An AHCA Amendment Puts New York’s Counties Between a Rock And a Hard Place

Hours remain before the U.S. House of Representatives is set to vote on the American Health Care Act—the Republican bill to replace Obamacare—and the fate of the bill is still up in the air.

Not a single Democratic member supports the measure in its current form. And, given the relatively slim margin of the Republican majority in the House, the bill cannot afford to lose the votes of more than 21 GOP members.

In this precarious environment, House Republican leaders have turned to targeted tactics to try to guarantee the votes of on-the-fence lawmakers. One particularly interesting last-minute addition to the bill sweetens the deal for a handful of upstate New York lawmakers, but steps into a minefield of decades-old intergovernmental strife in the process.

The deal in question would shift the costs of the Empire State’s Medicaid program away from its counties and onto the state. The saliency of this issue for counties across the state cannot be overstated.

As it stands, New York state law requires that counties contribute funding to Medicaid. At least 16 other states have similar laws in place. New York, however, is unique in that its county Medicaid contributions are the highest in the country.

Medicaid is the single largest state-imposed expense for New York counties, and they are forced to rely on property taxes to cover the cost. According to the New York State Association of Counties, if you leave out New York City taxes, Medicaid costs paid by the counties equal roughly half of the county property tax levy statewide.

It’s estimated that this cost-shifting AHCA provision has the power to save New York county governments outside of New York City—which is exempt from this provision—up to $2.3 billion a year.

The New York-centric amendment to the AHCA was first proposed by U.S. Rep. Chris Collins—who, prior to winning his seat in the House was the Erie County executive—alongside U.S. Rep. John Faso, who represents part of the Hudson Valley and Catskill Mountains.

Collins described the exchange that resulted in the deal in starkly transactional terms, according to The New York Times:

“I suggested we put this in,” Collins said, “and the question that came back was, ‘If we do it, can we get the New York votes?’” According to Collins, aside from a single New York GOP delegation member, “the rest of us, kind of as a pack, went to leadership and said, ‘Yeah, you get this in here, you’ve got our votes.’”

Naturally, lawmakers in Albany are not thrilled about the idea of picking up the remainder of the state’s Medicaid tab if counties are let off the hook.

New York Gov. Andrew Cuomo, a Democrat, has condemned the amendment in no uncertain terms.

"The more we learn about the repeal and replacement for the Affordable Care Act, the sicker New York gets,” Cuomo said in a statement on Monday.

In that same statement, Cuomo called the plan a “deathtrap” for upstate New York and cautioned that the real damage would be done to the region’s hospitals, nursing homes and assisted-living facilities.

On Tuesday, New York State Medicaid Director Jason Helgerson called the Collins amendment and its “$2.3 billion cut” a “war on New York.” The added insult to injury, according to Helgerson, is that the idea for the amendment came from within the state’s own ranks.

“All of us as New Yorkers—our health care system is now at risk because of that particular action that was taken by those two members of our own congressional delegation,” said Helgerson.   

So where does all this leave the state’s counties? In a very complicated position.

On one hand, these local governments have been advocating for some sort of relief from their Medicaid obligations for almost half a century—since the contribution mandate was put in place in 1966.  

But on the other hand, county leaders across the nation, including those in New York, have expressed the view that the AHCA would have a damaging effect on local budgets and public health systems.

This is a tightrope Stephen Acquario, the executive director of the New York State Association of Counties, knows these local New York governments must walk.

The AHCA on its own is not something Acquario is willing to advocate for.

“Overall the AHCA does disproportionately target New York state. That’s not right, and that’s not fair,” he said emphatically.  

“The general policies within the overall bill are not favorable and would have a drastic consequence in our state,” Acquario added, in a conversation with Route Fifty. And, he says, “to spin off 2 million uninsured in the state of New York who are presently covered is dangerous.”

Additionally, Acquario is quick to admit that he’s not unsympathetic to the concerns the governor has about the Collins Amendment and he says he appreciates Cuomo’s statements about possible ramifications for the state’s health care industry.  

But the irony remains that for these local governments, wrapped up in this unattractive piece of legislation, is a surprising silver lining.

“We find ourselves in a unique situation,” Aquario said. “If you look at the counties of New York, the 57 outside of New York City, and add up their [Medicaid] spending of $2.3 billion, that’s more than the entire 3,000 counties in the nation combined are [contributing]. That’s how severe this situation has become.”

And no matter how Acquario feels about the GOP health bill, he doesn’t believe that Congress is overstepping its powers by examining New York’s financing structure for its Medicaid program.

“I think it’s proper for this to be before the Congress,” he said. “It’s well within their jurisdiction to address this issue.”