Getting the budget passed on time has earned Andrew Cuomo a round of hosannas for his shrewd political maneuvering. But one of the smartest moves that Cuomo has made since becoming governor may have been hiring Jason Helgerson as his Medicaid director — if, for no other reason, than to hand over responsibility for the details of health care reform. Throughout the budget process, Cuomo got away with promising that the Medicaid Redesign Team, headed by Helgerson, was doing the most important work of anyone in the state — figuring out how to cut almost $3 billion from the Medicaid budget. This promise sounded impressive. It gave Cuomo an excuse to avoid talking about the details of the cuts or the technicalities of Medicaid. It also kept him from needing to sully otherwise stirring speeches with words like “utilization.”
Helgerson, on the other hand, talks about “utilization” a lot. He also tends to use words like “eligibility.” He learned, too, in the past few months that “care management” stings less than “managed care.”
Before Cuomo hired him, Helgerson was working on Medicaid in Wisconsin, his home state, and his first few months in New York have been intense. “I’m a survivor of the New York State budget,” he said last week, at an event hosted by the Center for New York City Affairs. He had not been aware, he said, that meetings might be scheduled at 4 a.m., but in the past months, he had attended more than one at that hour. With the budget over, “my life is going to be a little bit more sane,” he said.
Cutting the Medicaid budget, however, marked only the first step in reining in the largest Medicaid system in the country in total dollars, with the second highest per enrollee spending rates. Helgerson now has to keep tabs on costs, as they roll in over the year, and find places to cut if spending threatens to exceed the limits set in March’s budget.
The Medicaid Redesign Team purported to provide (and will continue to offer) a forum in which health care stakeholders could sit around a table together and decide on the best ways to cut Medicaid. But although the team was quick to pass the package of recommendations put before it back in February, not everyone agrees on how to improve the system.
“I guess the number one worry is that we not go back on coverage and not go back on long-term care,” said Robert Doar, New York City’s commissioner for human resources administration, at the CNYCA event. Doar’s department oversees public health programs in the city, and unlike Helgerson, he has been working in New York politics for awhile: he was the deputy commissioner and then the commission of the Office of Temporary and Disability Assistance at the state level. He has had his current job since 2007.
At the beginning of his remarks, Doar welcomed Helgerson to the state and promised, “New York is not as tough a place as they say. We want you to succeed.” Doar and Helgerson were two of five panelists that evening, and Doar was the audience favorite, the one to elicit happy laughter and murmurs of agreements. And although he was careful to say that the city wanted to work with the state to make Medicaid succeed, Doar quietly tried to insert questions and uncertainties into the picture that Helgerson had laid out of the Medicaid Redesign Team’s report and the advances the budget had made.
Helgerson had said, for instance, that the redesign team recommendations and the budget were moving the state towards more care management. He chose that term over “managed care” to indicate that he meant that the government was trying to ensure more rational, more streamlined, and therefore better health care, not as in “managed care,” trying to take away patients’ power to make their own health care choices.
While Helgerson took pains to distinguish those two ideas, Doar tried to conflate them.
“Managed care or care management — that sounds good,” he said. “I want to make sure it is good.”
“Managed care plans can cost more than personal cost plans,” he said.
Although Doar had welcomed Helgerson, he was also defending his territory. New York City, through state and federal health care reforms, is already losing control over one of the key aspects of Medicaid–enrollment decisions. And the city is also defending in court its decisions to enroll some Medicaid patients in home care programs.
“We are a leader in the much maligned community-based long-term care,” Doar noted, and when asked about the lawsuit, he argued that, while the city’s Medicaid program might not be perfect, the U.S. Attorney’s office was using an unnecessarily strong tool to crack down on it.
But New York City is not the biggest issue that Helgerson faces going forward. One issue that the budget this year did not address was “spousal refusal,” which allows a sick person’s partner to remove his or her income from calculations of the funds available to pay for health care. It’s an option that’s available in very few states and used most readily in New York and Florida. It also allows more middle class couples, who do have substantial resources available, to preserve their funds and tap into a program designed to help the least wealthy.
“I had one woman tell me that spousal refusal was middle class people’s portion of Medicaid,” said Helgerson, who still seemed a bit floored by the audacity of that statement.
The good news for Andrew Cuomo is that, with the budget done, he doesn’t have to talk about fixing health care anymore. That’s Helgerson’s job, and he still has a lot to do.