Several days a week, a New York City Access-A-Ride van picks up Margueritte Wilkins at her Bronx apartment and takes her to a senior center in midtown Manhattan.
There, Wilkins enjoys a hot lunch and participates in a variety of activities, including exercise and art classes, karaoke and memory games. For Wilkins, 67, the program has been rewarding, helping to restore her sense of self-worth after catastrophic illnesses in 2009 and 2013.
The SAGEDay program, sponsored by Services and Advocacy for GLBT Elders (SAGE) and the Hebrew Home at Riverdale, is free for people like Wilkins who are on Medicaid.
Medicaid, the federal-state health insurance program for low-income people that turns 50 this month, has a massive footprint in New York, covering nearly 1 in 3 of the state's roughly 20 million residents.
This year's $63.2 billion Medicaid budget—the single largest spending category in a $142 billion state total—pays for acute and long-term care for more than 6 million New Yorkers, a quarter of whom are 50 or older. The state and federal governments equally share the cost of Medicaid in New York.
New York's Medicaid is so generous with its benefits that it is often called the Cadillac of state health care programs.
But state officials acknowledge that bigger is not always better.
After taking office in 2011, Gov. Andrew Cuomo (D) ordered the state Health Department to overhaul the program to contain costs, streamline services and improve health outcomes.
Within the year the governor's Medicaid redesign team issued a report containing scores of recommendations and initiatives.
To pay for the reforms, the state applied for and received a waiver from the federal government, which let it reinvest savings in federal Medicaid dollars in new ways to deliver and pay for health care services. Then, in the midst of the redesign, the state expanded Medicaid coverage under the 2010 Affordable Care Act to people making up to 138 percent of the federal poverty level (about $16,240 for an individual and $33,465 for a family of four). It also set up a state-run health insurance exchange.
AARP New York supported both measures, lobbying the governor's office that "New York is unique and should run its own exchange," said Bill Ferris, associate state director for advocacy.
About 144,000 single, childless adults have been added to the Medicaid rolls through the expansion.
AARP New York has championed other goals of the redesign, including reducing the reliance on nursing home care.
"AARP has always supported a strong home- and community-based Medicaid program because it offers long-term services to people in their homes to keep them independent and out of more costly institutions," Ferris said.
About a third of New York's Medicaid money pays for long-term care, and about half of that goes to nursing homes. Jason Helgerson, state Medicaid director, said that's too much.
He made the remark two years ago at a conference on supportive housing, a state initiative to develop affordable housing with on-site social services. It's seen as a key part of Medicaid reform efforts.
"A major reason why people are in institutions today … is that there are not affordable options for them in the community," said Helgerson.
Helgerson's job entails overseeing the most sweeping reform in New York's Medicaid since the program was established in 1965. "The current Medicaid redesign initiatives exceed the scope of anything tried before and affirm a commitment to the program's future in New York," said Jim Tallon, president of the United Hospital Fund, a nonprofit research organization.
Lara Kassel, coordinator of Medi­caid Matters NY, a statewide coalition advocating for people on Medicaid, is watching the state's changes closely.