GOSHEN — Medicaid enrollment has grown so much in Orange County over the last decade that half of all children in the county are covered by that taxpayer-funded health insurance, even during a flush economy.
But county officials are dismayed that Gov. Andrew Cuomo would suggest that county governments and New York City bear some blame for the higher costs that have come with Medicaid’s growth – and propose shifting more of the expense to them. And Orange County Executive Steve Neuhaus questions how the state has allowed a program meant to be a safety net for the neediest to get so large.
“The economy’s rolling, we have 4 percent unemployment, but we have a third of our population, roughly, on Medicaid,” Neuhaus said. “So the system’s not working.”
He and other county leaders are waging stiff resistance to a proposal by Cuomo that could hike their Medicaid costs again after the state had frozen the local shares for the last several years. They protest that the move would wreak havoc on their budgets and makes no sense, since the state controls Medicaid and enrolls most of its beneficiaries.
In Orange County, which has been paying around $70 million a year for Medicaid, the cost might rise anywhere from $2 million to $10 million. The county’s cost is a fraction of the total Medicaid bill for Orange, which totaled $977 million last year and is borne largely by the federal and state governments.
The local hit would come from Cuomo’s plan to make New York City and each county cover any Medicaid cost increases over 3 percent a year. The state Department of Health hasn’t responded to requests for a spending breakdown for counties, but data provided by the Orange County Department of Social Services indicates that the county’s spending grew by 9.3 percent and 7.3 percent in the last two state fiscal years – well above the 3 percent mark.
In fact, the last calendar year when spending rose by less than 3 percent was 2006, according to county records.
On the other side of the Hudson River, Dutchess County’s $44 million annual tab could grow by $3 million to $5 million under Cuomo’s proposal, County Executive Marc Molinaro said.
Molinaro argues the state would renege on a promise if it lifts the local Medicaid cost caps, which were meant to help counties meet the state’s 2 percent limit on property-tax increases. He sent his county’s state lawmakers a letter this month to urge them to oppose the idea and warn that rising Medicaid costs could force Dutchess to cut spending on mental health and addiction treatment, 911 dispatchers and other services.
In an interview, Molinaro rejected the notion that counties are partners with the state in administering Medicaid and managing its costs, noting that his staff can’t even open fraud investigations without state permission.
“If we were partners, we would have the tools to be of assistance,” he said.
Elsewhere in the Hudson Valley, Medicaid bills totaled $443 million in Ulster County and $308 million in Sullivan County in the last state fiscal year, according to social services offices in those counties. Sullivan officials, whose capped contribution to Medicaid has been about $21 million a year, estimated that Cuomo’s proposal to charge counties for cost increases over 3 percent would have cost Sullivan an additional $2.5 million in the last fiscal year.
State sets rules for eligibility
Cuomo has suggested that freezing costs made counties and New York City lax in awarding benefits, giving them “blank-check syndrome,” as he put it. That snipe galled county officials, who point out that the state sets the rules for eligibility and services that the counties merely follow.
What’s more, most Medicaid recipients no longer enroll at their county social services offices, as they used to, but through the state-run health insurance website created to carry out the federal Affordable Care Act. In Orange County, only about 21 percent of roughly 105,000 enrollees signed up through the county. Those tend to be more complex cases that involve long-term care.
Darcie Miller, Orange County’s social services commissioner, said her department is required by law to scrutinize an applicant’s eligibility and looks at five years of income and banking records for prospective nursing-home residents.
“We do a very serious look-back,” she said.
By contrast, the state-run insurance exchange simply asks applicants to state their current and previous year’s income, Miller said. She said she didn’t know if and how the state verifies earnings, but noted that its main goal has been to get people covered if they don’t have insurance.
“They felt it was important that people have access to the coverage,” she said.
The Department of Health didn’t respond to the Times Herald-Record’s question about how it verifies Medicaid applicants’ income.
Just a dozen years ago, around 46,000 people in Orange County got their care through Medicaid, which was a little more than 12 percent of the population or roughly one in eight people. Then came the 2008 recession, which caused enrollment to climb, and the 2010 Affordable Care Act, which enabled New York to expand Medicaid eligibility in 2013, as others states have done.
As of last September, the number of Medicaid enrollees in Orange County (104,938) had more than doubled since 2007 and accounted for almost 28 percent of the population. Neighboring Sullivan County is even higher, with more than 34 percent of its residents (25,944) covered by Medicaid. The statewide count of 6.1 million is 31 percent of New York’s population.
State officials are now trying to reduce the growth in spending, which has risen for reasons beyond higher enrollment. One is a minimum-wage increase that boosted the earnings of the lowest-paid workers in health care. Others are increased use of long-term care and state payments to financially strapped hospitals.
Among the rising costs getting scrutiny as the state tries to close a $2.5 billion Medicaid budget gap is personal care for people with disabilities and homebound seniors. As home health aides have become more scarce in New York, more of that spending has shifted to consumer-directed assistance, a program that enables Medicaid enrollees to hire a relative or neighbor to help care for them.
A group representing that growing industry already has fought one state funding cut and is closely watching the budget deliberations. Bryan O’Malley, executive director of the Consumer-Directed Personal Assistance Association of New York State, argues the state should recognize the impact of its Medicaid expansion and be proud that it funds more personal-care hours than less generous states.
“The state should be very proud of the fact that we have a 95 percent insured rate,” O’Malley said. “But the state should be aware that when folks get insurance, they’re going to use long-term care.”
But as Neuhaus sees it, a series of policy decisions by the state now have unfairly put counties in a tight spot.
He argues that people with disabilities or who are elderly and poor unquestionably need Medicaid, but questions the long-term use of it by others. And he complains that shifting costs to counties could undercut economic-development gains by absorbing new revenue from businesses like the Legoland theme park set to open in Goshen this year.
“You would think that with 4 percent unemployment, you should have only a fraction of our population on Medicaid,” he said. “And just the fact that you can have people on Medicaid from the cradle to the grave shows that this system is a failure in this state.”
cmkenna@th-record.com