Medicaid

Congresswoman Claudia Tenney (NY-24) joined Congressman Nick Langworthy (NY-23) in introducing the Protect Local Taxpayers Act in response to Governor Kathy Hochul’s Fiscal Year 2024 Budget Proposal, which would keep $625 million in Federal Medical Assistance Percentage (FMAP) that have been shared with New York counties since 2011. Congressman Brandon Williams (NY-22) is also an original cosponsor of this bill.

New York State is one of the only states in the nation to require counties to pay a significant portion of the state’s non-federal matching share of its Medicaid program. This costs local counties in New York up to $7.6 billion per year, resulting in county governments imposing some of the highest property taxes in the country and stressing other critical local services.

The Protect Local Taxpayers Act would offer a straightforward fix by ensuring that FMAP funds are directed, as intended by Congress, to our state’s counties to cover their portion of Medicaid expenses. Since New York counties face a massive obligation under New York’s Medicaid program, this legislation will ensure they are never left with a significant and harmful budgetary impact, such as the one that would be caused by Kathy Hochul's irresponsible 2024 budget.

“As a result of one-party Democrat rule in Albany, New York State has among the highest taxes in the country,” said Congresswoman Tenney. “One reason upstate New York families face such high costs is that our local counties are forced to absorb and subsidize the soaring cost of New York’s Medicaid program. Enough is enough! I’m honored to join the Protect Local Taxpayer Act, which will prevent state governments like ours from further shifting our bloated state Medicaid expenses onto our local county governments, and then refusing to reimburse them for a portion of the costs. Albany should be focused on supporting our local communities, not taking more of their money to subsidize far-left priorities.”

“Governor Hochul’s budget proposal would force rural counties like the ones I represent in Western New York and the Southern Tier into doomsday decision-making, causing unnecessary panic among the people who rely on Medicaid services,” said Congressman Langworthy. “It is well past time to get fiscal sanity back into our state government, and I remain laser-focused on protecting the hardworking taxpayers who feel disenfranchised by state leadership.”

Photo: File photo by Howard Owens

Press release:

Congresswoman Claudia Tenney (NY-24) introduced the Property Tax Reduction Act, which would prevent state governments like New York from unfairly shifting state Medicaid expenses onto local county governments.

Congressman Nick Langworthy (R-NY) co-led this bill alongside Congresswoman Tenney. Congressman Brandon Williams (R-NY) and Congresswoman Elise Stefanik (R-NY) are also original cosponsors.

New York is the only state in the country that requires local counties to pay a substantial portion of the state’s share of Medicaid funding, amounting to nearly $8 billion per year or nearly a quarter of the non-federal cost share for the program. 

This places enormous fiscal pressure on our local governments and has led to some of the highest property tax bills in the country. This arrangement also enables the state to inflate and expand both the scope and the cost of Medicaid since the state is not directly responsible for absorbing the costs associated with burdensome changes and unfounded mandates to the program. This mandate is among the reasons New York also has the highest per capita Medicaid expenditures nationwide; as of 2019, per capita Medicaid personal spending for New York is close to 7 times higher than that of California and 10 times higher than New Jersey.

In New York’s 24th Congressional District, this irresponsible funding scheme shifts a burden of at least $180 million onto our county governments annually. Counties raise most of these funds through property tax levies. Tenney’s bill would stop Albany from passing this Medicaid share onto counties, saving local taxpayers millions. 

“New York State leads the country with the highest rate of outmigration,” said Congresswoman Tenney. “This mass exodus directly corresponds with outrageous property taxes, forcing families and small businesses to relocate. One of the driving causes of this crisis is that New York’s 62 county governments have zero say in how New York’s Medicaid program is operated but are forced to pay a significant amount of its costs. This dysfunctional and unfair system burdens county governments, driving up costs for working families. It also lets Albany Democrats off the hook for reckless spending and gross mismanagement. I am reintroducing the Property Tax Reduction Act to require New York’s Democrat lawmakers to start taking responsibility for reckless spending and to prevent them from unfairly shifting costs to local property taxpayers and counties.”

Genesee County is looking at losing some $188,000 this year alone if the state budget is passed as is. The county Legislature voted a week ago to send a letter opposing the move, and the state Association of Counties (NYSAC) passed a resolution Tuesday during its three-day conference to do the same, Assistant County Manager Tammy Ferringer said.

“All counties unanimously voted to bring forth the resolution, the take-back of eFMAPs. So they're hoping that that will be impactful, and then it won't go away,” Ferringer said Wednesday. “Generally, just before the budget goes through, the commissioner of Social Services will receive notice that the weekly shares have changed or that this is your amount for federal participation. So it won't be until March, the end of the month. Unless the budget doesn't pass, and then it could be April and prolonged even longer.”

EFMAPs are enhanced Federal Medical Assistance Percentage funds. Counties have been receiving funding for Medicaid costs, and Gov. Kathy Hochul’s proposed 2023-24 budget would eliminate that allowance from the upcoming fiscal year.  Earlier in February, NYSAC President Michael E. Zurlo called the governor's removal of the eFMAP funds an "unprecedented shift" that will saddle local taxpayers with up to $1 billion in new Medicaid costs with the state pocketing those medical assistance funds instead. 

"Not only does this proposal harm New York's local taxpayers, but it also subverts Congress' intent that eFMAP be shared with local governments that contribute to the Medicaid program. In March of 2020, New York Senator Charles Schumer championed that 'Enhanced FMAP funds are so important because they are immediate and flexible. The state – which gets billions and the most of any state in the nation – and counties use the money they save on whatever they want,'" Zurlo said in a news release.

"At a time when New York is facing an affordability crisis, the last thing the Governor should do is burden local taxpayers with more costs that will drive up the cost of homeownership and rent, increase business expenses and make New York more unaffordable," he said.

Congresswoman Claudia Tenney has also sounded the alarm, stating that up to $1 billion in eFMAP funds could be diverted to state coffers.

“This will force counties to further raise property taxes on local taxpayers to cover the difference,” Tenney said in a news release. “This resolution clarifies that it was Congress’ intent for eFMAP funds to be shared directly with the county and local governments that cover the associated costs.”

Congress delivers federal funds directly to states to cover a share of their Medicaid programs and other healthcare initiatives. Congress intended eFMAP funds to be shared with the New York counties and local governments that sustain the Medicaid program.

“Governor Kathy Hochul’s state budget proposal amounts to an egregious theft of taxpayer dollars. She proposes that Albany Democrats steal federal funds that Congress intended to go directly to our counties. This absolutely reckless proposal will lead to a tax hike on working families across New York,” Tenney said. “Our counties shoulder a significant portion of our state’s Medicaid share, and they should therefore receive federal reimbursement. If Kathy Hochul and Albany Democrats think they are entitled to these federal funds, they should shift the burden of funding Medicaid from our counties back to our state’s capital, as every other state in the country does. New York is the only state that demands local governments cover half of the Medicaid share. It is deeply unfair, and it must end.”

The resolution put forth by Genesee County Manager Matt Landers would reverse the governor’s plan that would also increase payments to healthcare providers and require the 57 counties to cumulatively spend at least $280 million more in the 2024 budget year, he said.

That additional $188,000 for Genesee County is for this year, and that number could likely change next year, Ferringer said. Are county officials hopeful that the governor’s budget will omit the eMAP portion? It’s possible.

“But the likelihood of that doesn't seem like it's probable,” Ferringer said. “We'll probably come to a real solution before that.”

File Photo of Tammy Ferringer by Joanne Beck.

Genesee County Manager Matt Landers and Legislature Chair Rochelle Stein are prepared to meet with the Darien Town Board over what they say is a “misunderstanding” about the practice of including the Medicaid portion of the tax rate on the annual county tax bill.

The situation was brought to the legislature’s attention via a letter dated April 7 from the Darien Town Board on behalf of a longtime Darien Center resident who objected to having to pay $2.90 per thousand of his assessed property value toward the county’s state-mandated Medicaid costs.

The resident wrote to the town board, bemoaning the fact that he was charged $782.14 in taxes for Medicaid, this coming on top of the $340 per month that he and his wife already have deducted from their Social Security checks for Medicare.

In the letter, he suggested that instead of taxing property owners “for other persons’ Medicaid,” the county could raise the sales tax rate slightly from the current 8 percent (of which 4 percent stays in the county) to cover the cost.

The town board, in turn, drafted its letter – supporting the resident’s viewpoint.

“As most County Taxpayers, he (the resident) and his wife do not use the programs offered such as HEAP, SNAP, free medical insurance, rent subsidy, over-the-county general use cards, etc.,” the letter states. “(As the expense is applied to property owners only), this burden is not shared equally by all county residents.”

The town board’s letter indicates a sales tax increase from 4 to 4 ½ percent would generate approximately $3.1 million per year “and these funds would be dedicated to stabilizing the Medicaid tax bill.”

At Wednesday’s Ways & Means Committee meeting, Landers and the legislature addressed the resident’s concerns and the Darien Town Board’s letter and accompanying resolution that authorized mailing it to county officials.

Landers noted that the county has broken out the Medicaid share of the tax rate on its annual bill since 2004 – doing so for informational purposes.

“The county tax bill is broken up into two lines,” Landers said. “It really is the total dollar amount – the whole levy in taxes and then we have a line broken out separately for the piece that is attributable to Medicaid. This was done purely as a message to taxpayers to understand how much of their property taxes are going towards Medicaid.”

He said that each year the county uses the same formula to figure out the mandated Medicaid expense.

Landers then pointed out that the county’s 2022 tax rate was flat (at $9.16 per $1,000, which includes the $2.90 per thousand Medicaid tax) “because you remember the rates have been dropping as assessments are going up.”

“I think it’s more or less just a misunderstanding of the way our tax bill is (displayed). It’s purely informational only,” he said, noting that the real property tax office could break the rate out “into a 100 different items but that would become more complex.”

Furthermore, the county doesn’t have the authority to raise the sales tax rate, Landers said.

Ways & Means Chair Marianne Clattenburg put it another way, stating, “The idea (of placing the Medicaid portion on the tax bill) was to show the taxpayers that if we didn't have this Medicaid mandate on our backs, this is what your taxes would be.”

“If they just look at that other number ($6.25 per $1,000 of assessed value), that's where they're getting their police, their EMS (Emergency Management Services), their roads, their bridges -- everything that we do in the county is that other item, and that Medicaid is a New York state mandate,” she explained.

Clattenburg acknowledged the “misconception” has grown from one citizen to the entire Darien Town Board, “which is under the impression that we have a control over that number, which we don't.”

After several more minutes on the topic, legislators decided to respond to the town board, starting with a letter and following that up by having Landers and Stein attend a board meeting in Darien in the near future.

Legislator Brooks Hawley agreed with that, saying, “I think it would be better if it was face-to-face instead of sending letters back and forth. It could be misconstrued.”

From the Office for the Aging:

Open Enrollment for those on Medicare is Oct. 15 to Dec. 7 each year. The NY Connects/Genesee County Office for the Aging continues to be an unbiased resource that has information on all plans available for Genesee County residents.

Even during COVID-19, we are still here to assist you with your choices. Please call us at 343-1611; Monday-Friday between the hours of 8:30 a.m. - 5 p.m. 

Gov. Andrew Cuomo's proposal to cap increases on Medicaid spending at 3 percent at the county level could cost Genesee County another $2.3 million over the next four years.

That's just a rough guess, said County Manager Jay Gsell.

He called Cuomo's accusation that counties are spending on Medicaid with a "blank check syndrome" since the county share of Medicaid was capped in 2012 a "lie." He said the attempt to shift the burden for increases on Medicaid to counties is "voodoo economics for 2020" and using the maneuver to shift the cost of the state's deficit spending to county taxpayers a "Ponzi scheme."

“The Medicaid system has to be fiscally sustainable,” Cuomo said during his 2021 budget address. “If it is not fiscally sustainable then we accomplish nothing.”

New York State is facing a $6.1 billion budget gap due in large part to rising costs of Medicaid, a health insurance program that serves the poor, elderly and disabled.

Since the state capped county expenses, the state's share has increased $20 billion.

“That’s the blank check syndrome,” Cuomo said Tuesday. “We are signing the check and they’re filling out the amount.”

All Medicaid expenses, Gsell said today, are the result of state mandates. The county has no control over how much Medicaid costs or how much expenses increase.

The increases are a result of NY, as mandated by Albany, offering among the most generous Medicaid benefits package in the Union, and an increase in enrollment of Medicaid-eligible residents under the Affordable Care Act.

There are now 13,300 Genesee County residents enrolled in an ACA medical plan (not all are Medicaid eligible) compared to 8,800 five years ago.

"The State about eight to 10 years ago promised to takeover Medicaid administration from the local DSS districts, which still hasn’t occurred," Gsell said. "It now appears easier to pick a 'fall guy' – NYS counties – for the ongoing quagmire since 1966 that -- unlike in 48 of the other U.S. states -- New York State has bought into lock, stock, and barrel. I have yet to be told that we NYS Counties are making up our own benefit levels for this entitlement, enrolling masses of ineligible recipients, promoting fraud, waste, and abuse and essentially not doing our jobs. That is a figment of someone’s imagination in Albany. It is a lie and convenient dodge for a problem of the State government’s own making."

Photo: File photo of Gov. Andrew Cuomo.

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Press release:

Congressman Chris Collins (NY-27) today hailed the inclusion of his amendment to the House passed American Health Care Act into the Senate version of the bill. The amendment, introduced with Congressman John Faso (NY-19), would require New York State to take over the county portion of Medicaid by 2020 and would provide the largest property tax reduction ever to Western New York.

 

“This was a long fought battle against the injustice in Albany and is a big victory for taxpayers,” Congressman Collins said.

 

Federal law now permits states to share some of their costs with local governments, but New York is the only state that has imposed this level of burden on property taxpayers. Counties currently have no say in how local revenues are spent on Medicaid; they’re simply required to foot part of Albany’s bill. Local state leaders agreed that the inclusion of the amendment is important and welcome news for Western New York residents.

 

"Mandate relief has been talked about in Albany for as long as anyone can remember - it certainly wasn't new when I was talking about it as mayor. It's not a headline-grabbing or attractive issue, so meaningful proposals on mandate relief are generally swept aside. But I can tell you that it's real. It's real for the local governments who deal with tight budgets and it's real for taxpayers who pay some of the highest property taxes in the nation. I applaud Congressman Collins for bringing this issue to the forefront. Ideally, this would have been a serious discussion at the state level, but having failed that, I'm pleased that we could possibly address the crippling burden placed on our local governments as part of larger, federal health care discussions,” said State Senator Ortt.

 

“As a long-time supporter of curbing the costs of Medicaid, which would take a heavy burden off of local governments, I am proud to support Congressman Collins’ amendment. The impact on my assembly district and local taxpayers will be tremendous with estimated tax reductions of 49 percent in Orleans County and 35 percent in Genesee County. It is clear that New York’s outrageous Medicaid spending is one of the driving forces behind property and school tax increases and it is time for government to take that burden off our residents’ backs,” said Assemblyman Steve Hawley.

 

"Western New Yorkers pay some of the highest property taxes in the state. Rep. Collins' amendment fixes this problem and protects upstate taxpayers from Albany’s unfunded mandates. Removing the unfunded county Medicaid mandate is key to reducing local property taxes and growing our economy,” said Assemblyman Ray Walter. 

 

"This amendment is a blessing for upstate families, small businesses, and farms that’ve been crushed by the high taxes and unfunded mandates coming from Albany. The inclusion of this amendment is a win for our towns and villages and I appreciate Rep. Collins efforts to stand up for our taxpayers,” said Assemblyman Joseph Errigo.   

 

"I'm pleased that the Senate has included Rep. Collins's amendment in the healthcare reform bill. This promises real relief for property taxpayers in communities like Niagara County, and holds state government accountable to fund their mandates instead of passing on costs to the local level. Americans deserve access to the best healthcare possible, but it shouldn't fall to just homeowners to fund the system,” said Niagara County Legislature Chairman Wm. Keith McNall.

 

"Congressman Collins' Medicaid proposal will provide historic “real” property tax relief for hardworking local taxpayers. Currently over 30 perfect of the Ontario County property tax levy currently goes towards paying for New York's unfunded Medicaid mandate. I look forward to working with Rep. Collins and the members of the Board of Supervisors as we continue our efforts to reduce the burden on hardworking taxpayers in our community," said Jack Marren, Chairman of the Ontario County Board of Supervisors. 

 

"This is an important step forward in our fight to reduce unfunded mandates and protect local taxpayers. This measure will reduce local property taxes and help ensure that our seniors can afford to stay in their homes," said Bob Green, Vice Chairman of the Ontario County Board of Supervisors.

 

“We as a board supported a resolution in support of this measure because protecting property taxpayers is one of our prime concerns. This legislation will reduce an unfunded state mandate and help us deliver real tax relief to local homeowners,” said Eric Gott, Chairman, Livingston County Board of Supervisors.  

 

“We appreciate Rep. Collins efforts to relieve the counties of this extraordinary unfunded mandate. This will be a tremendous relief to local county property taxpayers and will allow us to invest in our infrastructure and other county services,” said Raymond Cianfrini, Chairman, Genesee County Legislature.  

 

“For years counties in New York have decried the use of property taxes to fund New York State’s expansive Medicaid program. We are optimistic that changes at the federal level can result in real, substantive, positive changes to the bottom line for county property taxpayers,” said David B. Callard, Chairman, Orleans County Legislature.

 

The Senate is expected to vote next week on their version of the Obamacare repeal bill.

It's just two partisans fighting, County Manager Jay Gsell said of a proposal to shift money around so that counties in the State of New York could get relief from the unfunded mandate known as Medicaid.

Gov. Andrew Cuomo is backing legislation called the Empire State Equity Act, which would shift back to New York, some $30 billion in taxpayer money from the federal government to the state.

With that money, the state then could assume the cost of the $2.3 billion shelled out by counties now to support Medicaid, but only for counties that agreed to cut local property taxes by the amount of their current share.

That could be $277 average savings per property in Genesee County, according to a chart released by the governor's office.

Where the governor sees tax savings for county residents, Gsell sees smoke and mirrors and political rhetoric aimed at Rep. Chris Collins.

"It's a political war of words between two people, Collins and Cuomo, who seem to really dislike each other and engage in negative partisanship to the max," Gsell said.

The way Gsell sees it, the proposal is asking the feds to "artificially" adjust a funding formula for New York, which is similar to something Schumer did temporarily a few years ago, and give it the "innocent sounding phrase, 'Empire Equity,' and then only provide a cost shift."

Gsell noted the benefit level -- a cause of the state's high Medicaid expense as he sees it -- wouldn't be cut under the governer's proposal, which leaves him distrustful of the long-term effects.

He thinks many counties might pass 100 percent of the cost savings onto taxpayers in the form of lower property taxes, but he fears that is just a trap.

"Our concern, borne out of 50 years of NYS unilateral imposition of cost shifts and mandates," Gsell said, "is that just like with re-K/EI (early intervention) funding and the elimination of the counties from the AIM dollars (a state revenue share with municipalities), as the state was going to take over 75 percent of the total program cost, but they stopped at 59 percent and left the counties out to dry.

"The same can happen with the Empire Equity Act in that the state holds all the cards, all the control, and always blames we locals for the abysmal state of property taxes, and they -- and he, Gov. Cuomo -- refuse to take any responsibility for the unfunded mandates and cost shifts, creating in essence a NYS property tax 'levy' within our county budgets."

Cuomo has called New York a "donor state," in that it pays out $30 billion more in taxes to the federal government than it receives in benefits. He touted this bill as a way to "level the playing field."

The governor backed the proposal as a response to an amendment from Collins to the American Health Care Act, which was eventually pulled from a vote by Speaker Paul Ryan, that would have prohibited the State of New York from taking money from counties to help fund Medicaid. Cuomo called the Collins proposal "a fraud."

"Senator Daniel Patrick Moynihan, God rest his soul, used to talk about the unfairness that New York gave so much and got back so little," Cuomo said during a press conference on the proposal. "Second, the promises made, from Congressman Ryan to President Trump to Mr. Faso to Mr. Collins was tax relief for the working men and women of this country. Right? That’s what they all ran on. That’s what they all promised. That’s what they all said.

"Well, this actually does just that. This says, 'let’s give New York additional Medicaid money because they are a donor state, let’s reduce the inequity' and New York will then give the money to the taxpayers in property tax relief."

An aide to Collins provided this statement:

“Although late to the party, I am glad Governor Cuomo has finally seen how unsustainable it is to force hardworking property taxpayers to subsidize New York’s out of control Medicaid program,” said Congressman Chris Collins. “Unfortunately, instead of reviewing his own bloated budget for the 1.5 percent needed, the out-of-touch Governor demands more federal government for the nation's most bloated Medicaid program.

"The Governor needs to quit living a federally funded fairy tale and find savings in New York's Medicaid program which costs 44-percent more per recipient than the national average, and spends more than those of Texas and Florida combined.”

A proposal to block New York from using county taxpayer money to pay for Medicaid sounds good on paper, but as always, the devil is in the details, says County Manager Jay Gsell.

Gsell's biggest fear is that even if the proposal is passed by Congress, Gov. Andrew Cuomo's office would just find a way to shift other expenses to the counties.

"My sense of the reaction from the governor and the lieutenant governor over the last week is that it is very likely how they would respond," Gsell said. "They’re still putting a state budget together. Things could change on a dime."

The proposal comes from Rep. Chris Collins, who is having it added as an amendment to the House GOP's health care bill aimed at replacing the Affordable Healthcare Act.

From a Collins press release put out earlier today:

The Medicaid Local Share Limitation, which was proposed by Congressmen Chris Collins and John Faso, would bar federal reimbursements for New York State Medicaid funds raised from local governments. The proposal would only apply to the $2.3 billion being raised from counties outside of New York City. New York State currently raises $7 billion from its local governments to fund its $27 billion Medicaid liability, which is the largest amount in the nation.

“This is a huge win for our constituents,” Congressman Collins said. “I want to thank President Trump, House leadership, Congressman Faso, and the rest of my fellow New Yorkers for getting this key provision included. Year after year, Albany’s leadership relies on counties to foot the bill for New York State’s out-of-control Medicaid costs. Enough is enough.

"This amendment will stop Albany from forcing its unfunded mandate down the throats of taxpayers, and help counties lower the property tax burden on hardworking families. We understand the devastating impact New York’s reckless spending is having on everyday New Yorkers, and I’m proud to join with members of our delegation to bring vital tax relief to our constituents.”

In a tweet today, Collins said his amendment to the bill, called "Ryancare" by some, and "Trumpcare" by others, would save Genesee County taxpayers $9.4 million that the county currently pays as a local share of Medicaid expense.

Gsell said it's more than $9.6 million of an overall $68 million expense, with the Federal government and state government picking up the balance of the cost. 

The proposal from Collins has brought forth blistering attacks from Gov. Andrew Cuomo and Lt. Gov. Kathy Hochul.

Last week, Hochul said in a statement:

"What’s worse, a New York Republican Congressman, Chris Collins, is offering an amendment that would wreak havoc on the state. While I understand that the Democrats in Washington are attacking Collins on ethics issues and are having a heated political fight, they shouldn’t be played out at the expense of everyday New Yorkers.

“Here are the facts: The overall Medicaid plan would cost the state billions of dollars of lost federal funds and jeopardize hospital stability."

She said the Collins proposal would amount to a $4.7 billion tax increase on the people of New York.

According to a report in the Democrat and Chronicle, Cuomo ripped the bill as a "death trap" that would devastate hospitals, nursing homes and assisted living facilities in Upstate New York.

"My greatest fear from last year’s election has actually come true, which is you have a rabid, conservative ideology in Washington that would tell New York to drop dead, and that is exactly what is going on," Cuomo said.

At $60 billion per year, New York is topped only by California (at $85 billion) in total Medicaid spending. In New York, counties cover $7 billion of the state's share of the Medicaid expense, by far the highest share of any state in the union.

This for a program that is defined by the Feds as a "Federal and state" (not county) medical coverage benefit for people with limited income.

In her statement last week, Hochul offered up a history of how counties came to help pay for Medicaid, saying the counties agreed to take on this expense, but Gsell said that's not his understanding of the history.

Gsell said the counties got roped in against their will in the 1960s when Congress created a long-term care program and ordered states to help pay for it and New York turned around and told counties they would share in the expense. Then when Medicaid was created a few years later, New York told the counties they would pick up 25 percent of the tab, though at the time, the program was a lot less expensive than it is today.

"I saw some comments by Ms. Hochul last week that said, ‘oh, the counties have nothing to be grousing about -- they've been funding Medicaid forever,' " Gsell said. "She alluded to this one- or two-year-old piece of Federal legislation from the early '60s and says, ‘yeah, the counties volunteered to do it.’ No, even then, the state told the counties, 'you will fund this program.' "

New York's Medicaid bill is so high, Gsell said, because the state covers the full smorgasbord of coverage. Whereas the Federal government has only about 15 services that are mandated, New York offers the full slate of available options, more than 30 altogether.

At no time, Gsell said, have states been given any opportunity to have a say in who is covered, how they are covered or what is offered. Everything is mandated by the Federal government or the state.

When Gsell became county manager 23 years ago, the county share of coverage was about $4 million, but the expense started increasing at 5 to 10 percent per year until the county share was capped a few years ago.

The Collins amendment is designed, in part, to help secure support from New York's congressional delegation. That overt political maneuver prompted another statement from Hochul today:

"Mr. Collins has perpetuated a political scam on New York. As Mr. Trump’s bag man he has had to buy votes to pass the Affordable Care Act and did it by promising counties relief from their share of Medicaid. He now wants New York State to pay his $2.3 billion political IOU.

"The state cannot and should not. If Mr. Collins wants to buy votes let the federal government pick up the share rather that the people of New York. Local county taxes or state taxes New Yorkers still pay. One way or another, it is still coming out of New York taxpayers’ pockets. Let Mr. Collins help New York State and his district by having the federal government pay – that is why he is in Washington.

"He could easily help pay by reducing the $150 billion tax cut to the richest 1 percent of Americans or buying one less tank from Trump’s record defense budget. Why make the people of his district pay for his politics. We do know Mr. Collins is adept at corrupt financial schemes but this is the ultimate insider trading scam."

Ryancare/Trumpcare is by no means assured of passing. It will obviously receive Democratic opposition, but a number of House conservatives also oppose it. It will also face a tough fight in the Senate.

Still, if it does pass, Gsell is far from certain it will lift the burden from Genesee County for unfunded mandates. He believes, based on the stern opposition to the cost shift from Cuomo and Hochul, that Albany will just pull the purse strings tighter on other programs with county-state cost shares, such as indigent defense, Safety-Net, Pre-K early intervention and probation assistance. The state share of a total of nine state-mandated programs exceeds the potential $9.6 million in cost savings offered by Collins amendment.

"The money that the state has to start absorbing could turn on our budgets in these other areas with less state aid," Gsell said. "The state is not going to go quietly into the night."

Michael McAdams, a spokesman for Collins, rejected this contention outright.

"That's an unfounded hypothetical," McAdams said. "There's no basis for thinking that would actually occur."

The ironic piece of this fight between Collins and Hochul (who lost the congressional seat to Collins after one term) is Hochul has long been a strong proponent of local communities, making a point to shop local every holiday, for example, even stopping in Batavia stores.

Through the governor's press office and on Twitter, we reached out to Hochul to ask her to address the seeming contradiction of supporting local communities while backing an unfunded mandate, but we haven't received a response.

Gsell thinks Hochul's position may not be entirely her own.

"It struck me as she was being instructed," Gsell said. "This didn’t sound like a Kathy Hochul thing. It mirrored very much what the governor’s thing is, which is, ‘counties, shut up. You’ve got your Medicaid cap. We’ve given you pension reform with Tier 6. You’ve gotten enough. Go away. We’re not going to cost shift from counties to the state.' ’’

Press release from Lt. Gov. Kathy Hochul, a Democrat:

“Our Founding Fathers warned us this day would come. Partisan politics would overtake good government for the people. The Medicaid changes being proposed in Washington would cut taxes for wealthy special interests while devastating New York State’s finances and all but eliminating health care for the most vulnerable New Yorkers.

“What’s worse, a New York Republican Congressman, Chris Collins, is offering an amendment that would wreak havoc on the state. While I understand that the Democrats in Washington are attacking Collins on ethics issues and are having a heated political fight, they shouldn’t be played out at the expense of everyday New Yorkers.

“Here are the facts: The overall Medicaid plan would cost the state billions of dollars of lost federal funds and jeopardize hospital stability. As if that were not enough, Rep. Collins would have the state assume the counties’ share of Medicaid expenses outside of New York City. The current breakdown is 13 percent county, 36 percent state, and 51 percent federal. This ill-conceived plan would cost his home state approximately $2.3 billion. Unbelievably, that’s on top of the cost of the Republican Affordable Care Act repeal plan – another $2.4 billion.

“Translation: Rep. Collins is proposing a tax increase on New Yorkers to the tune of $4.7 billion. This one-two punch would destroy all the hard work the Governor and Legislature have accomplished in the last six years to lower taxes across the board and achieve the lowest spending increases in recorded history. New Yorkers will be at risk of losing their healthcare, hospitals will be forced to lay off workers, and our vulnerable elderly will find it much harder to afford nursing home care.

“On the merits, the counties have no right to claim this is an undue burden. They paid a percentage of health care costs even before Medicaid – and in fact, currently have a more favorable agreement than in decades.

“In 1960 – well before New York State and most counties had any sales tax revenue to pay for it – Congress passed the Kerr-Mills Act, which created a national role in funding health care for the elderly. Under this program, the counties in New York paid approximately 44 percent of the cost of care, the state paid about 38 percent, and the federal government paid around 18 percent. 

“In 1965, Medicaid replaced that program and the counties paid 25 percent. That same year, the state began giving counties the option of collecting sales tax on their behalf. Every county in New York has subsequently agreed to this option. Many counties in the nation don’t get sales tax, and most of those receive less than our counties. Moreover, the state recently agreed to give the counties additional help – after hearing the counties’ complaints of the growing Medicaid costs, the state has held them harmless for any increases since 2011. 

“As a result, the counties’ share for Medicaid is down from 25 percent to 13 percent, and the state assumed this cost while still living within the 2 percent spending cap, and all while cutting taxes. The state is not asking the counties to do anything more than we have done ourselves. In fact, the state has done far more. If the Collins amendment passed, the state would need to raise income taxes or the counties would have to forego their share of sales tax in exchange for the state picking up the additional Medicaid costs.

“In short, Rep. Collins’ amendment and the Affordable Care Act repeal would transfer $4.7 billion in costs to the state which would translate into a new tax for New Yorkers. I know firsthand that the people of the 27th Congressional District face enough challenges in their lives – they don’t need to worry about increasing health care costs or new taxes. 

“Rep. Collins should stop prioritizing his wealthy friends and start helping his home state by protecting the most vulnerable from losing their healthcare and not putting the state budget at risk. Remember, as my mentor Sen. Daniel Patrick Moynihan used to always point out, New York is a donor state – we pay more in federal taxes than we receive back.

“Mr. Collins, try practicing good government rather than partisan politics.” 

Through a spokesman, Collins responded in a story in the Buffalo News.

The state is planning to take over all of the administrative functions for Medicaid, but the state isn't ready and shows no signs of being ready any time soon.

That's what Eileen Kirkpatrick, commissioner of Social Services in Genesee County, told the Human Services Committee during its meeting Monday.

New York has set a deadline of April 2018 for Medicaid administration to be switched from county DSS offices to state employees, either working in Albany or at local offices.

The state, she said, "failed miserably" in its first pilot project to take over administration for 12 counties, with hundreds of cases being mishandled.

It would be easy to think, Kirkpatrick said, that for the sake of local Medicaid clients, the county should hold onto local administration as long as possible, but the state has capped reimbursement for administrative costs.

If the county continues to administer the program, local wages and benefits and other expenses will continue to go up, but the state won't reimburse at a higher rate.

That's why, Kirkpatrick said, the county should go ahead and request the state take over the program, even if they aren't entirely ready for it on schedule.

In New York, Medicaid is a $53 billion program. About 3 percent of the expense goes to administration.

Currently, the county fills 22 full-time equivalent positions to administer Medicaid.  Some of the employees currently in those jobs would be able to transfer to the state payroll and continue doing much the same job as they do now.

Press release from the Genesee County Legislature:

Importance of Medicaid Petition Drive. Why should Geneseeans Care?

$9.2 million six years ago was the amount Genesee County was spending for Medicaid. 50% of the total program cost is the responsibility of the taxpayer in New York State which is the same in most of the other 49 States. New York State has the 57 New York counties paying a share of this Medicaid Bill each week which in 2012 equals about 18.5% of that 50% state share.

Six years later, $9.8 million is the dollar amount representing 18.5 cents of every dollar spent for Medicaid that Genesee County taxpayers must fund in the 2012 budget year.

Approximately 7,200 individuals are enrolled in Medicaid in Genesee County. In 2014, the Federal Health Statute (Affordable Care Act) is mandating states to select a health care program for those particular state residents in need of health coverage and eligible to enroll. In New York state the choice has been made, Medicaid will be the primary payor. 

Current estimates that there are 5,000 additional county residents eligible for this proposed/expanded Medicaid program. This means an additional 69% increase in Medicaid funding, or in 2012 dollars would mean $6.30 per thousand just to pay the county’s 18.5% of this unfunded mandate.

This is a call to be answered by Genesee County and all New York State residents that have concern to be proactive with their county’s Medicaid petition drive.

Blank petitions are available at your town and village offices and once you have obtained signatures return to your town or village hall or local library. Petitions may also be sent to county residents electronically by contacting the Clerk of the Genesee County Legislature, Carolyn Pratt, 344-2550, ext. 2202, cpratt@co.genesee.ny.us

The future of Genesee Justice wasn't the only matter discussed at the county budget hearing a week ago. County Manager Jay Gsell made a presentation about the county's entire budget picture.

Among the most interesting slides were those dealing with Medicaid. As the pie chart above shows, Medicaid accounts for 41 percent of the county's property tax levy, even though only 10 percent of the county's residents are eligible for benefits.

Federally mandated medicaid services:

• Inpatient Hospital Services
• Outpatient Hospital Services
• Physician Services
• Medical and Surgical Dental Services
• Nursing facility services for individuals aged 21 or older
• Home Health Care (Nursing, Home Health Aide, Medical Supplies and Equipment)
• Family Planning Services and Supplies
• Rural Health Clinic Services
• Laboratory and X-Ray Services
• Nurse Practitioner Services
• Federally Qualified Health Center Services
• Midwife Services
• Early and Periodic Screening, Diagnosis and Treatment Services for individuals under 21 (Child/Teen Health Plan in NYS)
• Medicare Coinsurance and Deductibles for qualified Medicare beneficiaries for Chiropractors, Podiatrists, Portable X-Ray and Clinical Social Work Services

Additional mandated services covered by NYS Medicaid:

• Free-standing Clinic Services
• Nursing Facility Services for under age 21
• Intermediate Care Facility Services for the Developmentally Disabled 
• Optometrist Services and Eyeglasses
• Physical, Speech and Occupational Therapy
• Prosthetic Devices and Orthotic Appliances
• Dental Services, Audiology and Hearing Aids
• Clinical Psychologist Services
• Private Duty Nursing
• Diagnosis, Screening, Preventive and Rehabilitative Services
• Personal Care Services
• Transportation to Covered Services
• Hospice
• Case Management
• Inpatient Psychiatric Facility Services for Individuals under age 21 and over 65

This entry concludes Sunday's article on the comments of Victor DeSa, M.D., who spoke to senior citizens at Batavia's First United Methodist Church last week.

Please remember, this is a summary of DeSa's presentation and does not necessarily reflect the views of The Batavian:

Medicare, Medicaid and senior services

By requiring insurance companies to expand coverage, the new health care law will drive costs up, according to DeSa. The government has told consumers that these costs will be offset by subsidies for people making less than $80,000 per year.

These subsidies will be coming, in part, from a $500 billion cut from Medicare -- and that's where senior citizens and others eligible for Medicare should be concerned.

But this is not the only problem. Both Medicare and Medicaid, which DeSa called "the original two public options," have met with disaster. Medicaid has already failed, and Medicare is on the brink of failure.

"The government has no idea how to handle the rising costs. Their idea of handling the costs is to take a machete to (the programs) and cut."

The result is the "doctor fix," a 21-percent cut in doctors' reimbursements. This could be disastrous in a system where the cost of providing services is already greater than what the doctors receive in compensation.

For that reason, many doctors no longer accept Medicare. The Mayo Clinic in Arizona has already determined that because of the new health care legislation, it will no longer deal with the program.

"So Medicare patients are going to have fewer and fewer choices of who is going to take care of them."

With fewer doctors available, waiting periods will increase. So the direction Medicare is taking presents seniors with a double disadvantage.

The government "carved the 21-percent doctor fix out of the bill" in order to avoid upsetting America's seniors, but that doesn't mean they've addressed the cost. They are simply pushing it to the side and will have to deal with it later.

"Six months down the road, they have to still come up with a fix for this 21-percent cut that they are going to make on Medicare payments to the doctors."

So that's the story with Medicare and Medicaid. As far as insurance for retired citizens goes, people who worked in the public sector should be okay (although DeSa said it's not impossible that this could change, because "anything is possible" with what the government is doing), but people in the private sector should be concerned.

What to do?

When asked how we can change the course we've taken, DeSa answered: "We've got to kick out the guys who did this."

He appealed to the power of senior citizens -- which he became two years ago -- who are "feared in Washington because we vote."

Many seniors were suspicious when the government said that $500 billion had to be cut from Medicare to cover health care.

"If they really addressed costs the way we asked them to do, a person making $40,000 a year be able should be able to afford health care coverage without subsidies, don't you think?"

Failure to address the problem of cost in the current system was one of DeSa's main critiques of the health care bill. He said that in looking for alternative plans, we need to look for one that does address them.

Counting the costs 

There are three main factors driving health care costs:

1) Overuse

Back in the old days, when there was usually only one doctor in town and he had to go to patients' homes to treat them, people only went to the doctor when there was something really wrong.

Now, with easy access to medical examination and treatment, people will go to the doctor -- and even to the emergency room -- whenever they have a minor health concern.

"We have to change that if we want to truly address the cost of health care."

But it's not just patients -- doctors sometimes overuse the system, too.

"I hate to admit it, but there's greed in every profession. There are bad apples in every bunch, and you've got to admit it."

2) The fact that people have insurance in the first place

Strange as this may sound, this can be a problem.

"Insurance is like a credit card, but you don't have to pay every month. So there's no incentive for you to be prudent with the costs. You don't even want to know what the cost is, you just want the health care."

DeSa believes that while insurance cannot be eliminated altogether, people should reduce their dependence on it. For health purposes, they should only turn to insurance in times of emergency.

Generally speaking, the way people take care of this part of the cost is by having "skin in the game."

"If you shop around for a car or a house, why shouldn't you be able to shop around for a doctor? Especially in this day and age, with the Internet and everything."

3) Liability

"Everything from a Band-Aid to a heart valve has a mark-up depending on the risk."

In other words, the more dangerous the a product or its failure can be -- and, therefore, the greater the likelihood of a lawsuit -- the more expensive the product.

Because the liability cost is factored into the price of the product itself, "the little guy gets it in the neck every time."

DeSa fully supports the patient's right to sue when a doctor has done something wrong or is incompetent, but he also believes that the whole liability issue should be looked at when considering the cost.

Government out, skin in (the game)

Costs are going down for procedures that are not covered by insurance (Lasik surgery is one example). The reason?

Competition.

"Costs come down if there are market forces in place."

DeSa saw this in his native India, which had a socialized health care system until the early 1990s.

When he was studying at Jabalpur University in the mid '60s, the Indian government had total control of health care and sent all competing forces out of the country.

The effect of this was what DeSa called a "brain drain."

"The best and the brightest (doctors) were all leaving the country."

He sees the same thing happening here in Western New York, where there is a serious shortage of doctors.

"Over 80 percent (of young doctors surveyed at Western New York teaching institutes) say they'll train here, but they're not going to stay in New York to work. We are known as one of the most heavily taxed and over-regulated states in the country."

Our response to this situation should mirror the response taken in India back in 1990. At that time, India began to default on its World Bank loans. Finance Minister Monmohan Singh -- who is now India's Head of State -- saw that the system was not working and started the country on a different path.

"He got rid of the government, encouraged entrepreneurship and lowered taxes."

Above all, the patient must take responsibility and be in control of his/her own health care. It can't fall to the federal government to make important decisions regarding people's health care, no matter how well-intentioned they might be.

Déjá vu

In addition to drawing from the experience of his native country, DeSa also discussed two other examples of what he sees as a health care system set up for failure.

The U.S. government's new health care model is based on the Massachusetts health care model, which DeSa called "an abject failure." He cited problems related to his comments about young, healthy citizens abusing health insurance.

"Just Google 'Massachusetts Health Law -- success or failure?'"

Socialized health care has proven disastrously ineffective in Britain as well.

"Just this month, Britain recognized that its system is a failure and said they are going to change the whole thing."

Part of that change will be a shift in power from bureaucrats -- of which there are 1.5 million overseeing the United Kingdom's National Health System -- to the doctors. As good as this sounds, DeSa fears it may be too late for it to work.

"The doctors (in the UK) have no business experience. Up to this point, the government has been taking care of everything."

His concern is that U.S. doctors will share a similar fate. As his presentation drew to a close, he told everyone that under the government's new plan, there will be over 120 new bureaucracies controlling health care.

DeSa admitted right at the start of his presentation that he had a bias as a health professional. He encouraged everyone to do their own research and decide for themselves whether or not the new health care reforms are to be welcomed or feared.

Dr. Victor DeSa talked with seniors Friday about the federal government's new health care legislation. This followed his hour-long presentation, sponsored by the "Older Adult Ministries" program of Batavia's First United Methodist Church.

DeSa is a retired surgeon who had a private practice in Batavia for many years and currently serves on the United Memorial Medical Center Board of Directors. He is well renowned and respected in the community and very knowledgeable about how the health care field works -- including the role of legislation and the relationship between health care and the government.

There is a lot of misinformation about the new health care law and how it could affect  people -- especially Medicare and Medicaid recipients.

The doctor expressed disappointment in the mainstream media's handling of the topic.

"The people in the media are not doing their job," DeSa said. "The media used to look out for the common man, but now they have a bias and a preference. (Consequently), the news we get is filtered and we don't have all the information we need in order to make informed decisions."

For those who could not be there, here's the gist of DeSa's presentation (it will be divided into two parts for the reader's convenience) -- it reflects the arguments he made based on careful and meticulous research, and does not necessarily reflect the opinion of The Batavian.

Health care: rights and responsibilities

The question of whether health care is a right or a privilege came up early in the presentation. This language, said DeSa, is problematic. The real question is this:

"Is health care a right, or is it a personal responsibility?"

He pointed out that health care is considered a right in socialist countries, where people "have abrogated their rights to the government" so that the government "will take care of (them) from the cradle to the grave -- and that includes health care."

"The United States is not yet a socialist country," he said (and yes, he did emphasize yet), "so here, health care is a personal responsibility."

What he meant by this, is that each person has a certain amount of control over his/her own health (diet, exercise, etc). For instance, if someone chooses to live on bacon, cheeseburgers and cigarettes all the time, then he/she is indirectly "choosing" to have weight problems, heart problems, high blood pressure, etc.

"If I'm responsible for my own health, should everybody pay for it or should I?"

Misconceptions about U.S. health care

DeSa assured his listeners that we here in the U.S. do, in fact, have the best health care in the world. To prove it, he spent some time debunking two popular myths that lead people to believe the contrary: that our infant mortality rate is higher than in countries with socialized health care, and that lifespan is shorter in the United States than in said countries.

On infant mortality, he said: "We (in the U.S.) over-report infant deaths, while other countries under-report them. Here, we're so meticulous about reporting, that if a baby takes a couple breaths and has a couple heartbeats after birth, it's reported as infant mortality. But in developing countries, a baby dies an hour or two after being born and it's reported as a stillbirth."

He also pointed out that a large percentage of infant deaths take place in the inner-cities, where there are a lot of crack cocaine and AIDS babies.

"These babies die in spite of very good health care. Their deaths are due to social problems, not medical problems."

As far as lifespan goes, he said that longevity is about the same in this country as in those that have socialized health care; what doesn't get factored in with lifespan studies is the fact that the U.S. is the "murder and accident capital of the world."

"If you took the murders and deaths from accidents in Chicago, Detroit or New Orleans in one month, they are more than the deaths of our soldiers in Iraq or Afghanistan in one month."

In short, the evaluation of U.S. life and health often ignores social problems and unfairly puts all the blame on health care.

Universal care vs. universal insurance

...Wait a minute, aren't they the same thing? Not according to DeSa.

"We do have universal care in the U.S. The EMTALA Law ensures that no one who comes into the emergency room will be refused care -- even illegal immigrants. That's the right thing to do, the humane thing to do and the moral thing to do, and I support it."

He says there is a "subtle but important difference" between this and universal insurance, which we don't have. There are currently 47 million Americans uninsured.

The Congressional Budget Office predicts that as a result of the new health care legislation, 32 million people who were previously uninsured will be insured at the end of 10 years. However, there will still be 21 million people uninsured -- and this is in spite of the fact that the new law will require people to buy insurance!

Who are these 21 million uninsured, you ask? Young, healthy people making between $35,000 to $82,000 a year.

"When you're young, and you're starting a family, and you have mortgage payments, you have a whole host of other host of things you have to worry about. You're going to say, 'Well, I'm young, and I'm invincible...maybe I won't fall ill. I'll take the chance and hold off on buying health insurance.'"

This is going to have a couple of important consequences. First of all, DeSa said, "the IRS is going to need about 16,000 new agents to track them down."

Even if they do track them down, not much is likely to change.

"If I'm a young person," DeSa said, "and a federal agent tells me I have a choice between a fine -- which starts at $95 and over the course of seven years will go up to about $700 -- and purchasing health insurance for $12,000-$13,000, it's a no-brainer."

Secondly, these people will cycle in and out of insurance programs. Faced with a serious condition like cancer, a young person will go to an insurance company for coverage -- and they cannot be refused under the new law. But when they get better, they will forego the insurance.

"People will abuse the system. That's just human nature."

While uninsured, these individuals will be able to make partial payments for hospital visits about 27 percent of the time; the rest will be covered by the state's "uncompensated care pool," into which each hospital in the state pays.

But even this won't cover the whole cost. To whom does the remainder of the cost shift? The taxpayers.

"This varies from state to state depending on the percentage of uninsured they have, but the average each person pays is $300."

The second and final part of the article will be up soon.