New York Braces for Trump’s Big Medicaid Shakeup

Dan Gorenstein (DG): The clock is ticking for state Medicaid officials across the country.

They’re hustling to enact some of the major health reforms passed by Republicans last July.

Donald Trump: In a few moments we’re going to make official the greatest victory yet when I sign the One Big, Beautiful Bill [cheers].

DG: One particularly seismic shift: Roughly 20 million people nationwide will need to prove that they’re working, going to school or volunteering in order to keep their Medicaid coverage.

That starts next January, but the prep work is happening now.

Today, one state Medicaid chief talks about the intense pressure, the difficult choices and the high stakes that his team is facing.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

*****

DG: Amir Bassiri has directed New York’s Medicaid program for nearly four years now.

He’s got the salt and pepper beard to show for it.

It’s a big job. More than 6 million people enrolled, 1,000 staff, 10 divisions…

It’s also a job, says Amir, that a lot of people misunderstand.

Amir Bassiri (AB): Including my parents — when I told them I got the Medicaid director job, they said, oh, that’s great you’re overseeing Medicare. How wonderful.

DG: Medicare, of course, is the insurance program covering seniors.

Medicaid, the insurance program covering low-income kids and adults, became a flash point last summer as Republicans pushed major reforms through Congress. 

News Montage: The new federal spending bill is being called one of the most sweeping changes to Medicaid in years // New paperwork, new requirements, more frequent eligibility checks // The largest cuts to Medicaid funding in history.

DG: The Big Beautiful Bill also known as HR1, is projected to slash Medicaid spending by nearly $1 trillion and boot more than 7 million people off the program. 

Amir’s job is to steer New York’s Medicaid program through these turbulent waters.  

Here’s our conversation.

So look, it’s been almost exactly nine months since President Trump’s Big, Beautiful Bill became law. What have these past nine months been like, Amir, for you?

AB: The past nine months have been a blur, to be perfectly honest. We’ve had a lot of daunting and difficult meetings, policy decisions, trade-offs, no pun intended.

DG:  Amir, anytime someone says tradeoffs in the middle of an interview, they owe Tradeoffs $20. That’s the tax that we impose. 

AB: [Laughs] 

DG: So I’ll give you my address later.

AB: Okay.

DG:  I’m curious. This bill has a ton of moving pieces. It’s putting a lot of pressure, not just on you, but like the entire Medicaid office. How are you keeping the team motivated? Are you a donuts guy, a rah rah speech guy? You bring in some grapes. Like what’s going on?

AB: I am not a donuts guy, but I am a treats guy. We bring cookies and we try and spice up some meetings with desserts and sweets, but more on the rah-rah side right now. Like I have to be honest in that morale, there are good days, there are bad days. 

But fortunately, we have a fantastic team that I have to give a tremendous amount of credit and admiration to for their unwavering ability to remain focused and know their higher calling.

The other thing that’s been very uplifting is that when HR1 passed, while we were all somewhat dejected, you know, it seems like we’re going the wrong direction with some of these changes, we all accepted and discussed how important our jobs are and that they’ve never been as important as they are now. 

DG: You say, you know, when it comes to morale, you’ve got good days and bad days, but you all have a shared mission and I’m curious, Amir, like what’s the one sentence version of how you articulate the mission? What people are showing up to do right now in these tough times?

AB: What I would say or what I have said is, we’re not going to let them tear down what we’ve built over the last 40 years because we’re not. 

Ultimately our mission is to provide widespread coverage and access to low income New Yorkers at the highest quality service — not just the sick people, the healthy people, all people.

And we have done that effectively in the past. And we will do that within the new rule set that was outlined under that Big Beautiful Bill, but we’re not going to let them tear down what we’ve built.

DG: You say you want to cover as many people as possible. 

One of the biggest threats to that, though, is this new law’s work requirement, where some New Yorkers on Medicaid must prove they’re working, volunteering or going to school in order to keep their coverage. But these work requirements — and more frequent eligibility checks — could mean as many 1 million folks end up kicked off the program, according to experts.

Amir, what would that mean?

Bassiri: If a million people were to lose coverage, it could be catastrophic.

When there are higher uninsured rates that means providers are delivering care without getting reimbursed. That means people are choosing to forego care due to not wanting to pay out-of-pocket costs. You just start to see costs ripple through and down at the state level in the provider’s pockets, in the insurer’s pockets and in the patient’s pockets, so that is what is at stake.

DG: Technology seems key here, Amir. Like if you can find an easy way to verify someone is working or going to school, perhaps without them even needing to lift a finger, that could prevent a lot of folks from losing their coverage over a piece of missing paperwork.

At the same time, we’ve already seen some reporting out from folks like KFF Health News that some states that are already cash strapped are spending $10 [or] $20 million on these new systems. How are you trying to navigate this tech decision specifically?

AB:  You’re spot on in that technology is core to making this new requirement possible.  So let me tell the public why we had to buy something. What, like, why we need technology in the first place. And the reason we do is that prior to HR1, we used a lot of technology to verify someone’s eligibility. We have state wage data. We use the IRS data. And all those are great and is very effective for most consumers.

But now we have a work requirement, and that work requirement has to be met within three months of your application. State wage data is always a quarter lagged. IRS data is always a quarter lagged. So we need a new technology, and that’s what we’re buying.

DG: Got it, so that’s why you’re buying technology, Amir. Super helpful — thanks for that. 

As for what you’re buying, understand that your team took a less traditional route. You passed over the dominant but controversial king of the income verification industry: Equifax.

You instead chose a more local tech company that costs a lot less. Can you explain why you made that choice?

AB: Immediately after the passage of this law we took a very rigorous process to assess the technology solutions and the vendors behind them, but the tradeoff we had to make — the hardest thing to decide — was not doing what may have been the easiest thing to do also the most expensive, and that is Equifax.

We did not choose Equifax. We felt that it was the right tradeoff to make from a cost effectiveness standpoint. And then the other tradeoff was customizable. Is your solution, is your technology customizable so that we could integrate this into our standard application so it would be seamless for the member? Because one of the very large focuses of ours is to reduce the burden on members and for those reasons, we landed where we did.

DG: That was a $60 answer. You know, you used tradeoffs three times, right? 

AB: [Laughs]

DG: I am keeping track. So like, the tab is 80 bucks, Amir. I don’t know. I mean, you’re a state employee, maybe you get paid really well because you’re the director, but like, I’m just, I’m just saying 80 bucks.  

AB: [Sigh] Okay.

DG: So we’ve heard some chatter about the federal government building its own tool named Emmy that helps states collect from their Medicaid members the data and documents they need to prove they’re working or volunteering or going to school. It’s open source, so in theory, states can use it for much less than the millions of dollars that they’re spending on other tech and consultants. Why not use that tool?

AB: We are not not using it, let me put it that way. 

It will be a tool in our toolbox, but based on what we have learned about it and our experience demoing it we think that it’s more appropriate for certain workers and primarily like gig economy workers, you know, Uber drivers, DoorDash delivery and the reason for that is that you do need to be pretty tech savvy in order to use it efficiently. It’s very much electronic. You’re uploading documents on your phone, and that’s going to work for some people, but not for all. But we still plan to explore and use the Emmy tool once we get the pricing details.

DG: I can imagine a lot of folks already being skeptical about sharing their financial data, for example, with some new app that they’ve never seen before, right? Like, this is pretty vulnerable stuff. But then you add on the news stories about Medicaid now sharing state data with ICE and the Department of Homeland Security. I mean, do you worry about building some like great tech, but then a whole lot of folks being like, no way, Medicaid?

AB: Totally, Dan, I mean this is what keeps me up at night for sure. Will people maintain the trust they have with the state, especially when it comes to data sharing? 

This is part of the reason why we made the — I’m not gonna use the word because I don’t have unlimited money — but if we were going to buy something, we wanted it to be embedded completely in our solution so that when we are asking a member, do you want to share this information with us we can clearly explain to them why, and we can ensure that they know they are sharing it with New York state and that New York state is going to protect that information

But this is the hardest part of this entire initiative. You’re asking for people to have trust and faith that what you’re asking them for is only going to be used to help them. And that is difficult with this federal overlay as you started with ICE and it’s been a big challenge of ours but fortunately our marketing and communications team has been thinking about that every single day.

DG: When we come back, more on those messaging challenges; Amir sees a silver lining in this law; and we get a glimpse at how the other 49 states are faring.

BREAK

DG: Welcome back. We’re talking with New York state’s Medicaid director Amir Bassiri.

Amir, before the break, you said that messaging these new Medicaid reforms to your members could be the hardest part of this whole deal.

And we’re not only talking about messaging around these work requirements. There are other changes in the law too, like needing to renew your Medicaid twice a year now instead of once.

I’m wondering — how are you preparing for all of these communications? Because, I mean, no matter the tech that you have here like this is a lot of human touch needed.

AB: Yeah, we’re leaning into something we have in New York that most don’t, which is thousands of people on the ground who are helping individuals in different communities in a culturally competent way get connected and stay connected to keep their Medicaid. We’re investing in that network.

And then we’re planning to do a widespread and large communications campaign to reach people via text and through some of our provider partnerships like pharmacies but it, you know, there’s a lot of moving pieces really quickly, and I can’t say it isn’t a challenge to make sure that everything is working in sync and that we had a sufficient time to test things. But this is gonna be something we learn as we go and we evolve as we go and we tailor messaging as we go.

DG:  Listening to you right now, I’m having this flashback to the early days of Obamacare and the messaging campaign sometimes included you know getting athletes, getting entertainers out and talking about this. Is there any thought or consideration going to, like, let’s get some New York Knicks out there talking about this?

AB: I definitely think that is on the list of ideas that we’re trying to explore. I don’t want to get too far in front to tell you that we will,  it’s sort of like, before we do that, let’s make sure the pipes are wired correctly. Let’s make sure the technology works. But I think that’s something we’re exploring right now and hoping to get in place before the notices go out in September.

DG: Maybe some kind of like Broadway musical? Is that on the table? 

AB: Broadway musical has not been one we’ve talked about, but I will add it to the list, Dan.

DG: So we’ve talked a lot about the challenges this law is posing for your Medicaid program. I’m curious. Is there a silver lining here? Is this law pushing your team to reconsider anything at all in a way that you’re finding genuinely helpful?

AB: Absolutely. This is expediting and supercharging us with some tech modernization that had already been underway to literally modernize the entire eligibility and enrollment system for our highest need New Yorkers  — those that are aged blind and disabled on Medicaid. So that’s super exciting. That’s one of my top priorities since I took this job.

DG:  Final question. Amir, you are trying to keep the team, you’re, you’re, you’re trying to keep your team motivated in part through snacks, right? Nothing wrong with cookies. But you also said that you’re really trying to keep people motivated by reminding them of the shared mission — that, this is a time to rally together to make the state’s Medicaid program the best it can be. I’m curious and this is a personal question: How do you keep yourself motivated? 

AB: Yeah, I remind myself that I have my dream job. And that I never, when I joined state service, ever even thought that this was a possibility to be the Medicaid director.

The people we have, the mission we have, why we all care and do these thankless jobs is because we sincerely and genuinely enjoy solving real problems for people and that is very gratifying when you see it come into practice. So, as played out as it may sound, Dan, I wake up and I am grateful every day to have the privilege to have this job, especially right now.

DG: Amir, thanks for taking the time to talk to us on Tradeoffs.

AB: You said it not me. Thank you.

DG: Before we sign off today, we wanted to give you a glimpse into what’s going on with Medicaid programs in the rest of the country.

Since New York is of course, just one place with one perspective. 

So we brought senior reporter Leslie Walker into her closet where she records for a quick debrief on our interview with Amir.

DG:  Okay. Leslie, you sat in on the conversation with Amir from New York. One thing that jumped out at me was this note of almost ‘defiance’ from Amir when he said in response to the Big Beautiful Bill something like ‘we’re not going to let our program get torn down.’ Are you hearing that same kind of thing from other states? 

Leslie Walker (LW): I think the word I would use, Dan, maybe instead of ‘defiance’ is more like ‘defense’, you know a lot of states know that this law could result in a lot of their folks losing coverage and so they are thinking about how do we minimize those losses.

On the other end of the spectrum, you know, there are some states who are excited about some of these changes, for example, the state of Nebraska is going live ahead of schedule actually with work requirements. And then a couple other states, Montana and Arkansas are following in July. So we are seeing kind of a range of approaches from states. 

DG: Something else I noticed in the conversation with Amir was this emphasis on communications and trying to kind of convey trust here and how tough… 

LW: The Broadway musical that you suggested?

DG: Yeah, that’s right. He said it’s keeping him up at night. And that a lot is hanging in the balance if they don’t get this right — namely, lots of people could lose insurance and then there could be major financial fallout from that. When it comes to communications, are we beginning to see states sort of develop a kind of comms playbook or anything, Leslie? 

LW: Yeah, I mean, I think the playbook is pretty much what Amir described, which I would call like spaghetti at the wall. Yeah. I think it’s, states are really kinda like, let’s, we don’t know what’s gonna work. We haven’t done this before. Let’s kind of pull out all the stops.

A theme that I’ve been hearing from some folks is that I think there’s a concern that there’s a lot of emphasis right now on technology, which I think everyone agrees is important and can make a big difference here. But some of the nonprofits I talked to are worried that people are ignoring what one person called the ground game here, right?

Like you’re pouring $10 million into this app or whatever but ultimately, there are still gonna be a lot of humans with questions that other humans need to answer and there is a concern about lack of investment in kind of the more old school stuff that ultimately needs to happen to get folks to keep their coverage.

DG: That brings up my third and final question here. You know, having a ground game would take a lot of resources. That’s something that is in short supply right now as a result of HR1. I still remember reporting on the Great Recession and I in New Hampshire, and so much time and consternation was spent trying to figure out what to cut, how to cut, how to minimize the harm of cuts. We didn’t get too deep into this with Amir, but I’m wondering what you can tell us. Have we begun to see states enter into some sort of belt tightening process? 

LW: I think we’re in the early stages of that really tough work you just described. A couple states have made moves to cut a payment rate here or pare back a benefit there, but a lot of states are still considering their options, none of which are good. I mean, in a lot of cases this could result in people losing benefits. For example, help for families who have autistic kids: Are all those services necessary? This is really tricky.

One other thing to keep in mind here, Dan: There are 39 gubernatorial elections this fall. That’s 39 states where governors are gonna be trying real hard not to piss off hospitals, doctors, advocates — all powerful political blocs.

One source I talked to said she expects to see a lot of kicking of the can on these unpopular decisions, even though most states know they ultimately need to make them. We’re likely to see a lot of that stuff happen after the fall. 

DG: Leslie Walker, thanks so much for your time on this, your reporting. 

LW: Thanks, Dan.

DG: I’m Dan Gorenstein. This is Tradeoffs.