The New York Division of Budget recently released its mid-year financial plan update, which shows that the state is facing its largest budget gap since the recession in 2010. This time, however, the economy is not to blame. It is largely Medicaid that is causing the gap.

The report shows the $78 billion Medicaid program — the state’s publicly funded health-care system — will cause a nearly $4 billion deficit in the current year. This is happening in a strong economy where Wall Street is healthy and when personal income and business tax collections are up. In fact, total tax receipts were $406 million above the enacted budget estimates, so why is there a budget gap?

The simple answer is that Medicaid costs, which consume about a third of the state’s budget, have not been controlled or estimated appropriately. The Cuomo administration knows that if not kept in check, Medicaid costs can quickly spin out of control. To help keep costs under control, Gov, Cuomo and the state legislature imposed a global cap on the state’s share of Medicaid spending in the 2011-12 fiscal year. This slowed the rate of costs until the administration grew lax and implemented spending exemptions to the cap. One of the exemptions was made for higher labor costs. In 2016, the state failed to adequately account for how the new minimum-wage mandate would impact the cost of Medicaid, so it made exemptions to the cap to help pay for the increased labor costs associated with health care. 

Budget gimmickry is also to blame for the budget gap. In 2018-19 the Cuomo administration postponed a $1.7 billion payment to providers at the end of March to early April — effectively putting off the expense from one fiscal year to the next. This allowed the state to keep Medicaid spending under the global cap for fiscal year 2018-19, but it punted the expense into the future. (More on Medicaid can be found in this recent column https://nyassembly.gov/mem/William-A-Barclay/story/89519.)

The mid-year plan reports that the Division of Budget, the governor, and the Department of Health are developing a savings plan that would maintain the Medicaid global cap and result in savings of $1.8 billion for the current fiscal year. Details are expected to be released in the executive budget in January. Adjustments to when health-care payments are made, reductions in rates paid to providers and other administrative reductions are expected to be put forth as solutions. But at this time, there are a lot of unknowns.

Clearly, action must be taken to reign in the growth of Medicaid spending and mismanagement. In the last 10 years alone, the program has gone from $52 billion to $78 billion and serves 6 million people — roughly one-third of the state’s population — with the highest per-capita spending in the nation. This trend is unsustainable and if not addressed, Medicaid spending will crowd out every other spending priority in Albany.                      

William (Will) A. Barclay is the Republican representative of the 120th New York Assembly District, which encompasses most of Oswego County, including the cities of Oswego and Fulton, as well as the town of Lysander in Onondaga County and town of Ellisburg in Jefferson County. Contact him at barclaw@assembly.state.ny.us or (315) 598-5185.

To me, it was a thunderclap. Years ago, when I was in Congress, we were in the midst of a tense, contentious debate. Members had become irritated, levying charges back and forth, and tempers were rising. It was starting to look like we might just go off the rails. Then one member stood up, asked for our attention, and said to us, “Let’s remember: trust is the coin of the realm.”

 His statement at that moment hit me broadside: If we were to have any hope of progress, we had to have some faith in one another — even our opponents. Apparently, other members of Congress came to that same realization. The debate got back on track, with less acrimony and mean-spiritedness.

 It was a lesson I have never forgotten. Our system rests on all sorts of values: open-mindedness, an informed citizenry, honesty, civility, and competence. But at its heart, representative democracy is about how we resolve our differences in order to move the country forward. And, if the parties lack trust, then it becomes hugely more difficult to do so. In many ways, trust is at the center of this democratic experiment.

 A representative democracy rests on a straightforward premise: Because nothing gets done without others — whether in our communities or our legislatures or in Congress, —you have to have confidence in people and believe that they will do what they say they will do. Without that trust, you simply can’t engage productively in negotiations, compromise, debate, and all the mechanisms we use to resolve differences in our society. 

 As the country has grown larger, more complex, and more diverse in all sorts of ways — and as the changing media world has given us all our own echo chambers and undermined the shared sources of information on which we once relied — resolving conflict has become much more difficult. When we don’t trust one another — or don’t trust one another’s facts — reaching agreement and drafting laws becomes infinitely more difficult. Governing becomes fraught with complexity, as efforts to implement and enforce laws, regulations, and standards come under constant fire. The result is that often, cynicism, suspicion, and lack of confidence in the system hamstring our democracy.

 To be sure, it’s pretty much impossible to deal with people you don’t know well without wondering about their integrity, honesty, and motivations. It’s what you have to work through when you’re trying to resolve differences. Healthy skepticism about adversaries is natural and appropriate, but you can’t let it override everything and bring progress to a screeching halt.

 Both nationally and internationally, we manage this by striving to tie things down: by law, by regulation, by treaty, and above all by verification. Nonetheless, some measure of trust is required. And when it’s missing…. Well, I would argue that one reason our government no longer works as well as it once did and should now, is that our trust in one another has diminished.

 So what can we do about this? In the end, I believe that building — or rebuilding — trust is both a human and a systems issue. On the large scale, government has to be effective at meeting the needs of citizens, delivering the goods, services, and protections that people expect. But I also think it’s vital that elected officials — especially of opposing parties — spend time with one another, learning to see one another as human beings who all, regardless of party, care deeply about the country. Similarly, the more ordinary people participate regularly in organizations, political parties, and even ad-hoc efforts to improve their communities and states, the more likely they are to learn the fundamental importance of trust. In short, the more interaction you have with others, even with your adversaries, the more common ground you can find, and the more confidence you can have in them — and the more likely you can move forward.

 The fact is: In a system that depends on negotiation, compromise, and cooperation to achieve our goals, finding ways to build trust is essential. Without it, our democracy simply won’t work.        

Lee Hamilton, 88, is a senior advisor for the Indiana University (IU) Center on Representative Government, distinguished scholar at IU Hamilton Lugar School of Global and International Studies, and professor of practice at the IU O’Neill School of Public and Environmental Affairs. Hamilton, a Democrat, was a member of the U.S. House of Representatives for 34 years (1965-1999), representing a district in south central Indiana.