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SOINS DE SANTÉ GARANTIS POUR TOUS

HAKIKISHO YA HUDUMA YA AFYA KWA WOTE

سب کے لئے ضمانت صحت کی دیکھ بھال

BẢO VỆ SỨC KHỎE CHO TẤT CẢ

ЗАКОН НЬЮ -ЙОРКА О ЗДОРОВЬЕ

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Universal Healthcare as Racial Justice

Maternal mortality

Highest maternal mortality rate among “developed” countries

Black women 3-12 times more likely to die from �pregnancy-related causes

Medical debt

Albany - 10% of white residents / 26% POC residents

Onondaga - 14% of white residents / 41%in POC neighborhoods

Monroe - 7% of white residents / 26% of POC residents

COVID Impacts

Buffalo - Preventable conditions (asthma, diabetes, coronary heart disease, COPD and hypertension) conditions spike dramatically east of Main St, where ~85% of Black Buffalonians live.

COVID case counts were higher in the five majority-Black zip codes

Syracuse - African Americans have been hospitalized from COVID at almost 3Xs the rate of white residents. The death rate for Black residents is more than 50% higher than for white residents.

And the health inequities go on and on. We spend at least twice as much as every other industrialized country but we die younger, more of our babies and more of our mothers die - maternal mortality is a hallmark of how well a country’s healthcare system is doing. And the US does not know how to take care of our parents or children.

Maternal mortality -

The United States has the highest maternal mortality rate among industrialized countries. In most other countries, midwives outnumber OB-GYNS by several fold, and primary care plays a central role in the health system. In the U.S., it’s the opposite - we have less midwives and more higher paid OB-GYNS.
We are the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period. The results are higher risk for women in the U.S., especially Black women
Black women are three times more likely to die from a pregnancy-related cause than White women.
In New York City Black mothers are 12 times more likely to die from pregnancy related complications�And of those deaths, the Centers for Disease Control says 60 percent are preventable.
The image on the right is from the Save a Rose Foundation, named after Amber Rose, the 26-year-old Bronx woman and mother-to-be died after an emergency c-section operation to bring her son Elias into the world. C-sections are more profitable to hospitals and doctors than natural births.

Again, the NY Health Act extends beyond our health and our doctors offices. The current healthcare system forces us into impoverishment and affects all parts of our lives.

Medical debt is a top reason for people being denied housing opportunities (mortgages or rental). if they have medical debt on their credit reports

Medical debt statistics from around upstate NY from the Urban Institute:

Albany - While 10 percent of white residents have medical debt, 26 percent of residents of color have medical debt in Albany
Onondaga - 10% of white residents have medical debt, but 41% medical debt is found in primarily black neighborhoods.
Similar stats in Monroe County
And so forth.

And all tis suffering, impoverishment and death for what?

In thinking about injustice in the healthcare system, we have to ask, who PROFITS? �Hospitals, insurance companies - over the last year, while New Yorkers were dying, losing income and struggling to pay unaffordable medical bills, for-profit health insurance companies were raking in billions of dollars in profits. Anthem, Humana and UnitedHealth Group, reported increased profits throughout 2020, double what they gained in 2019.

Looking at racial inequity in healthcare helps us understand the 4 Evils - before we Zoom into our stories, lets talk about the big picture of healthcare inequity

We purposefully use the term Racial Health INEQUITY rather than DISPARITY because negative health outcomes are the result of inequitable distribution of protection and resources (for a deep dive, check out the work of Dr. Rhea Boyd)

We see this to be true before and during COVID -

Maternal mortality -

Shockingly or perhaps not: The United States has the highest maternal mortality rate among so-called developed countries. In most other countries, midwives outnumber OB-GYNS by several fold, and primary care plays a central role in the health system. In the U.S., it’s the opposite - we have less midwives and more higher paid OB-GYNS.
We are the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period. The results are higher risk for women in the U.S., especially Black women
Black women are three times more likely to die from a pregnancy-related cause than White women.
In New York City Black mothers are 12 times more likely to die from pregnancy related complications�And of those deaths, the Centers for Disease Control says 60 percent are preventable.
The image on the right is from the Save a Rose Foundation, named after Amber Rose, the 26-year-old Bronx woman and mother-to-be died after an emergency c-section operation to bring her son Elias into the world. C-sections (C-sections are more profitable to hospitals and doctors than natural births)

Medical debt -a top reason for people being denied housing opportunities (mortgages or rental) if they have medical debt on their credit reports

Medical debt statistics from around upstate NY from the Urban Institute:

Albany - While 10 percent of white residents have medical debt, 26 percent—of residents of color have medical debt in Albany
Syracuse - 10 of white residents have medical debt, 41% medical debt in primarily black neighborhoods.
Monroe County

Black maternal mortality

Lack of care for undocumented people

In thinking about injustice in the healthcare system, we have to ask, who PROFITS? �Hospitals, insurance companies - over the last year, while New Yorkers were dying, losing income and struggling to pay unaffordable medical bills, for-profit health insurance companies were raking in billions of dollars in profits. Anthem, Humana and UnitedHealth Group, reported increased profits throughout 2020, double what they gained in 2019.

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What’s Wrong with Private Insurance?

Discriminates on the basis of race, gender, age, ability-to-pay, employment status
Fragmented care
Inequitable
Unaccountable
Perverse incentives

Let’s start with a quick check over the problems with private insurance (for profit and nonprofit) First of all, PI discriminates.

It is racist: According to KFF, as of 2018, most POC are more likely to be uninsured compared to White people

· It is sexist: Published in JAMA in 2019, between 19-34 pay almost 2x as much of men for health insurance but more often skip care

· It is agist: PI and Medicare together have very limited home care coverage and pushes people into nursing homes; relying on Medicaid means spending down your savings to be eligible

· And of course: fundamentally it discriminates on employment status and ability to pay: if you are unemployed, self-employed, or work for a company offering lousy insurance options, you pay huge amounts or go without health care that you need, and that’s a form of discrimination that affects all of us

· PI industry creates fragmentation in healthcare: When your insurance changes because of work, your doctor and hospital may change. We don’t have interoperable HER in this country, so continuity of care is huge a problem. Not to mention the financial burden created by interactions with out-of-network doctors, oftentimes unexpectedly. Your surgeon might be covered by insurance but your anesthesiologist isn’t, and once you wake up from your surgery you might discover a massive bill

· Inequitable: Its also inequitable in its outcomes. We have too many doctors and hospitals are concentrated in where the wealthy live and few in low income and rural communities. Unaccountable: Medical decisions end up being made by insurance company employees on what kind of medication you might be eligible for. Someone you’ve never met.

· Private Insurance creates perverse incentives, as insurance companies make money by not covering those who are too sick or too poor, and putting up barriers to reimbursement that often end up complicating the job of physicians and caregivers. Hospitals and doctors who are also driven by these perverse incentives to overtreat the healthy but wealthy and neglect people who are actually sick but have no money

https://www.kff.org/racial-equity-and-health-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/you can pay more you get ”more” – not necessarily better – health options.

https://jamanetwork.com/journals/jama/fullarticle/2735482

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Number of People WITHOUT health Insurance�1976-June, 2020

ACA

COVID

The Affordable Care Act was a step in the right direction in getting more people insured, but it is far from. We see from this graph that the number of people without health insurance had been steadily rising since 1976 until the passage of the ACA in 2011, after which we see this dip in the number of people uninsured. But It never went down to zero. Around about 2017, the number of uninsured in the U.S started to go back up to 30 million and by Jun of 2020, pandemic job loss potentially displaced about 20 million people from their insurance plans with the number of people uninsured reaching to pre-ACA levels. While many of those people may have gotten on Medicaid or gotten coverage through the insurance exchanges, the pandemic revealed that the ACA did nothing to solve the problem of tying health insurance to employment status.

Himmelstein & Wooldhandler, based on CPS, ACS & NHIS Data

Figure for 2020 estimated based on increase in unemployment – these people may have subsequently gotten on Medicaid

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Question 1:

As a result of the Affordable Care Act, which of the following went down?

Premiums
Deductibles
Copays
Out-of-pocket healthcare costs
None of the above

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Question 1:

As a result of the Affordable Care Act, which of the following went down?

Premiums
Deductibles
Copays
Out-of-pocket healthcare costs
None of the above

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Interviewed 2,409 New Yorkers

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Insurance Overhead ($ per Capita)

Source: OECD 2019; NCHS; CIHI

Notes: Data are for 2018 or most recent year available. Figures adjusted for Purchasing Power Parity

Per Capita

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�New York Health Act � A6058/S5474

A publicly funded, privately delivered State fund covers every resident and full-time worker

Passed in 2015,16,17,18

with 2:1 Majorities

Carl Heastie

2021 Re-introduced with 33 Co-Sponsors

(total 63, 43 D & 20 R)

Andrea Stewart-Cousins

Gustavo Rivera

Richard Gottfried

https://www.nysenate.gov/legislation/bills/2021/s5474

Comprehensive benefits

One income-based payment

No other premiums, deductibles, copays, coinsurance or out of pocket costs

Costs less than we’re spending now!

So, the New York Health Act, designed to help solve the issues of inequity, fragmented care, perverse incentives and even the high cost.

It was first introduced by Assemblyman Dick Gottfried in 1992! It was passed in the Assembly in 2015, and again in 2016, 2017 and 2018 with wide majorities. When we flipped the NY Senate in 2019 Gustavo Rivera introduced it there. That first year it was sidetracked for easier bills, and 2020 was pretty much lost to the coronavirus. But in 2021 for the first time in history it was introduced in the Senate with a majority of co-sponsors - 33 cosponsors out of 63 Senate votes. It did not pass because it was not brought up for a vote, but for the first time it was brought up for a discussion by the entire democratic caucus, who wrangled for three hours over misinformation promoted by the insurance and drug companies. Just for a peek ahead, that’s what we need to overcome this year.

So, what IS the New York Health Act?

· It creates a publicly funded, privately delivered system of universal healthcare covering every resident & full-time worker in New York State. Publicly funded means: everybody, which means individuals who live in NY (regardless of documentation) plus people who work full time in NY even if they live out of state, and also retirees who worked full time in NY even if they spend part of the year out of state, plus businesses which will continue to pay their part, and government sources like Medicare and Medicaid, everybody pays into the same pot, which is publicly managed and overseen. And the bill includes a bunch of sunshine provisions to keep it out of back rooms. Then that public pot pays the hospitals, doctors, and other providers, who negotiate and bill as usual, only with just one public payor instead of the farrago of profit and non-profit insurers we have now. And it covers that same everybody, whether they earn enough to pay in or not.
· Comprehensive benefits means that it includes full medical coverage, plus dental, mental health and substance abuse, hearing, vision and long-term care (home care and nursing home). Obviously, if you are the only game in town you have to be sure you are covering all the bases.
· Your premium is based on your personal income. It will come out of your paycheck just like Medicare tax to go into that public pot, or if you are self-employed or earn a lot of dividends and capital gains it will be added to your quarterly estimated tax payments. And that is all you pay.

There will be no other premiums (including Medicare Part B or D), no deductibles, no co-pays, no other out-of-pocket expenses.

· The premiums will cost less than the average health plan if you earn less than about $200,000 per year. If you earn less than $100,000 per year, the cost difference is likely to be significant. If you earn less than $25,000 a year there will be no cost for the coverage; it will be like Medicaid except that you can go to any provider you want. And the entire cost of the plan, including this universal comprehensive coverage is LESS than what we in New York are paying now, due to those efficiencies in overhead, and to better negotiated drug and device costs. The sunshine provisions should also make it easier to catch fraud and abuse, which is rampant in the current system.

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NY Health Act and COVID?

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CORE VALUES: HUMAN RIGHT TO HEALTHCARE

Universal (covers everybody!!): employed & unemployed; rich & poor; citizen & non-citizen

Comprehensive: For all medically necessary health services

With free choice of doctor, dentist, NP, hospital
With no financial barriers to care (no co-payments, deductibles)

Fair: progressive, public financing

Equitable: quality health care delivery systems made accessible to all residents

Accountable & Transparent to the Public

Now let’s take a step back. Here are some of the core values embodied in New York Health, which is what the new system will be called when we get it passed.

· universal means not only that poor people are treated equitably, but also that powerful people are motivated to make the system work well, since they also have to live with it.

· Comprehensive means no more gold standard for the wealthy and substandard for the rest of us.

· The fairness will help end the incentive for health care providers to provide unnecessary care to those who can afford to pay and skimp on everyone else.

· Finally, there are those sunshine provisions I mentioned, which includes requiring a public meeting every three months in each of six regions across the state, where providers will be required to document what treatments they provided, how much they charged, and what the outcomes were. That gives opportunity for wonky old ladies like me to check the data and pick out pick out patterns of fraud and abuse, and for doctors to be informed of the most effective treatments.

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Comprehensive Benefits

Primary & Preventive Care
Reproductive Care
Inpatient and Outpatient Hospital Care
Prescription Drugs
Dental, Vision, & Hearing Care
Mental health and Substance Abuse Care
Long-term care & support services
Free choice of provider (no narrow networks)
Covers you when you travel as long as you are considered a resident of NYS

*Any procedure covered by Medicare, Medicaid, or the state employee health benefit package is covered by NYHA

And a little more on what comprehensive means. I think the big takeaway here is that it means that anything currently covered by the state employee health benefit package is covered – and the bill specifically says that provider compensation negotiations will be based on the state employee package, NOT Medicare or Medicaid – which is what the insurance industry has been telling providers!

And there are no longer provider networks; New York Health will cover every New York provider, plus providers out of state if the patient is travelling out of state or needs specialized treatment not available in New York. (My doctor required a DNA analysis from a California company for my breast cancer. It made a big difference in my treatment plan, and cost me $4,000. Since it was prescribed by a New York doctor, it would have been covered under New York Health.)

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What if I am on Medicare?

The New York Health Act will:

Improve benefit package: vision, dental, hearing, long-term care will be covered.
Eliminate out-of-pocket costs.
Eliminates donut hole for prescription drugs.
You can travel or live part-time out-of-state and New York Health will pay for medical expenses.

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What if I am in a union?

Most or all unionized companies and schools will end up paying less for health care under New York Health
This means that negotiating for the company to pay the full 100% for union members will be very straightforward
New York Health covers not only the usual medical, dental and pharmacy services, but also vision, hearing and mental health services, plus long term care; not all union plans cover all of these for all members
Without the constant burden of keeping up health coverage, unions can go back to negotiating for higher salaries and other goals

Insurance lobbyists would like us to think that lots of people will end up paying more for health care than we are now, but nothing is further from the truth, even for union workers who currently do not pay premiums. Think back over what you had to give up in order to keep your health care covered. This is what you have to gain going forward! And since companies that employ union workers have been forced to offer high quality health coverage, they will be the ones who gain the most in savings under New York Health. Paying for union coverage in full will in practically all cases be cheaper than what they are paying now. This means the first negotiations under New York Health would be for full coverage plus meeting other agreed on union goals. And since New York Health also covers retirees and long term care, there will be no worries about future coverage either.

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What if I am on Medicaid?

The New York Health Act will:

Improve provider network and access to specialists
Maintain generous benefit package: �vision, dental, hearing, long-term care will be covered (but with no means testing).
Ends different standards of care based on type of insurance patient has.
End means-testing for eligibility.

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Who’s Going to Pay for It?

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Current Sources of Funding vs Funding Under NY Health

This is who pays. This slide compares how the current system is funded with how New York Health will be funded. Note that the graph was produced by the Rand corporation, not generally considered a leftist group!

As you see, most of the funding is covered by federal and state money (Medicare, Medicaid, CHIP and other government programs); that will not change. What will change is the other 45%. Currently that is split between private insurance, what we pay out of pocket, and what counties pay toward Medicaid – which will go away, by the way, so you can ask them politely to lower your property taxes after the Act goes through.

Under New York Health, all of that will be covered under the new income-based payments – except that even with universal and comprehensive coverage, the overall cost of care will go down by 4% in sheer savings. That’s according to the Rand Corporation figures – again certainly not swayed by progressive leanings.

So the real question is not “how will we pay for it?” but rather “what will we do with our savings?” Because municipalities will save big.

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Local Government Saves Money = Tax Cuts and Balanced Budgets

95%

83%

84%

Example of saving for the local governments of Albany area, prepared by Albany’s own Treasurer

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Buffalo Health Care Cost Comparison for 2020

2020 salaries totaled $191,904,120

2020 health care expenditures were $79,172,897

NYHA assessment, per Rand, would be $14,998,249

Buffalo’s employer share would be $11,998,600

SAVINGS: $67,174,297

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Paying for NY Health through a Payroll & Non-Payroll Tax

Source: L Rodberg, Summary and Evaluation of the RAND Corporation’s Assessment of the NY Health Act (September 2018).

$400K

$25K

$50K

$100K

$200K

20%

16%12%

8%

4%

Tax Rate %

Tax Bracket

Effective Tax

Wages & Salary & Taxable Investment Income

$75K

	Income/year	Effective Tax Rate	Employee Pays (20%) /year	Employer Pays (80%) /year	Non-Payroll (investor pays)
A	$50K	6.9%	$690	$2,760	$3,450
B	$75K	10.2%	$1,535	$6,140	$7,675
C	$100K	12.3%	$2,455	$9,820	$12,275
D	$200K	16.9%	$6,775	$27,100	$33,875
E	$400K	20.8%	$16,615	$66,460	$83,075

NYH tax will be collected progressively. Under this taxation scheme, people making less than 25 thousand dollars per year will pay no tax, while the top tax bracket making more than 400 thousand annually will pay a 20% income tax rate. This may look like a new tax, but it actually redirects a fraction of what 90% of New Yorkers currently pay-to-insurance-companies.

How does it work for individuals? Well, the premiums are collected like a tax, which means deducted from paychecks or set aside in the estimated payments you use to pay taxes if you earn enough as a small business or from dividends and capital gains.

They are also graduated like tax; you pay nothing for income under $25,000, a certain percentage for income over that, and a certain percentage more for any income exceeding other income brackets. Those percentages and income brackets aren’t spelled in the bill itself (remember, it’s been around since 1992; things change, and Gottfried knew they would).

However, this slide shows the recommendation from the Rand corporation, altered to exempt people earning less than $25,000. I earn about $50,000 as a librarian. I had breast cancer in 2017, my husband has a heart condition, and we currently hit our out-of-pocket limit of $6,000 on the U or R plan in about August, and then we only pay for things that require providers outside the U of R – that low limit is tied to a narrow network. Under NYH I would be paying nearly 90% less.

Meanwhile, if I were running my own small business making an annual profit of $100,000, I would need to pay a little over $1,000 per month. A bronze plan under the ACA would cost less than half that in premiums if it were just me, or about the same amount for a family of 2 or more. Oh! Except that bronze plan has a deductible of over $6,000 for an individual, $13,000 for a family, in addition to the premiums. And New York Health would have coverage equal to the platinum plan, with no deductible.

It’s only when you get into the higher income brackets, right around $200,000, that the cost of New York Health comes to more than the total out of pocket cost for private insurance. It’s the top 1-2% of New York earners who would lose money on the plan, while the bottom 50% save significantly.

The only other group who would pay more for health insurance under New York Health than they do now would be those who are uninsured – and lucky.

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Cover Everyone While Saving Money

Sources: Liu, et al., An Assessment of the NY Health Act, RAND Corporation, August 2018; Rodberg, Summary and Evaluation of the RAND Corporation’s Assessment of the NY Health Act, September 2018. https://www.nyhcampaign.org/faq

Reduced Prices of Drugs & Devices: -6%

Covering Everyone & Eliminating Cost Sharing: +5.5%

Net Savings:�11.4B/4%

Net:

–$11.4 B

$17.1B

$8.8B

Total:

+$43.9 B

Total Additional Costs: +14.1%

Total Savings: –17.7%

Total

–$55.1 B

-$20.4B

-$18.6B

Reduced Insurance Admin Costs: -6.5%

Improved Provider Fees +2.8%

Total projected status quo spending in 2022: $311B

-$16.3B

Reduced MD & Hospital Admin Costs: -5.2%

$18B

Long-term Care +5.8%

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Big Savings from Single Payer:�Private Insurance Overhead Far Exceeds that of the Public Medicare Program

SEC Filings/Reports to Shareholders. Data for Q1 or Q2 2017

Medicare

2%

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Question 2:

According to the 2018 RAND study, what is the single biggest source of savings created by the NYHA?

Increased reimbursement to healthcare providers
Decreased administrative cost
Reduced cost of prescription drugs and medical devices
Covering fewer services overall

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Question 2:

According to the 2018 RAND study, what is the single BIGGEST source of savings created by the NYHA?

Increased reimbursement to healthcare providers
Decreased administrative cost
Reduced cost of prescription drugs and medical devices
Covering fewer services overall

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Question 2:

According to the 2018 RAND study, what is the estimated effect of the NYHA on the number of jobs in New York State?

Creates 50,000 jobs
Creates 150,000 jobs
Destroys 50,000 jobs
Destroys 150,000 jobs

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Question 2:

According to the 2018 RAND study, what is the estimated effect of the NYHA on the number of jobs in New York State?

Creates 50,000 jobs
Creates 150,000 jobs
Destroys 50,000 jobs
Destroys 150,000 jobs

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The New York Health Act is too expensive

�The Truth:

It Redistributes Cost and Saves Money Overall

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Transition

Fully implemented 2-3 years after passage of NY Health Act

YEAR ONE:

Apply for federal waivers (can be implemented with or without)
Establish Board of Advisors
Establish Regional Advisory Councils
Establish Commission to handle implementation and enrollment

YEAR 2:

Set the rates for reimbursement and tax brackets

YEAR 3 (starting January 1):

Start payroll deductions and passive income assessments
Start paying for healthcare services

So how do we get there from here?

Contrary to what insurance lobbyists would like us to believe, the path is spelled out in the bill and reasonably straightforward. It will take two or three years to complete.

· The first step is getting the architecture in place – getting the federal waivers, which will be a lot easier now than under the previous administration, and setting up the planning boards and commissions – a Board of Trustees: 29 members including consumer advocates, healthcare workers (physician and non-physician), union representatives, social workers, and even patients – and 6 Regional Advisory Councils. According to the bill, these posts will not be paid, though expenses will be covered.

· The second step is doing all the negotiations with the providers. Much this can be done by negotiating based on what is already paid by state employee plans, as suggested in the bill language. Then tax rates will be set so that anticipated tax income will cover the anticipated cost of care.

· Then, on January 1^st of probably year Three (about the same time the legislature returns to session) the financial switch will be flipped, employers will begin making deductions from paychecks and those funds can go into the new single payer pot and then flow out again to cover services, as they are used. This is exactly how Medicare was first rolled out in 1965; we did it then, we can do it again.

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Implementation Process

Tax revenue and provider reimbursement set after one year through proposal from administration and separate legislation
Start paying for healthcare services
Apply for federal waivers (can be implemented with or without)
Establishes Board of Trustees: 29 members including consumer advocates, healthcare workers (physician and non-physician) etc.
Establish 6 Regional Advisory Councils
Fully implemented 2-3 years after passage of the NYHA

It’s implementation process is where participation from everybody is important.

All of this is after passage of the NYHA

A year from then, reimbursement rates for providers will be set through separate legislation after a period of deliberation

Payments for healthcare services will begin

We have to apply for federal waiver to channel funds from Medicare, Medicaid, ACA

A board of trustees for NYH consisting of 29 members including patient advocates and healthcare workers will over see implementation

In addition there will be 6 regional advisory councils

Oversee the full implementation in about 3 years after passage of NYHA – so getting the bill passed is the crucial first step

2021 update: Newly added non-physician HCW members of the Board of Trustees increased from 3-5

There shall be a regional advisory council established in each of 33 the following regions: 34 (a) Long Island, consisting of Nassau and Suffolk counties; 35 (b) New York City; 36 (c) Hudson Valley, consisting of Delaware, Dutchess, Orange, Putnam, 37 Rockland, Sullivan, Ulster, Westchester counties; 38 (d) Northern, consisting of Albany, Clinton, Columbia, Essex, Frank- 39 lin, Fulton, Greene, Hamilton, Herkimer, Jefferson, Lewis, Montgomery, 40 Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, St. Lawrence, 41 Warren, Washington counties; 42 (e) Central, consisting of Broome, Cayuga, Chemung, Chenango, Cort- 43 land, Livingston, Madison, Monroe, Oneida, Onondaga, Ontario, Oswego, 44 Schuyler, Seneca, Steuben, Tioga, Tompkins, Wayne, Yates counties; and 45 (f) Western, consisting of Allegany, Cattaraugus, Chautauqua, Erie, 46 Genesee, Niagara, Orleans, Wyoming counties. 47 3. Each regional advisory council shall be composed of not fewer than 48 twenty-seven members, as determined by the commissioner and the board, 49 as necessary to appropriately represent the diverse needs and concerns 50 of the region. Members of a regional advisory council shall be residents 51 of or have their principal place of business in the region served by the 52 regional advisory council.

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Q&A