Issue Brief

Shifting
Shares
The Costly Challenge of a
State Medicaid Takeover
by Bill Hammond

N

ew York shifts more of its Medicaid costs to local
government than any other state.1 The 57 counties
and New York City currently fund 12 percent of the overall program, or almost $8 billion a year.2

Published by the Empire Center for Public Policy

There is little dispute that requiring local governments to
shoulder a large share of Medicaid costs—based not on
ability to pay, but on historic patterns of need—is outmoded, dysfunctional and unfair. This system puts a disproportionately high burden on localities with poorer residents and weaker tax bases. Even for wealthier counties,
Medicaid is one of Albany’s most onerous unfunded mandates—a major, ongoing expense over which local officials
have no control.
Over the decades, state lawmakers have mitigated the
burden by gradually lowering the counties’ share of total
spending, which was initially 25 percent. They capped the
annual growth of local payments in 2006, and froze the
payments as of 2015. If not for those steps, local governments would be paying $3.3 billion more per year than
they do now.3
To date, however, the counties’ longstanding plea for full
relief from Medicaid costs has been stymied by the price
tag: The local share now stands at $7.6 billion, including
$5.3 billion from New York City and $2.3 billion from the
other 57 counties.4
Offsetting the loss of that much revenue would require
either an enormous tax hike, deep cuts to health care

 spending or, most plausibly,
a concerted, multi-year push
to squeeze efficiency from the
Medicaid program.

Table 1. Impact of Local Medicaid Cost by Region

Further complicating the task
is the lopsided regional distribution of the burden. New
York City accounts for fully
two-thirds of the local cost,
and poorer upstate areas pay
proportionally more than the
wealthier downstate suburbs.
A comprehensive solution
would necessarily skew in the
opposite direction, with New
York City residents reaping
most of the benefit, and downstate suburban taxpayers taking a financial hit.

Long Island

$174

$2.50

$1.04

Capital

$190

$3.63

$2.18

Southern Tier

$192

$4.81

$3.14

North Country

$203

$5.16

$2.79

Mid-Hudson

$205

$2.99

$1.61

Central New York

$214

$4.88

$3.90

Finger Lakes

$215

$4.72

$3.79

Western New York

$233

$5.21

$4.28

Mohawk Valley

$241

$6.12

$3.97

New York City

$630

$9.82

$5.02

Region

Sources: Empire Center calculations using data from the NYS Association
of Counties, the Census Bureau, the Bureau of Economic Analysis and
the Office of the State Comptroller

In the past two years, county leaders’ perennial call to be relieved from Medicaid costs has
gained new momentum. State takeover plans
have been put forward by members of Congress, state legislators and at least two candidates for governor. However, these proposals
either exclude New York City or offer it only
partial relief—which would be hard to justify as a matter of fairness—and none fully addresses the question of financing.
This issue brief explores the financial considerations and policy challenges associated with
eliminating the local Medicaid share and reviews the major options for implementing a
state takeover.
Regardless of how approached, such a takeover
would represent a major change in a program
affecting the lives and livelihoods of millions of
New Yorkers. The cost and complexity of the
task should not be underestimated, and all options would require difficult trade-offs.

Issue Brief

Background

July 2018

2

Per $1,000 of:
Medicaid
Per Capita Personal Income Property Value

Medicaid is a government-run health plan for
the poor and disabled that is managed by states

under federal guidelines, and was significantly
expanded as part of the Affordable Care Act.
New York’s version is one of the largest, most
generous and costliest Medicaid programs in
the country. It currently covers more than 6
million New Yorkers, or about one-third of the
population, with a total budget for fiscal year
2019 of $70 billion.
The program is financed with a mix of federal and state-based money, with the federal
share varying according to a state’s per capita
income. In New York, Washington pays a bit
more than half of overall costs.
States also have the option of shifting costs to
local government, which New York does more
than any other. This policy dates back to the
program’s inauguration in 1966, when it replaced pre-existing health programs that were
shared between New York City, the other 57
county governments and the state.5
Local governments originally paid half of
the non-federal share, or 25 percent of total
costs, for medical bills incurred by their low-income or disabled residents. This percentage
declined over the years as the state reduced

 Figure 1. Local Medicaid Contribution
Per Capita

or limited the local share of certain portions of
the program.
Starting in 2006, then-Governor George Pataki successfully pushed the Legislature to cap
the growth of counties’ Medicaid expenses at 3
percent per year, shifting more costs to Albany.
In 2012, in a measure advanced by Governor
Cuomo, lawmakers phased the cap down to 0
percent, freezing the local share as of 2015.

Putnam
Saratoga
Tompkins
Wyomin g
Hamilton
Livingston
Dutchess
Ontario
Wa yne
Ma dison
Genesee
Tioga
Suffolk
Yates
Nassau
Seneca
Otsego
Jefferson
Essex
Columbia
Wa shington
Schoharie
Cayuga
Lewis
Orange
Wa rren
Delaware
Broome
Fra nklin
Orleans
Steuben
Ulster
Rockland
Chenango
Albany
Greene
Schuyler
Oswego
Cortland
Allegany
Rensselaer
Clinton
Niagara
St. Lawrence
Herkime r
Cattaraugus
Schenectady
Onondaga
We stchester
Erie
Chemung
Mo nroe
Oneida
Chautauqua
Mo ntgomery
Fulton
Sullivan
New York City

The resulting savings have been significant.
Had those steps not been taken, the Division
of the Budget estimates that local governments
would currently be spending an additional
$3.3 billion per year. The cost-shift back to the
state has increased by $2.3 billion since Cuomo
took office in 2011—representing 15 percent of
the overall growth of state-funded spending
during that time.6
The frozen amount now paid by local governments is $7.6 billion, including $5.3 billion from
New York City and $2.3 billion from the other
57 counties combined. That amounts to about
12 percent of the total Medicaid budget, a
share that gets gradually smaller as overall
spending rises.
Impact on local finances
Even with the freeze, Medicaid remains one
of the largest expenses faced by local governments in New York—and one they have little
or no means to control. For 2016, it represented 9 percent of total expenditures for both
New York City and, on average, the other 57
counties’ governments.7
This heavy burden falls unevenly across the
state—because the cost for each jurisdiction is
based not on ability to pay, but on historic usage of the program by local residents.

$-

$100 $200 $300 $400 $500 $600 $700

Sources: Empire Center calculations using data from the
NYS Association of Counties and the Census Bureau

Hardest hit by most measures is New York
City, largely due to its disproportionately large
population of Medicaid recipients. (See Table 1.)
Its Medicaid costs are the highest in the state,
both on a per-capita basis and as a share of
Shifting Shares

3

 Figure 2. Per Capita Medicaid Costs and Poverty
(Excluding New York City)
$325

Sullivan

County Medicaid spending per capita

$275

Montgomery

$225
Nassau
$175

Tompkins
$125
Saratoga
Putnam
$75

4%

6%

8%

10%

12%

14%

16%

Percent of county residents below Federal Poverty Level

18%

20%

22%

Sources: Empire Center calculations using data from the NYS Association of Counties and the Census Bureau

personal income, and fifth highest as a share of
property value.
The burden on the other 57 counties varies
widely. Per capita Medicaid costs range from
$100 in Putnam to $279 in Sullivan. The cost per
$1,000 of personal income ranges from $1.68 in
Putnam to $6.83 in Chautauqua. The cost per
$1,000 of property value ranges from 19 cents
in thinly populated Hamilton to $5.63 in Montgomery. (See Figure 1 and Appendix 1.)

Issue Brief

The distribution of Medicaid costs among local governments is generally regressive, in that
counties with proportionally higher Medicaid
payments also tend to have higher poverty
rates and lower median incomes. (See Figure 2
and Appendix 2.)

July 2018

4

The local share of Medicaid also contributes
to the burden of property taxes, which are a
principal source of revenue for counties. Outside New York City, Medicaid costs equate to
40 percent of overall county property tax revenues. Among individual counties, the ratio

of Medicaid spending to property tax revenue
varies widely, ranging from 8 percent in Hamilton to 79 percent in Oneida. (See Table 2 and
Appendix 3.)
With sales taxes and other revenues factored
in, Medicaid accounts for 9 percent of counties’
total spending on average, ranging from 3 percent in Hamilton to 16 percent in Fulton.
Of course, property owners outside New
York City pay taxes not just to county governments, but also to school districts, cities, towns,
villages and fire districts. As a share of total
property-tax liability—which is arguably the
more relevant comparison—local Medicaid
costs average 7 percent outside New York City.
This, too, varies considerably by county and
region, as seen in Table 2 and Appendix 3. Regionally, the share of combined property taxes devoted to Medicaid ranges from 4 percent
on Long Island to 13 percent for the Mohawk
Valley and Western New York. By county,
the share ranges from 2 percent for residents

 of Hamilton County to 17
percent for residents of
Chemung County. (See Figure 4.)

Table 2. Medicaid and County Finances By Region, 2016

For New York City, which
is both much larger and
differently structured than
other counties, Medicaid
costs equate to 24 percent
of property tax revenues,
and 9 percent of overall
revenues.

Capital

46%

10%

8%

Central NY

52%

10%

10%

Finger Lakes

45%

9%

10%

Long Island

29%

7%

4%

Mid-Hudson

36%

9%

5%

Mohawk Valley

54%

13%

13%

New York City***

24%

9%

24%

Past proposals

North Country

45%

9%

11%

Southern Tier

43%

9%

10%

Medicaid Share of:
Region

County
County
Property Taxes* Expenditures*

Combined Municipal &
School Property Taxes**

Calls to eliminate the local
Western NY
61%
12%
13%
share of New York MedSources: Empire Center calculations using data from the NYS Association
icaid date back to its earof Counties and the Office of the State Comptroller. *Based on county fiscal
liest years. One of the first
data for 2016. **Includes all county, city, village, town, school and fire district
came from Governor Nelproperty taxes. ***New York City encompasses the governmental functions of a
son Rockefeller in 1967,
county, a city and a school district
just one year after lawmakers launched the program
at his urging. Also proposing state takeovers minority leader, who had campaigned on the
during their terms were Governors Hugh Car- issue. In March 2017, Faso and Rep. Chris Collins (R-Erie County) cosponsored federal legisey and Mario Cuomo.
lation requiring New York to eliminate the loThose early plans typically called for some ver- cal share of Medicaid for counties outside New
sion of a tax swap. In 1994, for example, Mario York City within two years.9 Faso and Collins
Cuomo called for counties to forfeit a portion later added the same provision as an amendof their sales tax revenue—and for New York ment to several GOP bills aimed at repealing
City to give up part of its income tax revenue— and replacing the Affordable Care Act—one of
in return for the state taking over the local which came within a single vote of passage in
Medicaid share. This would have been advan- Congress.
tageous for counties at the time, because Medicaid costs were rising more rapidly than sales In March 2018, the Assembly’s minority Retax revenue.
publicans unveiled a proposal to eliminate the
57 counties’ Medicaid contributions gradual“In the first couple of years the swap would ly over 10 years, along with half of New York
be nearly even,” The New York Times wrote in City’s contribution over 20 years.10
1994. “But if Medicaid costs continue to explode, the city and counties would eventually This plan was part of a broader package that
come out ahead.”8 However, Mario Cuomo’s called for a mix of spending cuts, spending
plan was not taken up by the Legislature.
increases and revenue raisers—the latter including a 50 percent reduction of what are
The debate over a state takeover was rekin- now $420 million a year in state tax credits for
dled in 2017 with the election of U.S. Rep. John film and TV production, which are due to exFaso (R-Columbia County), a former Assembly pire in 2022, and the elimination of a $1 billion
Shifting Shares

5

 property tax relief credit that is due to sunset at
the end of 2019. However, the proposed revenue increases and program savings would not
fully offset the cost of the Medicaid takeover
and other spending increases.11
In May 2018, majority Republicans in the state
Senate introduced and quickly passed two
variations of a takeover. The first called for
a five-year phase-out of the local share for
counties outside New York City only. The second called for a 10-year phase-out that fully
eliminated payments by the 57 counties and
partially eliminated New York City’s share,
limiting the city’s savings to $2.3 billion. Neither bill included a plan to replace or offset the
lost revenue.12
The Senate bills would mandate that local governments dedicate their savings to reducing local taxes, but provide no specifics for how compliance would be defined or enforced.
Although recent proposals have been advanced by Republicans, there is some bipartisan support for the underlying goal. Assemblywoman Crystal Peoples-Stokes (D-Buffalo)
is lead sponsor of a bill that would phase out
the local share of Medicaid over a five-year period. Originally introduced in 2011, the bill is
currently cosponsored by a fellow Democrat,
Phil Steck of Albany County, along with Republicans Joseph Giglio of Cattaraugus County
and Andrew Goodell of Chautauqua County.13

Issue Brief

A state takeover of local Medicaid costs has
also been advocated by two gubernatorial candidates: Dutchess County Executive Marcus
Molinaro, a Republican, and former Syracuse
Mayor Stephanie Miner, a Democrat seeking to
run as an independent. As of early July, neither
had released a detailed plan.

July 2018

6

The primary goal of all such proposals is property tax relief. A full state takeover would
equate to a 24 percent reduction in property
taxes imposed by New York City, and an average 40 percent reduction in county taxes elsewhere in the state. As discussed, however, the

potential relief as a share of total property taxes
outside New York City would average a relatively modest 7 percent—lower in downstate
suburbs, higher in upstate counties.
Policy options
As it now stands, the local share of Medicaid
is an unfunded mandate that imposes disproportionate costs on poorer jurisdictions while
contributing to New York’s high local tax rates
across the board. It’s unlikely that state lawmakers would approve such a system if they
were designing the program from scratch.
Worthy as it is, however, the goal of eliminating
the local share is expensive and must compete
with other priorities. If Albany had an extra $8
billion per year to spend, it’s not clear that local
tax relief should take precedence over, say, an
investment in infrastructure.
Assuming the state does commit to a takeover,
it should take care to do so in way that does
not create equally problematic tax burdens and
inequities somewhere else.
A review of the major policy options follows:
Excluding New York City
One strategy for reducing the cost of a takeover
would be to limit is applicability to New York
City, which accounts for 70 percent of local
spending on Medicaid.
The Assembly minority’s plan would eliminate
only half of the city’s contribution, and do so
over twice as long a period as for other counties. One of the two bills passed by the Senate
would phase out $2.3 billion of the city’s share,
which is less than half of its $5.3 billion tab. The
second Senate bill would omit the city entirely, as would the Collins-Faso amendment in
Washington.
While this would expediently reduce the cost
of a takeover, excluding New York City would
be hard to justify on policy grounds.

 Creating such an exception would
arbitrarily limit or deny relief to the
group of local taxpayers shouldering by far the heaviest cost. Plus, it
would put city residents (and a large
number of Connecticut and New Jersey commuters with jobs in the city)
in the position of subsidizing relief
for others, because they pay a disproportionately large share of the state
taxes redistributed from Albany.
The effect would be to make the
state’s Medicaid financing system
more inequitable than it already is.
A more constructive way to limit cost
would be to provide partial relief to
all jurisdictions based on need. For
example, the state could commit to
take over the portion of each county’s
contribution that exceeds a certain
share of its residents’ incomes, or of
the local property value.

Table 3. Regional Impact of Medicaid-for-Sales
Tax Swaps, Including and Excluding NYC
Gain (Loss) from a Swap
Region

Excluding NYC1

Capital

Including NYC2

$(17,752,273)

$(212,935,500)

Central NY

$29,139,426

$(91,787,522)

Finger Lakes

$43,994,765

$(144,566,659)

Long Island

$(186,382,794)

$(782,346,619)

Mid-Hudson

$(10,588,915)

$(436,037,222)

$38,221,112

$(19,484,991)

New York City

N/A

$3,934,508,705

North Country

$15,791,922

$(45,016,300)

Southern Tier

$19,045,886

$(82,040,852)

$68,530,870

$(153,038,687)

Mohawk Valley

Western NY
1

1.2% of taxable sales

2

2.2% of taxable sales

Sources: Empire Center calculations using data from the NYS
Assn. of Counties and the NYS Dept. of Taxation and Finance

Under any such scenario, however, New
York City would likely receive the bulk of the
benefit.
Swapping for a share of sales tax
One takeover approach that has been floated repeatedly in the past—by Mario Cuomo
and others—would take the form of a sales
tax “swap”: The state would assume responsibility for the counties’ share of Medicaid
costs in return for counties giving up a portion
of their revenue from sales taxes.
This has the potential advantage of spreading
costs less regressively—at least among counties
outside New York City.
Table 3 and Appendix 4 show the effects of two
tax swap scenarios.
The first assumes that New York City would
be excluded. To offset the Medicaid payments
of the other 57 counties, the state would need

to divert 1.2 percentage points of the counties’
taxable sales. Counties with relatively more
Medicaid recipients and less retail business—
mostly upstate—would generally save money,
at least in the short term. The mid-Hudson suburbs and Long Island, with relatively few Medicaid recipients and stronger retail economies,
would pay more.
Under the second scenario, which includes
New York City, the share of sales tax necessary
to finance the swap would rise to 2.2 percentage points. The city would reap the vast majority of savings and most other counties would
experience a net loss.
A swap made more sense years ago, when
counties’ Medicaid costs were typically growing faster than sales tax revenue—meaning
the trade almost certainly would have saved
money for all counties in the long run.
Now that the local share is frozen, however,
the dynamic has reversed. Sales taxes generally
rise and local Medicaid costs are fixed, meaning a swap would eventually leave all counties
worse off than before.

Shifting Shares

7

 Table 4. Using Personal Income Tax to Replace
County Medicaid Payments (In Millions)
Region
NYS Residents
Nonresidents
New York City

Current Medicaid Share of $7.6B Savings
Payment
Increase in PIT (Loss)
$7,634
$0

$6,377

$1,257

$1,257 ($1,257)

$5,378

$3,168

$2,210

Capital

$206

$223

($17)

Central NY

$168

$127

$40

Finger Lakes

$260

$209

$51

Long Island

$497

$1,194

($697)

Mid-Hudson

$477

$1,025

($548)

Mohawk Valley

$104

$50

$54

North Country

$86

$42

$43

Southern Tier

$135

$97

$38

Western NY

$323

$227

$96

Mayor Bill de Blasio’s proposed tax
on the wealthy, intended to finance
repairs to the subway system, would
raise $1 billion or less.17
Financing a takeover through the
state income tax would shift the tax
burden rather than reducing it. Poorer parts of the state would generally
pay less, while richer areas would
pay more. (See Table 4 and Appendix
5.) One group that clearly stands to
lose is out-of-state commuters, who
would go from contributing nothing
toward Medicaid’s local share as of
now, to carrying 17 percent of the
cost post-takeover.

Assuming the increase is weighted
toward higher income groups—as
Sources: Empire Center calculations using data from the NYS
such proposals usually are—this apAssn. of Counties and the NYS Dept. of Taxation and Finance
proach would further increase the
state’s heavy reliance on revenue
Increasing state taxes
from high earners, and from the financial sector in particular. This would heightEven in the context of a $170 billion all-funds en the state’s fiscal vulnerability to volatility on
state budget, finding another $7.6 billion in rev- Wall Street and the broader economy.
enue would be no small matter.
The cost of a full takeover would equate to a
15 percent hike in the state’s personal income
tax, which is projected to bring in $50 billion in
fiscal year 2019.14

Issue Brief

The state’s total tax collections—including levies on personal income, business income, retail
sales, cigarettes and gasoline—are projected to
be $78 billion.15 The cost of a takeover equates
to an across-the-board increase in all of those
taxes of almost 10 percent.

July 2018

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The revenue needed to finance a takeover would
be much more than the amount to be raised by
other state tax hikes currently on the table. The
Assembly Democrats’ proposed hike on New
Yorkers with incomes of $5 million or more—
earmarked for spending on schools and health
care—would raise $5.6 billion, or three-quarters of the amount necessary for a takeover.16

Any move in this direction would also aggravate New York’s status as a high-tax state. The
enactment of federal tax changes last year—
which capped the deductibility of state and
local tax payments—effectively increased the
marginal cost of residing in New York compared to states with lower taxes. The net combined state-and-city income tax rate on New
York City’s highest earners has jumped to almost 13 percent, its highest level ever, and second only to California among the 50 states.
In this context, any significant income tax hike
would further damage New York’s economic
competitiveness and undermine the benefit of
tax relief at the local level.
Especially counterproductive would be any
increase in taxes on health care itself. The state
already raises $4.5 billion per year from taxes
on health insurance.18 A takeover that excludes

 New York City would entail a 51 percent
increase in these surcharges, which are already
among the largest levied by any state. A statewide takeover would require an increase of
169 percent.
This approach would further drive up the cost
of health insurance for New Yorkers, who
already pay some of the highest premiums in
the U.S. This would cause more people lose or
drop coverage and ultimately drive up Medicaid enrollment and costs.
Cutting state spending
While there is certainly waste in the state budget, financing a Medicaid takeover through
spending reductions would require much more
than belt-tightening.
The price tag for a takeover, at $7.6 billion,
equates to 8 percent of all spending funded by
state taxes. It’s more than the entire budgets
for major functions such as parks and the environment ($1.6 billion), economic development ($2.1 billion), mental health ($2.9 billion),
prisons ($3 billion), the state-funded portions
of transportation ($5 billion) and the State University of New York ($7.2 billion).19
Realistically, a cost-cutting effort on this scale
would have to consider the two largest items in
the state budget: school aid and Medicaid itself.
A takeover could hypothetically be funded
by a 29 percent cut in school aid. But that
would likely backfire if local districts responded by raising their property taxes, which
are much costlier for most homeowners than
county taxes.
The most logical place to look for cuts would be
Medicaid, both because it is the original source
of the counties’ expense, and because New
York’s program is so expensive. Its per capita
cost in 2015 was $3,054, the highest of any state
and 76 percent above the national average.20

Finding sufficient savings from the program
would be complicated by the federal aid formula, which matches state and local spending
on a roughly dollar-for-dollar basis. As a result,
the state would have to cut overall Medicaid
spending by $15 billion—or 22 percent—to
achieve net savings of $7.6 billion for itself.
Even after a 22 percent cut, however, New
York would still rank among the top 10 states
in terms of per capita Medicaid spending.
Cutting the Medicaid budget
The least painful way to cut Medicaid spending
would be rooting out waste, fraud and abuse—
which certainly remains a significant factor in
New York’s program. To cite one example, a
recent audit by the office of state Comptroller
Thomas DiNapoli found that the Health Department spent $1.3 billion over six years on
Medicaid managed care premiums for recipients who already had other health insurance.21
Another desirable approach would be improving the efficiency of care delivery—for example, by encouraging patients to use clinics and
urgent-care centers instead of emergency rooms
for non-emergency issues, or better managing
chronic illnesses such as diabetes and asthma
to avoid hospitalizations. If successful, these
steps would have the added benefit of improving outcomes for recipients.
However, the state already devotes considerable resources to eliminating waste through the
comptroller’s office, the Health Department,
the Office of the Medicaid Inspector General
and various law enforcement agencies.
The state is also currently improving efficiency
by enrolling most recipients in managed care
plans and increasing coordination among providers through the Delivery System Reform
Incentive Payment program.
Given those existing efforts, it’s unlikely that
additional anti-fraud and efficiency efforts, by

Shifting Shares

9

 themselves, would generate $15 billion in savings in the short term.
To quickly lower spending by 22 percent, the
state would have to consider more politically
difficult steps, such as cutting fees to providers, trimming benefits for recipients or reducing enrollment. Each of those steps comes with
drawbacks.
Medicaid fees are generally lower than those
paid by Medicare and commercial insurance,
and many providers report losing money when
they treat Medicaid recipients. Among other
consequences, this discourages doctors from
participating in the program and strains the
finances of hospitals who serve the needy, potentially compromising the quality of care for
all patients. A further significant reduction in
fees would aggravate all of these problems.
Another cost-cutting option would be trimming the benefits that Medicaid provides,
some of which are optional under federal law.
Theoretically, for example, New York could
end Medicaid coverage for adult dental care,
eyeglasses, hospice care, prosthetics or even
prescription drugs.22
Such steps would affect the range of Medicaid
recipients, from low-income able-bodied adults
to severely disabled children and frail residents
of nursing homes. Many would have no other
way of paying for the services, and their health
and quality of life might be compromised as
a result.

Issue Brief

Eliminating even major benefits would not necessarily generate sufficient savings. For example, Medicaid’s total prescription drug spending for 2016 was $3.3 billion, less than a quarter
of the amount necessary to finance a takeover.23

July 2018

10

A third approach to cutting Medicaid costs
would be reducing enrollment. New York’s unusually expansive program covers 6.1 million
people, or a third of the population, which as of
2015 was the second-highest share of any state
after New Mexico.24

The state could potentially trim the rolls by, for
example, restricting eligibility for the “medically needy,” who live above the poverty line but
have medical or nursing-home bills that exceed
their income.
This would come at the cost of allowing more
New Yorkers—especially the elderly, disabled
and seriously ill—to be impoverished by medical expenses. It would also be difficult politically: For 28 years in a row, governors of both
parties have proposed ending “spousal refusal”—a legal strategy that allows long-term care
patients to qualify for Medicaid while protecting the income and assets of their spouses—
and they were turned down by the Legislature
every time.25
Strengthening the Medicaid ‘global cap’
The challenge of eliminating counties’ Medicaid
costs becomes more manageable if the change
can be phased in over a period of 10 to 20 years.
This opens the door to an existing cost-cutting
strategy with a record of success: the “global
cap” on Medicaid spending growth.
If the existing cap were broadened and strengthened, it could potentially generate enough savings to finance a gradual takeover.
The current cap was enacted in 2011 as part
of Governor Andrew Cuomo’s first budget. It
limited year-to-year growth of state Medicaid
spending to the 10-year rolling average of the
medical inflation rate.26
To find the necessary savings, the governor
empaneled a Medicaid Redesign Team representing various stakeholders in the health-care
system. If the team’s efforts fell short, the health
commissioner was empowered to cut Medicaid
fees as necessary to meet the cap.
This system largely worked as intended, especially in its early years.
Under Medicaid director Jason Helgerson, the
Redesign Team advanced dozens of reform

 Figure 3. Potential Savings from Tightened ‘Global Cap’ on Medicaid Spending
$50,000
$45,000
$40,000

Projected state spending at
4.5% annual growth

$35,000

(Millions)

$30,000

Projected state spending at
3.1% annual growth

$25,000
$20,000
$15,000
$10,000

$6,621 $7,383
$5,233 $5,905
$4,602
$3,457 $4,011
$2,453 $2,938
$1,576 $1,999
$584 $1,008 $1,181

$5,000
$0

2018

2019

2020

2021

2022

2023

2024

2025

Savings (in millions)

2026

2027

Fiscal year

2028

2029

2030

2031

2032

2033

$8,194

2034

$9,056

2035

Source: 2018-2022 Medicaid spending figures from the NYS Division of the Budget

ideas intended not just to save money, but also
to improve care and broaden access. Perhaps
most importantly, the state enrolled a far greater share of Medicaid recipients into managed
care plans, including groups that had previously been exempt, such as the mentally ill and
nursing home residents.
Meanwhile, state Medicaid outlays stayed at
or below the global cap, even as enrollment
surged with enactment of the Affordable
Care Act. Per-recipient spending dropped significantly—from $12,000 in 2011 to $9,700 in
2015—and measures of care quality generally
held steady or improved.27
Over time, however, weaknesses in the global
cap became apparent. It restrained spending on
the bulk of the program, known as Department
of Health (DOH) Medicaid, but did not cover
services provided through the Office of Mental Health, the Office for People with Developmental Disabilities or the Office of Alcoholism
and Substance Abuse Services. Certain expenses were also exempted, such as labor costs associated with a Cuomo-sponsored hike in the
minimum wage.

As of 2017, the cap governed 97 percent of DOH
Medicaid. That dropped to 93 percent for 2019,
and is projected to fall to 88 percent by 2022.28
Meanwhile, enrollment leveled off, rendering
the cap significantly less restrictive. Per-recipient spending climbed back to more than
$11,000.
The result of these trends is that overall state
spending on Medicaid is growing substantially faster than the medical inflation rate. The
state’s latest financial plan shows increases of
4.2 percent in the current fiscal year, 6.3 percent
for 2020, 5.4 percent for 2021 and 4.2 percent for
2022—whereas medical inflation is projected to
continue at about 3.1 percent.29
If the growth rate could be lowered by 1.4
points—the difference between medical inflation and the current trend—the annual savings would be substantial. As shown in Figure
3, they would reach $1.2 billion by fiscal year
2022, and $8.2 billion—enough to eliminate the
local share—by 2034.

Shifting Shares

11

 To achieve those savings, the global cap could
be strengthened in two ways:
First, it could be expanded to cover all Medicaid spending, including the portions managed
by OMH, OPWDD and OASAS and minimum
wage-related costs for all providers.
Second, the global cap should be supplemented with a per-recipient cap, to protect against
excessive spending growth when enrollment is
flat or declining.
State officials would still face the hard work
of removing waste and improving efficiency and, possibly, the hard choices to cut fees,
benefits or enrollment. But they could do so
gradually and carefully, without sudden or
severe changes.
Local tax relief
If the goal of a state takeover is property tax
relief—as opposed to giving local officials more
money to spend—the state will need to set
guidelines for how the savings are used.
A readily available mechanism is the state’s
property tax cap.* Enacted in 2011, this law
limits the year-to-year growth of each jurisdiction’s property tax collections to 2 percent or
the inflation rate, whichever is less. The cap applies to the total amount to be raised by property taxes, known as the “levy,” with certain
limited exceptions.

Issue Brief

The cap can be overridden only with approval
by a 60 percent majority of the decision-making
body—which, for counties, would be a legislature or board of supervisors. The law does not
currently apply to New York City.

July 2018

12

In enacting a takeover plan, the state could
require that the annual savings accruing to
each county be subtracted from its current levy
before calculating the capped amount for the
next year.
* This mechanism was suggested to the author by
Charles Brecher of the Citizens Budget Commission.

Take, for example, a hypothetical county with a
property tax levy of $100 million and Medicaid
takeover savings of $5 million. As things stand
now, it would be allowed to increase the levy
by as much $2 million, to raise a total of $102
million in the following year—plus spend the
$5 million as it wished.
Under a modified cap, the county’s current
levy would be reduced by the $5 million in
savings, to $95 million. The county would then
be allowed to increase taxes by no more than
2 percent of that reduced base, or $1.9 million,
for total collections of $96.9 million in the ensuing year. Instead of increasing by $2 million,
tax collections would decrease by $3.1 million.
Under this plan, a county would have the flexibility to override the cap, but only with 60
percent approval by its legislature in a separate
vote preceded by a public hearing. This would
put the public on notice of the decision and
encourage local officials to prioritize tax relief.
The tax cap, as modified, could be expanded
to include New York City—requiring the City
Council to clear at least one additional hurdle
before adding to the city’s already enormous
tax burden.
Using the savings to reduce the city’s income
tax—as contemplated in one of the Senate GOP
proposals—would be more complicated. While
property tax rates are controlled by the City
Council, changing city income tax rates would
require further action by the state Legislature.
Conclusion
The local share of Medicaid has evolved into
something that’s hard to defend, but also hard
to unwind. Eliminating it entails either the reallocation of almost $8 billion in state resources, or $15 billion in cuts to a program that pays
medical bills for one in three New Yorkers and
serves as a financial mainstay of the state’s entire health care system.
Because the current system distributes costs so

 unevenly, any solution must therefore distribute relief unevenly. Including New York City
more than triples the cost, from $2.3 billion to
$7.6 billion, but excluding it would be manifestly unfair and politically impractical.

norms. The state effectively began that process
more than a decade ago, when it capped and
then froze local payments, causing them to
gradually shrink in real terms due to the effects
of inflation.

The most plausible approach is to slowly phase
out the local share over a period of 10 years or
more, and make up for the lost revenue with
savings squeezed from the Medicaid program
itself—which, despite efficiency improvements, remains much costlier than national

Committing to full elimination, however,
would be a major escalation, both in dollars
and in difficulty. Leaders committing to this
path must be prepared to grapple with tough
choices for years to come.

Figure 4.
Medicaid Local Share as a Percentage of Combined Local Property Tax Levies, 2016

Sources: Empire Center calculations using data from the NYS Association of Counties and the Office of the State Comptroller.
Combined levies include county, city, village, town, school and fire district property taxes.

Measured as a percentage of combined county, municipal and school property taxes, the local share
of Medicaid costs adds the most to property tax burdens in upstate counties with large low-income
populations, the more darkly shaded areas above. Medicaid has the least impact on total property taxes
in affluent suburban counties on Long Island and in the Hudson Valley, which are lightly shaded. Two
outliers at opposite extremes: New York City, whose Medicaid share equates to nearly one-quarter of
property taxes, and Hamilton County in the North Country, which has a tiny year-round population and
low Medicaid property tax impact. See Appendix Table 3 for detailed county percentages.
Shifting Shares

13

 Appendix 1. Local Medicaid Payments by County
Local Medicaid Payment
New York State

New York City
Albany

Allegany
Broome

$630a

$9.82a

$10,236,935

$217

$6.39
$5.96

$65,153,487

$39,624,111

$211

$203

$3.70

$3.20

$250

$6.83b

Chenango

$10,218,715

$210

$5.48

$11,419,246

$187

$3.68

Clinton

Cortland

Delaware

Dutchess
Erie

Essex

Franklin

$20,748,386
$17,937,879

$5.72

$4.51

$43,750,481

$149

$2.96

$1.49

$6,937,297

$182

$4.41

$8,945,565

$215,758,575

$1.56

$205

$5.61

$2.87

$9,880,283

$169

$4.21

$3.58

$663,757

$146

$20,563,032

$10,323,790

Herkimer

$13,978,850

$264

$212

$6.73

$5.01

$1.03

$4.39

$1.82

$2.78

$0.193

$180

$4.13

$2.60

$148

$3.88

$223

$3.00

$2.56

$161

$4.01

$2.87

$12,307,071

$250

$6.43

$5.61a

$46,872,407

$221

$5.28

$4.55

$227

$4.73

$4.02

$73,757,613

$195

$4.11

$2.45

Oswego

$25,614,052

$215

$5.84

Putnam

$9,905,951

$100c

$1.683

$68,516,660

$210

$3.78

$34,978,252

$226

Madison

$9,539,179

$11,475,963

Monroe

$184,837,175

Nassau

$240,813,962

Montgomery
Niagara

Oneida

Onondaga

Ontario

Orange

Orleans

Otsego

Rensselaer

Rockland
Saratoga

Schenectady

Schoharie
Schuyler

Seneca

St. Lawrence

Steuben

Suffolk

Sullivan

Tioga

Tompkins

Ulster

Warren

Washington

Wayne

Westchester
Wyoming

Yates

$57,338,984

$105,614,117
$16,736,310
$8,542,627

$10,811,129
$34,834,303
$25,396,222

$194

$5.94

$4.82

Livingston

$5,203,749

$234

$5.40

$4.15

$10,062,792

Lewis

$197

$1.58

$4.93

Greene

Jefferson

$4.90

$4.30

$215

$14,194,376

Hamilton

$4.64

$3.76

$10,355,510

$221

$6.02

$4.21

$5.40

Fulton

Genesee

$240

$2.73

$5.18

$4.90

$32,343,192

$189

$5.02

$4.07

Chautauqua

$14,734,435

$3.43

$5.05

$224

Columbia

Issue Brief

$6.49

$5,378,022,327

$17,371,071

Chemung

14

$387

Per $1,000 of
Personal Income
Property Value

Cattaraugus
Cayuga

July 2018

$7,633,673,109

Per Capita

$247

$177
$248
$152

$207

$180

$218

$5.13

$2.23
$6.16

$3.08

$2.80

$4.53

$1.13

$5.44

$1.95

$5.90

$5.17

$4.65

$2.48

$4.81

$4.41

$0.75
$3.43

$1.95

$112

$1.80

$1.09

$189

$5.13

$2.62

$6,152,710

$177

$5.06

$20,077,343

$207

$20,897,591

$279b

$12,297,913

$5,903,803

$3,865,285

$24,548,788

$256,134,440

$214

$4.82

$3.77

$5.36

$2.86

$223

$6.49

$4.37

$172

$2.82

$0.96

$172

$4.21

$5.12

$3.06

$3.54

$6.57

$2.79

$117

$2.88

$1.77

$12,591,527

$195

$4.03

$1.19

$14,534,805

$160

$3.84

$8,363,335

$37,366,146
$11,608,683

$223,035,011
$5,584,596
$4,391,315

$208

$188

$4.63

$3.26

$2.12

$5.12

$2.47

$229

$2.43

$1.37

$176

$4.91

$1.84

$137

$3.66

$3.03

$2.57

Sources: Empire Center calculations using data from the NYS Association of Counties, the Census Bureau, the Bureau of
Economic Analysis and the Office of the State Comptroller. aHighest, bHighest outside NYC, cLowest

 Appendix 2. Poverty Rate and Median Income By County
Medicaid Per
Capita
New York State
New York City
Albany

Allegany
Broome

Cattaraugus
Cayuga

Chautauqua
Chemung

Chenango
Clinton

Columbia
Cortland

Delaware

Dutchess
Erie

Essex

Franklin
Fulton

Genesee
Greene

Hamilton

Herkimer

Jefferson
Lewis

Livingston
Madison
Monroe

Montgomery
Nassau

Niagara
Oneida

Onondaga
Ontario
Orange

Orleans

Oswego
Otsego

Putnam

Rensselaer
Rockland
Saratoga

Schenectady
Schoharie
Schuyler
Seneca

St. Lawrence
Steuben
Suffolk

Sullivan
Tioga

Tompkins
Ulster

Warren

Washington
Wayne

Westchester
Wyoming
Yates

$387

Poverty Rate
15.5%

$60,741

12.9%

$60,904

$630a

20.3%

$217

17.1%

$211
$203
$224
$189
$250
$240
$210
$221
$187
$215
$197
$149

17.4%
17.5%
11.4%

$146
$223
$180
$194
$148
$161
$247

12.7%
13.8%
15.9%
9.2%

10.1%
16.7%
12.5%
13.0%
11.3%
14.0%
14.6%
14.0%
14.9%
11.9%
14.9%

$250

20.6%a

$221

13.6%

$227

15.2%

$177
$248
$152
$195
$207
$215
$180

$100c

10.3%
12.6%
15.6%
18.3%
16.3%

5.2%b

14.5%

$226

12.0%

$214

14.6%

$207
$172

14.1%
12.4%
19.2%
15.1%
7.3%

$279b

17.1%

$117

20.1%

$172
$208
$195
$188
$160
$229
$137
$176

$59,916
$50,910
$46,055
$72,706
$52,744
$53,244
$49,782
$46,090
$52,641
$51,013
$52,708
$48,893
$49,911
$49,976
$52,724
$55,858
$53,568
$44,455

$49,838

6.4%

$223

$50,502

16.7%

$112

$177

$49,578

$102,044a

12.4%

$189

$53,114

6.0%

$218
$210

$43,884

$46,979

16.1%

19.2%

$212

$47,744

15.4%

15.9%

$205
$169

$44,085

$43,211c

14.7%

$264

$55,191

19.4%

$234
$182

Median Household
Income

11.0%
13.0%
11.1%
12.9%
11.9%
9.8%

11.5%
13.9%

$50,094
$55,717
$58,070
$71,910
$48,731
$49,571
$49,689
$97,606
$61,754
$86,134
$74,080
$59,959
$50,607
$47,229
$50,073
$46,313
$48,823
$90,128
$52,027
$58,115
$54,133
$60,393
$57,174
$51,449
$51,627
$86,226
$53,612
$50,105

Source: 2016 poverty rates and median household income, Census Bureau.
a
Highest, bHighest outside NYC, cLowest

Shifting Shares

15

 Appendix 3. Medicaid and County Finances

New York State

New York City***
Albany

Allegany
Broome

Cattaraugus
Cayuga

Chautauqua
Chemung

Chenango
Clinton

Columbia
Cortland

Delaware

Dutchess
Erie

Essex

Franklin
Fulton

24%

9%

24%a

11%

12%

8%

11%

11%

52%

7%

32%

14%

9%

67%
32%

Combined
Property Taxes**

8%

10%

36%

10%

58%

10%

17%b

10%

11%

51%
37%
73%
27%
30%

12%
11%
7%
9%

11%
13%
11%
7%

11%

27%

10%

76%

13%

13%

57%

10%

12%

6%

9%

37%
30%

9%
7%

7%
5%
6%

37%

10%

Herkimer

48%

15%

13%

Lewis

29%

4%

9%

Hamilton

Jefferson
Livingston
Madison
Monroe

Montgomery
Nassau

Niagara

35%
8%c

35%
32%

11%

24%

Otsego

Putnam

Rensselaer
Rockland
Saratoga

Schenectady
Schoharie
Schuyler
Seneca

St. Lawrence
Steuben
Suffolk

Sullivan
Tioga

Tompkins
Ulster

Warren

Washington
Wayne

Westchester
Wyoming
Yates

10%
7%

14%
7%

2%c

13%
8%
8%

11%
13%
4%

52%

12%

12%

71%

9%

11%

30%

Oswego

6%

40%

51%

Ontario

Orleans

10%

10%

79%a

Orange

3%c

31%

Oneida

Onondaga

Issue Brief

27%

County
Expenditures*

16%a

Greene

16

Medicaid Share of:

49%

Genesee

July 2018

County Property
Taxes*

55%

13%
8%
9%

15%
7%
7%

49%

12%

13%

78%

11%

10%

51%

10%

10%

43%

9%

41%
22%
40%

13%
6%

10%

9%
2%
6%
5%

46%

11%

10%

32%

9%

12%

50%

13%

14%

38%

8%

25%
61%
43%
32%

8%
9%

11%
9%

7%

10%
10%
4%
8%

32%

11%

46%

11%

34%

11%

10%

32%

8%

5%

27%
29%
34%
28%
26%

7%
8%
8%
4%

10%

9%
5%
6%
7%
8%
9%
9%

Sources: Empire Center calculations using data from the NYS Assn. of Counties and the Office of the State Comptroller. *Based on
2016 county fiscal data, **Includes all county, city, village, town, school and fire district property taxes, ***New York City encompasses
the governmental functions of a county, a city and a school district, aHighest, bHighest outside NYC, cLowest

 Appendix 4. Impact of Medicaid-for-Sales Tax Swaps
Including and Excluding New York City
Gain (Loss) from Swap

New York City
Albany

Allegany
Broome

Cattaraugus
Cayuga

Chautauqua
Chemung

Chenango
Clinton

Columbia
Cortland

Delaware

Dutchess
Erie

Essex

Franklin
Fulton

Genesee

Excluding NYC*

N/A

$(10,113,927)
$5,246,030

$893,238

$1,955,514

$(9,189,556)

$5,590,822
$14,803,581

$(4,683,262)
$(493,502)

$4,774,651

$(9,156,760)

$3,389,144

$(9,299,461)

$3,757,662
$702,906

$2,268,468
$2,662,828

$(11,435,087)

$(1,877,313)
$(8,643,295)
$(4,784,604)
$(2,816,629)

$(59,564,900)

$33,159,781

$(126,092,828)

$3,933,560

$(1,639,646)

$(1,147,051)
$6,326,277

$(8,197,773)
$(535,846)

$(875,034)

$(10,255,229)

$(349,817)

$(1,233,800)

Herkimer

$5,910,092

Lewis

$1,792,278

Madison

$2,647,071

Livingston

$(75,758,020)
$(26,505,725)

$1,305,354

Jefferson

$1,967,254,353

$4,301,078

Greene

Hamilton

Including NYC**

$(6,332,401)
$(1,127,035)

$(944,062)

$(19,701,365)

$569,116

$(7,254,078)

$(1,183,018)
$(5,053,003)

Monroe

$46,635,785

$(73,895,855)

Nassau

$(67,813,661)

$(336,981,672)

Oneida

$20,551,168

$(11,533,139)

Ontario

$(9,778,439)

Orleans

$4,084,409

Montgomery
Niagara
Onondaga
Orange

$4,127,792
$9,730,656
$8,547,584

$(8,954,202)

$(3,005,725)

$(22,662,334)
$(76,108,498)
$(32,903,142)
$(81,090,890)
$196,197

Oswego

$13,720,789

Putnam

$(6,363,852)

$(20,553,478)

$10,253,875

$(40,559,716)

$7,051,598

$(17,304,492)

Otsego

Rensselaer
Rockland
Saratoga

Schenectady
Schoharie
Schuyler
Seneca

St. Lawrence
Steuben
Suffolk

Sullivan
Tioga

$302,234

$11,597,588

$(24,289,488)
$1,655,601

$924,028

$(757,831)

$8,768,051
$4,868,968

$3,348,140

$(8,863,045)
$(8,668,194)

$(67,622,626)
$(2,049,447)
$(1,641,174)
$(6,784,824)
$(4,995,038)
$(8,394,938)

$(118,569,133)

$(445,364,948)

$2,724,796

$(2,192,828)

$9,801,303

$123,732

Tompkins

$(5,270,360)

$(20,592,441)

Warren

$(8,360,036)

$(26,632,836)

Wayne

$2,530,593

Ulster

Washington
Westchester
Wyoming
Yates

$5,118,216
$4,353,732

$(23,006,653)
$(1,973,637)
$(7,938,820)

$(9,009,168)

$(211,385,317)

$1,096,632

$(1,776,808)

$489,533

$(3,954,100)

Sources: Empire Center calculations using data from the NYS Association of Counties and
the NYS Department of Taxation and Finance. Based on taxable sales for SFY 2014.
*1.2% of taxable sales, **2.2% of taxable sales.

Shifting Shares

17

 Appendix 5. Using Personal Income Tax to Replace
County Medicaid Payments (In Millions)

NYS Residents
Nonresidents

New York City
Albany

Allegany
Broome

Cattaraugus
Cayuga

Chautauqua
Chemung

Chenango
Clinton

Columbia
Cortland

Delaware

Dutchess
Erie

$5,378
$2,256
$65
$10

$6,377

$3,195

$(940)

$3,168
$70

$5

$29

$15

$10

$21

$12

$32
$10

$8

$13

$5

$10

Jefferson
Lewis

Livingston
Madison
Monroe

$14

$5
$4

$2

Greene

$1

$8

$(2)

$5
$5

Herkimer

$9

$(26)

$10

$10

$5

$70

Fulton

$14

$10

$5

$5

$7

$6

$11

$5

$10
$44

$(4)

$20

$10

$9

$2,210

$13

$18
$11

$1,257

$(1,257)

$40
$17

Savings (Loss)

$1,257

$172

Hamilton

$6
$8
$7
$1
$6

$43
$6
$8
$2
$3
$0
$8

$21

$10

$10

$10

$8

$1

$5

$11

$3

$10

$3
$1

Montgomery

$185

$145

$39

Niagara

$241

$679

$(439)

$57

$29

$29

Nassau
Oneida

Onondaga

$12
$47

Ontario

$106

Orleans

$74

Orange

Oswego

$17
$9

$5

$30
$88
$22
$71

$4

$7

$17
$17

$(5)
$3
$5

Otsego

$26

$14

$12

Rensselaer

$10

$33

$(23)

$69

$83

$(14)

$59

$(34)

$4

$2

Putnam

Rockland
Saratoga

Schenectady
Schoharie
Schuyler
Seneca

St. Lawrence
Steuben
Suffolk

Sullivan
Tioga

Tompkins

$11
$35
$25
$25
$35

$6
$4
$6

$20

$8

$27
$10
$28

$2
$4

$13

$256

$514

$8

$6

$21

$9

$3
$8

$14
$7
$2
$2
$7

$(258)
$12
$2

Ulster

$12

$18

$(6)

Washington

$13

$12

$0

Warren

Issue Brief

-

$216

Genesee

18

$7,634

Share of $7.6B
PIT Increase

Essex

Franklin

July 2018

Current Local
Medicaid Share

Wayne

Westchester
Wyoming
Yates

$37
$12
$15

$223

$6

$32
$6

$12

$728

$5

$5
$5
$3

$(505)
$1

Sources: Empire Center calculations using data from the NYS Association of Counties and the NYS Department of Taxation and
Finance. Based on income tax collections for SFY 2014.

 ENDNOTES
1 National Association of Counties, “Medicaid and
Counties: Understanding the program and why it
matters to counties,” January 2017, http://www.
naco.org/sites/default/files/documents/NACo-Medicaid-Presentation-updated%201.26.17.pdf.
2 Data provided to the author by the New York
State Association of Counties.
3 Data provided to the author by the New York
State Division of the Budget.
4 Op. cit., NYS Association of Counties.
5 Citizens Budget Commission, “A Poor Way to
Pay for Medicaid: Why New York Should Eliminate Local Funding for Medicaid,” December 2011,
https://cbcny.org/sites/default/files/media/
files/A%20Poor%20Way%20to%20Pay%20for%20
Medicaid.pdf.
6 Op. cit., Division of the Budget.
7 Based on county revenue and spending figures
for 2016 obtained from OpenBookNewYork.com,
operated by the New York State Office of the State
Comptroller.
8 “Mr. Cuomo’s Medicaid Cure,” The New York
Times, February 18, 1994. https://www.nytimes.
com/1994/02/18/opinion/mr-cuomo-s-medicaidcure.html.
9 Jesse McKinley, “Medicaid Fight Lands in
New York, Crossing Party Lines,” The New York
Times, March 21, 2017, https://www.nytimes.
com/2017/03/21/nyregion/health-care-medicaidnew-york-collins.html?_r=0.
10 “Addressing the Medicaid Mandate,” posted
on Medium.com by the New York State Assembly
Republican Conference, March 12, 2018, https://
medium.com/@NYS_AM/addressing-the-medicaid-mandate-362882036e90.
11 “Our Vision for New York: Structural Changes
for a Stronger State,” Assembly Republican Conference (PowerPoint presentation), April 17, 2018.
12 Senate Bills 8411 and 8412 of 2018.
13 Assembly Bill 2236 of 2018.
14 FY 2019 Updated Financial Plan, New York
State Division of the Budget, May 2108, p. 73,
https://www.budget.ny.gov/pubs/archive/fy19/
enac/fy19enacFP.pdf.
15 Ibid.
16 E.J. McMahon, “Heastie’s gazillionaire tax,”
New York Torch, January 26, 2017, https://www.
empirecenter.org/publications/heasties-gazillionaire-tax/.
17 Emma G. Fitzsimmons, “Bill de Blasio Will
Push for Tax on Wealthy to Fix Subway,” The New
York Times, August 6, 2017, https://www.nytimes.
com/2017/08/06/nyregion/bill-de-blasio-will-

push-for-tax-on-wealthy-to-fix-subway.html.
18 Op. cit., FY 2019 Updated Financial Plan, p. 106.
19 Budget numbers for FY 2019 obtained from SeeThroughNY.net, operated by the Empire Center,
https://www.seethroughny.net/nysbudget/disbursements/.
20 Calculations by the author based on data from
the Centers for Medicare & Medicaid Services and
the Census Bureau, https://www.empirecenter.
org/publications/medicaid-chip-spending-bystate/.
21 Audit Report 2016-S-60, Office of the State
Comptroller, June 2018, http://www.osc.state.
ny.us/audits/allaudits/093018/sga-2018-16s60.
pdf.
22 Listing of mandatory and optional Medicaid
benefits at Medicaid.gov, https://www.medicaid.
gov/medicaid/benefits/list-of-benefits/index.
html.
23 Bill Hammond, “The Cost of Cures,” Empire
Center, April 10, 2018, https://www.empirecenter.
org/publications/the-cost-of-cures/.
24 Calculations by the author based on data from
CMS and the Census Bureau, https://www.empirecenter.org/publications/medicaid-chip-enrollment-vs-poverty-rate-by-state/.
25 Dan Goldberg, “28th time’s the charm,” Politico New York, January 18, 2018, https://www.
politico.com/states/new-york/newsletters/politico-new-york-health-care/2018/01/18/28th-timesthe-charm-025437.
26 “Governor Cuomo Announces On-Time Passage of Historic, Transformational 2011-12 New
York State Budget,” press release from the governor’s office, March 31, 2011, https://www.
governor.ny.gov/news/governor-cuomo-announces-time-passage-historic-transformational-2011-12-new-york-state-budget.
27 Per-recipient spending figures based on calculations by the author. For more on the track record of
the Medicaid Redesign Team, see also, “What Ails
Medicaid in New York: And Does the Medicaid
Redesign Team Have a Cure?” Citizens Budget
Commission, May 2016 (https://cbcny.org/sites/
default/files/media/files/REPORT_MEDICAID_05232016_1_0.pdf), and “Medicaid in New
York: The Continuing Challenge to Improve Care
and Control Costs,” Office of the State Comptroller, March 2015 (http://osc.state.ny.us/reports/
health/medicaid_2015.pdf#search=%20medicaid).
28 Op. cit., FY 2019 Update Financial Plan, pp. 99101.
29 Ibid.
Shifting Shares

19