’s stake in the company. The Horizon Watch Coalition, a group of nearly two dozen labor, consumer, small business and social justice groups, including NJ Appleseed and NJ Citizen Action, based its campaign against conversion on those principles. To date, Horizon remains a nonprofit insurer.
Horizon Blue Cross Blue Shield (2019-2022)
In 2019, Horizon Blue Cross Blue Shield initiated an effort to convert to a for-profit entity without having to make the charitable trust settlement required by the 2001 conversion law (see above). Legislation that would change the law to enable this was circulated among legislators and others. NJ Appleseed was provided the opportunity to analyze the bill and prepared a memo setting forth our concerns and those of NJ Citizen Action, which was submitted to Governor Murphy. Our December 13, 2019 memo pointed out how the proposed changes in the law would enable Horizon to circumvent the approval process and many of the existing protections, harming the public and policyholders for the sole benefit of management and future private shareholders. That legislation was never introduced.
Horizon tried again in late 2020. A draft bill began circulating in November, slightly different from the one in 2019 but equally problematic in that it essentially enabled Horizon to convert to a for-profit entity while failing to protect its estimated $7 billion in assets, which would be required for a charitable trust settlement under the 2001 law. NJ Appleseed updated its 2019 memo, pointing out the similar flaws in the new bill, which was introduced in the Senate as S3218 on Dec. 7 and in the Assembly as A5119 on Dec. 10. It was rushed through the Assembly Financial Institutions (AFI) and Senate Commerce Committees on Dec. 14 with little opportunity for the public or even the legislators to understand its complexities. NJ Appleseed Executive Director Renée Steinhagen testified against the legislation at an invitation-only hearing before AFI on Dec. 1 and on Dec. 14, presented joint testimony with NJ Citizen Action’s Maura Collingsru at the AFI and Senate Commerce Committee hearings. NJ Appleseed and NJ Citizen Action also submitted a letter signed by about 40 NJ organizations opposing the bill to Governor Murphy, Senate President Sweeney and Assembly Speaker Coughlin on Dec. 10.
Nevertheless, the legislation passed both houses on Dec. 17, 2020 and was signed into law on Dec. 23, 2020. It allowed Horizon to reorganize as a mutual holding company that, although a nonprofit. would be allowed to invest in for-profit businesses and ventures, transforming it into a de facto for-profit operation. Amendments to the bill meant to allay our concerns included requirements that the Attorney General get a copy when Horizon submitted its application for reorganization to the Department of Banking & Insurance and that three public hearings be held within 90 days of the application, and also allowed the Department to have a study done on the health impact of the reorganization. The study was done but not released to the public until the date the Department approved the application, Nov. 1, 2022, and the three public hearings, held in the absence of that report and other vital information about the proposal, were rushed through in a period of only 11 days, between Oct. 6 and 17, 2022. NJ Appleseed submitted testimony in opposition on behalf of itself and NJ Citizen Action. More information about the approval process can be found here.
On Dec. 13, 2022, NJ Appleseed, together with co-counsel from the firm of Adkins, Kelston & Zavez, appealed the Department’s decision to approve the Horizon reorganization on behalf of Horizon policyholders as well as NJ Citizen Action, a consumer advocacy group, and Health Professionals and Allied Employees, a health care worker union. The following day, we asked the Department for a stay of its Nov. 1 order approving the reorganization, pending a decision on the merits of the appeal by the Appellate Division. The stay was denied. On February 21, 2023, we filed our appeal brief, arguing that the order authorizing the Horizon conversion should be reversed on the grounds, among others, that the Commissioner of Insurance acted contrary to law and treated policyholders inequitably by failing to provide them with adequate notice.
Star Ledger article about Horizon Reorganization
Star Ledger article about Filing of Appeal
Consumer Advocacy Project
NJ for Health Care Coalition
NJ Appleseed is one of the founding members of the NJ for Health Care Coalition, the state’s primary healthcare consumer advocacy group. The Coalition is “dedicated to common sense, consumer-friendly solutions to ensure that every New Jerseyan can get the health care they need, when they need it, at a price they can afford.” We provide legal services to the Coalition, its member groups and the public generally, with respect to various legal health care issues, drafting and analyzing legislation, preparing regulatory comments, and writing reports and consumer manuals from the perspective of the health care consumer. We serve on the Coalition’s Leadership Team and advise the Coalition with respect to legal matters. Matters undertaken on behalf of and with the Coalition include the following:
Affordable Prescription Drugs
NJ Appleseed is the legal arm of the NJ for Affordable Drugs campaign, which has been working for the passage of legislation that would establish a Prescription Drug Affordability Board (PDAB) to help rein in the high cost of prescription drugs. Other members of the campaign include NJ Citizen Action, NJ Policy Perspective and the Anti-Poverty Network.
When S-1066, which would create a PDAB, was introduced in January 2020, we sought to strengthen it by suggesting amendments that would give the board power to take concrete action rather than merely make recommendations that might be ignored. At a hearing on its companion bill, A-2418, held on May 14, 2021, before the Assembly Financial Institutions and Insurance Committee, supporters of the Affordable Drugs campaign testified, including Maura Collingsru of NJ Citizen Action and Leigh Purvis of AARP’s Public Policy Institute. NJ Appleseed submitted written testimony by Executive Director Renée Steinhagen, which included FAQs about what a PDAB is and how it would work. She provided oral and written testimony in support of the bill at a second hearing before the same committee on June 2, 2021.
Unfortunately, the PDAB did not pass in the 2020-2021 legislative session and thus, was reintroduced in January 2022, as A-1747/S-329. NJ Appleseed Executive Director Renée Steinhagen provided written testimony in support at the March 10, 2022 Senate Health Committee hearing and both oral and written testimony before the Assembly Health Committee on May 24, 2022. At that same hearing she also testified in opposition to A-2840, which purports to address the problem of excessive prices for prescription medication but would actually do little to lower them and appeared to have been introduced to distract from the more effective approach represented by the PDAB.
News Coverage of May 24, 2022 Hearing before Assembly Health Committee
Easy Enrollment Health Insurance Program
NJ Appleseed submitted written testimony in support of A-5213/S-3238, which would establish the NJ Easy Enrollment Health Insurance Program, to the Assembly Financial Institutions and Insurance Committee in advance of a May 14, 2021 hearing at which it voted 11-0 to advance the bill. The proposed program would utilize a simple checkoff on state tax returns to initiate a process for determining eligibility for Medicaid, NJ FamilyCare or private insurance subsidies available on the state health exchange and then enrolling individuals in the appropriate plan. It passed both houses on June 21, 2021 but was conditionally vetoed on November 8, 2021. The changes proposed in the conditional veto included a longer implementation timeline, a clearer delineation of the work to be done by each department and other steps meant to increase efficiencies and ensure full compliance with federal law.
In response, the Coalition wrote to legislators on December 13, 2021, urging them to make the changes set forth in the conditional veto but when voting on the amended legislation, to make a statement calling for timely rulemaking regarding implementation of the program and for appointment of the Exchange Advisory Group, along with additional members, and for the holding of regular meetings.
Surprise Medical Bills,
“Surprise Medical Bills: What they are an how to stop them, while ensuring access to needed services and adequate payment for providers.” White paper written by Executive Director Renée Steinhagen on behalf of NJ for Healthcare and Consumers Union.
NJ Appleseed testified before the Senate Commerce Committee on April 5, 2018, in support of S-485, the Out-of-Network Consumer Protection and Accountability Act, which was signed into law on June 2, 2018.
On November 29, 2019, NJ Appleseed and NJ Citizen Action submitted comments on behalf of the Coalition to the Department of Banking & Insurance in response to its advance notice of intended rulemaking to implement the provisions of the Out-of-Network Act. The comments point out areas requiring clearer and more complete information for health care consumers concerning the protections provided by the Out-of-Network Act and one instance, regarding carriers’ setting of initially determined allowed charges for inadvertent and/or involuntary out-of-network services, in which the intended rule would conflict with the specific terms of the Act and defeat its stated purpose to rein in rising costs.
On January 4, 2022, NJ Appleseed joined with the NJ for Healthcare Coalition in a letter to state legislators asking them to oppose S-6245/A-3458, which would amend the Out-of-Network Act. We told them that the bill was poorly timed, ill-advised and illogical in that the federal No Surprises Act, which is both more protective and applies to all insureds in NJ, not just the 2.1 million who have state-regulated health plans, just took effect on January 1. The pending state bill would create unnecessary differences with the federal law, making things more confusing and increasing administrative costs. Instead, we urged that New Jersey make its law consistent with the federal law so that doctors and other health care providers can use the same disclosure forms and notices for everyone and treat everyone the same when it comes to surprise medical bills.
The bill was reintroduced in the new legislative session as A-4032 / S-1177. It omitted the language requiring arbitrators to look at providers’ usual and customary fees but still diverged from the federal law in extending certain deadlines and lowering the threshold for arbitration from $1,000 to $500. On June 2, 2022, when the bill came before the Assembly Financial Institutions and Insurance Committee, we joined with the NJ for Health Care Coalition, NJ Citizen Action, NJ Policy Perspective and NJ Health Care Quality Institute in testimony opposing it.
In addition to opposing amendments to the state Out-of-Network Act that would clash with the federal No Surprises Act or create confusion among consumers, NJ Appleseed has joined with other stakeholder groups representing patients, consumers, unions, and employers in urging the federal government to stand firm in defending the No Surprises Act, especially in the face of numerous court challenges that seek to weaken or block it. On June 28, 2022, we were one of 68 groups that wrote to the Departments of Health, Labor and Treasury to urge them continue to stand firmly on the side of consumers and patients in defending the No Surprises Act, including implementing the law in a manner that helps reduce health care spending. The letter pointed out how effective the federal law has already been in shielding millions of consumers from surprise medical bills and the need for a predictable Independent Dispute Resolution (IDR) process centered on market-based reimbursement for services to aid in the continued success of the law. We followed up on December 12, 2022, participating in a second letter from 58 signatories that urged the Departments to continue to stand firmly on the side of patients and consumers in the face of continued efforts to erode the No Surprises Act. We expressed concern about excessive use of the IDR process, often by private-equity backed provider groups, which threatens to drive up the amount of provider reimbursement and thus inflate the cost of healthcare.
The Affordable Care Act (ACA)
On March 4, 2021, NJ Appleseed and NJ Citizen Action submitted to the state on behalf of the Coalition comments regarding proposed tax rules meant to implement the NJ Health Insurance Market Preservation Act enacted in 2018 to create an individual state insurance mandate, replacing the federal one that had been repealed. We urged flexibility in the application of the income eligibility cap for the “substantial deprivation” exemption, one that would allow rebuttal of the proposed rule’s 138% of federal poverty level standard. We also pointed out the need to take into account pending legislation for an Easy Enrollment Health Insurance Program operated by the Department of Banking and Insurance which would have to coordinate with tax authorities regarding the mandate. At minimum, tax authorities should ensure that nothing in the proposed rules “will hinder its obligations to facilitate the enrollment of uninsured taxpayers in a health plan in lieu of imposing” the penalty – the “individual shared responsibility payment” – for violation of the insurance mandate. Lastly, we commented that the cost-benefit analysis of the rules’ impact should specify the income level, race and ethnicity of the taxpayers who are likely to be impacted by the proposed regulations rather than merely stating generally that the rules will constitute a liability for those who are required to pay the penalty.
NJ Appleseed Executive Director Renee Steinhagen submitted a Comment and testified before the Senate Commerce Committee in support of legislation (S-49 and S-3807) that would establish a state-based health insurance exchange. She did so together with Maura Collingsru, the Health Care Program Director at NJ Citizen Action, on behalf of the NJ for Health Care Coalition (June 3, 2019).
Comment filed on behalf of Coalition with U.S. Dept. of Labor regarding proposed change to ERISA rules that would impact Association Health Plans available under the ACA (March 4, 2018).
Comment filed on behalf of Coalition with U.S. Dept. of Health and Human Services, Centers for Medicare and Medicaid Services, regarding proposed ACA Rules on Basic Health Program (November 25, 2013).
Comment filed on behalf of Coalition with U.S. Dept. of Health and Human Services, Centers for Medicare and Medicaid Services, regarding proposed ACA Rules on Health Insurance Market (December 25, 2012).
Comment filed on behalf of Coalition with U.S. Dept. of Health and Human Services, Centers for Medicare and Medicaid Services, regarding proposed ACA Rules on Essential Health Benefits (December 25, 2012).
Memorandum to Coalition regarding establishment of a state healthcare exchange, comparing S-2597 (2010) and S-1319 (2012), in context of N.J. for Healthcare Coalition Exchange Principles (February 3, 2012).
Memorandum, entitled “Understanding independent government agencies, and nonprofits performing a government function” (October 24, 2011).
Health Insurance Assessment Legislation
On July 23, 2020, NJ Appleseed, as a member of the NJ for Health Care Coalition, submitted written testimony in support of A-4389/S-2676, which was advanced by committees in both houses on that same date. The legislation would impose a state health insurance assessment on health insurers, replacing the federal one established in 2014 to help fund the Affordable Care Act, which will expire on Jan. 1, 2021. The NJ assessment, which is expected to bring in more than $300 million next year, would have to be used to improve health care access and affordability through mechanisms such as subsidies, reinsurance, tax policies, outreach and enrollment efforts, and other efforts to extend coverage to and improve affordability of health insurance for low- and moderate-income families and the uninsured, with a primary focus on households with an income below 400 percent of the federal poverty level. The funds also “may be used” to reduce racial disparities in coverage for the uninsured. The bill was signed into law, P.L. 2020, ch. 61, on July 31, 2020.
On June 21, 2019, NJ Appleseed submitted a comment to the Office of Management and Budget concerning its proposal to change the manner in which it makes annual adjustments for inflation to the federal poverty guidelines. Those guidelines determine who is eligible for health, housing, food assistance and other programs that help poor people meet basic needs. The OMB has proposed using an alternative to the traditional Consumer Price Index. Our comment, submitted on behalf of the NJ for Healthcare Coalition, expressed concern that the proposed alternatives would result in a lower poverty line than under the current methodology, with a gap that would widen each year. The poverty line is already too low and the proposed change would make it even less accurate for measuring the needs of low-income Americans and increase the number of Americans without health insurance and experiencing other forms of hardship.
Medicaid Coverage for Immigrants
In a matter challenging the constitutionality of NJ’s decision to dis-enroll legal immigrants from the Medicaid program, we organized an Amicus Brief filed by the McCarter & English law firm on behalf of NJ Appleseed; NJ Policy Perspective; NJ Citizen Action; State Parent Advocacy Network; Family Voices of NJ; Next Steps; NJ Working Families Alliance; Blue Wave NJ; South Chapter of the National Organization of Women; Unitarian Universalist Legislative Ministry of NJ; Lutheran Office of Governmental Ministry in NJ; Latino Action Network; and Democracia. The Supreme Court agreed with the Appellate Division that the denial of Medicaid benefits did not violate the federal or state constitutions, saying the Equal Protection Clause does not bar a state from acting consistent with a clearly expressed federal policy, as expressed in the residency requirement of the Personal Responsibility and Work Opportunity Reconciliation Act.
Guaman v. Velez, 221 N.J. 213 (2015), aff’g 432 N.J. 230 (App. Div. 2013).
On December 10, 2018, NJ Appleseed submitted a comment on behalf of the New Jersey for Health Care Coalition to the Department of Homeland Security, U.S. Citizen & Immigration Services in opposition to a proposed expansion of an immigration rule that allows officials to deny admission to the U.S., a green card or other adjustment to legal status. Under the current “public charge” rule, a person seeking entry to the U.S. or adjustment of their status is inadmissible if deemed likely to become a public charge—i.e., become primarily dependent on the government for support. The proposed change, published in the Federal Register on October 10, 2018, would disqualify immigrants who receive such public benefits as Medicaid, Supplemental Nutrition Assistance Program (SNAP) and Section 8 housing assistance. NJ Appleseed and the Coalition oppose the change because of its direct impact—the exclusion of low-income immigrants and the effect in restricting family-based petitions—and also its indirect impact. It will chill the use of essential public benefits for health care, nutrition, housing and other needs, by immigrants, as well as their children, who qualify for those benefits but fear that accepting them puts them or their family members at risk of deportation or other adverse consequences. New Jersey Policy Perspective has estimated the chilling effect could reach 700,000 New Jersey residents, which will harm not only them and their families but cause a loss of federal funding that will hurt local businesses and workers, especially those in the health and retail food industries.
Nevertheless, on Aug. 14, 2019, the proposed Inadmissibility on Public Charge Grounds Rule, 84 Fed. Reg. 41,292, was adopted and published as a final rule that will take effect in 60 days, on October 15. That same day, New Jersey joined 12 other states in a lawsuit filed in the U.S. District Court for the Eastern District of Washington that challenges the Rule on the basis that it unlawfully expands the definition of “public charge,” in violation of federal immigration statutes, the Welfare Reform Act and the Administrative Procedure Act.
Children’s Health Insurance Program (CHIP)
We organized an amicus brief in support of the State’s challenge to new rules from the Center for Medicare and Medicaid Services affecting New Jersey’s CHIP, or Children’s Health Insurance Program, which provides health care to uninsured low-income children. The NJ program, known as NJ FamilyCare NJ, went beyond the federal standard of covering those with income below 200% of the federal poverty level to include those with up to 350% of that amount, in part to reflect the higher cost of living here. At the time, the NJ program covered 124,000 children. The State alleged that the new requirements on states providing coverage to those above 250% of the federal poverty level would have been impossible to meet, or at least costly and time-consuming, and would also cause hardship. The brief was filed by Arent Fox LLP on behalf of NJ Appleseed and 16 other amici: Alliance for the Betterment of Citizens with Disabilities; Alliance for the Disabled in Action; Blue Wave NJ; Catholic Charities-Diocese of Trenton; CWA Local 1034; CWA Local 1037; Elder Rights Alliance of NJ; Family Voices of NJ; Health Care for All/NJ; Health Professional and Allied Employees; National Association of Social Workers, NJ Chapter; National Organization for Women–Morris County Chapter; NJ Citizen Action; Next Step; Statewide Parent Advocacy Network; and Workmen’s Circle/Arbeter Ring NJ Region. The case was dismissed for lack of ripeness.
State of New Jersey v. U.S. Department of Health and Human Services, 07-cv-04698 (D.N.J. 2008).
Covering All Kids
The Coalition’s Covering All Kids initiative seeks to provide health care coverage to every child in NJ, regardless of income or immigration status, helping to reduce the racial and economic disparities in our healthcare system, which is more important than ever to do, as shown by the COVID-19 pandemic. Our efforts have included support for legislation, S-876/A-4387, which would expand NJ’s FamilyCare program to ensure that all children in NJ under the age of 19 have health care benefits by allowing any child who meets the income eligibility requirements for the Children’s Health Insurance Program (CHIP) to enroll. It would also reestablish a buy-in program open to families without access to affordable employer-based coverage or coverage under the Affordable Care Act. On February 18, 2021, the Coalition wrote to Governor Murphy discussing the need for the legislation and asking that the forthcoming state budget include funds to implement it.
NJ Appleseed Director Renée Steinhagen testified before the Senate Health, Human Services and Senior Citizens Committee in support of a related bill, S-3798, on June 10, 2021. S-3798 is a necessary first step to covering all kids because it would eliminate the 90-day waiting period for coverage, eliminate premiums for all children below19 who are currently eligible for NJ Family Care, expand the advisory council and outreach efforts to include several consumer advocacy representatives, re-establish the NJ Family Care Advantage buy-in program (but with no income minimum for eligibility) and authorize a hardship waiver to permit some families not to pay part or all of the buy-in premium. The bill passed both houses on June 24, 2021 and was signed into law five days later.
The NJ Sentinel Project, a two-year joint endeavor with Seton Hall Law School, funded by the Robert Wood Johnson Foundation, evaluated the performance of small and individual health plans in the state. NJ Appleseed specifically operated a hot line for the public and offered to represent individuals in insurance appeals. As part of the project, we created a manual to assist persons wishing to appeal an adverse benefit decision by their insurance company.
A NJ Guide to Insurance Appeals: Understanding How to Contest Adverse Benefit Determinations in the State (Dec. 2015).
Transforming Healthcare Delivery Project
As part of our health care advocacy, NJ Appleseed participates in efforts seeking to transform the health care system so that it is more equitable, socially just and effective in improving the health status of communities. In particular, Executive Director Renée Steinhagen was one of three attorneys who assisted Dr. Jeffrey Brenner in drafting the New Jersey Medicaid Accountability Care Organization legislation and she currently serves on the Board of the Greater Newark Healthcare Coalition and as Co-Chair of its Legal and Advocacy Committee. The mission of Greater Newark is “to significantly improve quality and access to health care for people in the communities we serve by collaborating to develop initiatives specifically aimed at identifying and eliminating disparities and other barriers that lead to poor health outcomes.” NJA helped found Greater Newark, which began as an organization known as the CEO Working Group. It was created as a direct outcome of the closure of St. James and Columbus Hospitals, which both served the Greater Newark area.
Medicaid Accountable Care Organization Legislation
NJ Appleseed worked with Seton Hall Law Professor John Jacobi, attorney Elizabeth Litten of Fox Rothschild and Dr. John Brennan, President and CEO of Newark Beth Israel Medical Center to propose a Medicaid Accountable Care Organization (ACO) bill. ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to provide coordinated high quality care to their patients. A version of the proposal was enacted in 2011, as P. L. 2011, c. 114, codified at N.J.S.A. 30:4D-1 et seq. and the subgroup also commented on proposed regulations implementing the statute. The law created a three-year Medicaid ACO Demonstration Project by which non-profit managed care organizations serving a minimum of 5,000 Medicaid beneficiaries within a designated region apply for recognition as a Medicaid ACO. Three were certified, in Camden, Newark and Trenton. The legislative goals and process are discussed in “The Journey to Creating a Safety Net Accountable Care in New Jersey,” Alexis Skoufolos, Ed.D. and Kate Cecil, M.S., in Population Health Management, Vol. 16, Supp. 1, 2013.
Greater Newark Healthcare Coalition
When St. James and Columbus Hospitals, both in Newark, closed in 2008, the state conditioned its approval of the closures on the establishment of a CEO Working Group of the remaining hospitals in the Greater Newark area in order to preserve access to health care. NJ Appleseed assisted in the operation of the Group, which was incorporated in 2010 as the Greater Newark Healthcare Coalition. NJ Appleseed Executive Director Renée Steinhagen serves on the Board and is Co-Chair of Legal and Advocacy Subcommittee.
The Greater Newark Healthcare Coalition is currently engaged in a campaign to educate the community about the importance of window guards and to get more window guards installed in multi-dwelling rental units in which children ages 10 and younger reside. The Coalition has propounded a revised Newark Ordinance that no longer requires tenants to request the window guards and instead requires landlords to determine whether young children will be living or spending substantial time in the unit and, if yes, to install the guards. While advocating for passage of the new Ordinance language, the Coalition is distributing informational material about window guards and a request form that tenants can complete and present to their landlords to get the guards installed.