Medicaid is a federal and state program established in 1965 to provide health care for people with limited wealth. It is often confused with Medicare, which is a federal program that provides health coverage to people, regardless of wealth, who are age 65 and over and to people who are under 65 and who have a disability.

 While all states are required to provide Medicaid, states have flexibility on how the program is managed. Among other things and within certain confines, states have the ability to set income-eligibility limits and to determine what types of services are covered under the program. Compared to other states, New York has an expansive Medicaid program with high income-eligibility limits and wide-ranging services. As a result, on a per-capita basis, New York has the most expensive Medicaid program in the nation. On an overall spending basis, the New York Medicaid program is second in the nation only behind California, a state twice the size of New York. This year, Medicaid spending in New York is expected to reach $74 billion. Of the total Empire State Medicaid expense, 57 percent is paid for by the federal government, 33 percent is funded by the state, and 10 percent is paid for by the counties and New York City.

 In the 2011-12 state fiscal year, Gov. Andrew Cuomo and the state legislature, facing a tremendous potential increase in Medicaid cost, imposed a global cap on the state’s share of Medicaid spending through the New York Department of Health. It was envisioned that the cap, based on a rolling average of the medical inflation rate, would slow the rate of state Medicaid costs. Indeed, it did. During the first few years of its implementation, along with various reforms put in place by a Medicaid redesign team, per-receipt spending dropped even while enrollment, due to Obamacare, surged 31 percent.

 Unfortunately, the global cap has weakened over time because, among other things, various spending exemptions to the cap have grown. One example is a result of the state’s minimum-wage hikes that were enacted in 2016. The state has boosted Medicaid payments to reflect providers’ higher labor costs due to the increase in the minimum wage, but excluded this additional expense from the cap. That amount is expected to be $1.1 billion for 2020. Also, the state, rightfully so, in 2012 froze the local share of Medicaid costs. This increased cost to the state is also exempt from the cap and has risen to $1.1 billion per year.

Putting aside the exemptions, the biggest blow to the Medicaid global spending cap came in 2018-19 when the Cuomo administration postponed a month’s worth of Medicaid payments from the end of March to early April effectively putting off the expense from one fiscal year to the next. This, which is nothing more than a budgetary gimmick, allowed the state to keep Medicaid spending under the global cap for fiscal year 2018-19. However, it simply puts the expense into this fiscal year and will make it even more difficult for the state to abide by the spending cap this year.

The increase in Medicaid spending has real consequences to the state budget and to the state’s spending priorities. In an excellent report recently published by the Empire Center, which can be found at https://www.empirecenter.org/publications/busting-the-cap/, it was noted that if, beginning in 2013, the global Medicaid cap had been applied without exception, the program’s 2019 budget would be $9 billion less than it is now. That is $9 billion that could have been returned to taxpayers, spent on education, or solved some of New York’s many infrastructure’s needs.

Medicaid is an important program that has helped millions get health coverage. In our state, about 6.2 million New Yorkers are enrolled in the program. However, we must do more to control our spiraling Medicaid costs. Tightening up the Medicaid global cap and not resorting to budget gimmicks would be a good place to start.        

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.

“I ask how and why this decision was reached,” Sen. Mitt Romney (R–Utah) said in the Senate recently. He was calling for an investigation into President Trump’s decision to pull U.S. armed forces out of Syria. “Was there no chance for diplomacy? Are we so weak and so inept diplomatically that Turkey forced the hand of the United States of America?” 

 Good questions, but here’s a wager: If the Senate does launch an investigation, would you bet that Romney or any other senator would even get close to posing them directly to the President? I didn’t think so.

 We have a presidential accountability problem that has significantly worsened over the years. We’re losing — or maybe we’ve already lost — the ability to call presidents to account on a regular basis for their actions, their conduct, and the way they fulfill the responsibilities of office. Sure, we have the big guns: an election after the first term, in which voters could choose to end a president’s time in office, and impeachment, in which members of Congress can choose to do the same. But these are drastic one-time steps, hard to employ and infrequently available. 

 What I’m talking about is a way for knowledgeable people to step beyond the White House’s control of presidential appearances, ask tough questions, and get real answers so that the American people can judge the president’s actions and reasoning. Instead, these days presidents appear only in highly structured circumstances, avoid specificity and candor, and sidestep detailed discussion of the issues and policies they’re pursuing. 

 It didn’t used to be this way. When Franklin Delano Roosevelt was president, he would call the Washington press corps into the Oval Office and hold extended conversations. Reporters could ask anything they wanted; Roosevelt of course used them for his own purposes, but the press corps had plenty of opportunities to hold his feet to the fire.

 When more formal press conferences took hold, they were frequent and generally free-wheeling affairs. Americans learned a great deal both about the men who inhabited the Oval Office and their thinking. Over time, however, press conferences became infrequent, stage-managed performances. All of us remember Ronald Reagan walking by a group of reporters, holding his hand up to his ear and answering only the questions he wanted while claiming he couldn’t hear the rest. President Obama held only a handful of formal gatherings with the press each year. President Trump holds few solo press conferences. 

 So how do we get the president to outline the thinking behind a policy? Or go into details on what led to a given decision? How do we even ask a president questions these days, or more importantly, ask the follow-ups? Even when presidents do hold press conferences, they rarely answer the follow-up questions that actually pin them down on what they’re doing; instead, they move on to the next questioner. They like to appear they’re being fair. Really, what they’re doing is avoiding more pointed second questions.

 I contrast this with the British “question time,” which takes place for an hour four days a week, in which government ministers — including the prime minister — must face questions from members of Parliament. It would be refreshing to see a president put in a position where he or she had to answer questions about policy and politics in public, with no restraints on what could be asked. When I was in Congress, I actually submitted a bill to this effect; it was pretty much laughed out of the room.

Simply put, that’s what we should be doing. On a regular basis, presidents should have to answer questions about their thinking and their policies, put to them by people who know enough to dig deep.                  

Lee Hamilton 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, representing a district in south central Indiana.