NYSAC briefing: Medicaid uncertainty, county infrastructure program and EMS proposals top state budget risks for counties

Ryan Gregoire, legislative director for the New York State Association of Counties (NYSAC), gave Tompkins County’s Intergovernmental Relations Committee a detailed overview of Gov. Kathy Hochul’s proposed FY2026 executive budget and what NYSAC sees as the key items affecting counties.

"Medicaid is the single largest program that keeps me up at night. It it scares the death out of me," Gregoire said, explaining the risk that federal changes to Medicaid financing or to reconciliation negotiations in Washington could shift costs to the state and, ultimately, to counties. He told the committee New York receives substantial federal Medicaid funding and that counties together provide roughly $8.5 billion a year toward the state share.

Gregoire described several budget provisions that matter locally: the executive budget totals about $252 billion, and it includes targeted increases such as $45 million to address unmet needs in aging services and proposals to maintain a funding floor for community colleges. NYSAC is pressing the governor and the legislature to increase a new County Infrastructure/Partnerships Program from $50 million to $100 million to fund sewer, water, wastewater and supportive or affordable housing projects.

Medicaid and federal risk: Gregoire warned that if the federal match floor changes, the fiscal impact on New York could be large; he noted that every percentage point change in the federal match equates to roughly $1 billion-plus in state exposure. He urged counties to remind the congressional delegation of local consequences during federal budget negotiations.

Other highlights Gregoire raised for Tompkins County:

- Community colleges: the executive budget includes targeted tuition support for certain high‑demand occupations and maintains a funding floor; the state would cover a larger share for these programs so counties are not required to contribute the usual matches.

- County infrastructure grant program: NYSAC wants the fund increased from $50 million to $100 million and emphasized that counties know where sewer, water and housing investments are needed.

- EMS: the governor’s proposal would designate emergency medical services as an ‘‘essential service’’ and require local governments to provide EMS; NYSAC is seeking flexibility so that the change does not impose a new unfunded mandate and so counties and municipalities can craft locally appropriate funding or joint-district models.

- Elections and public safety: Gregoire noted the governor included $5 million for absentee ballot postage but that operating and capital assistance for elections was not included in the executive budget. He also flagged that last year’s $85 million appropriation to start E911 implementation is not continued in the proposal.

Gregoire recommended that county officials engage state legislative chairs and committee members to press for increases to key pots of money and to push for county input on allocation rules for clean water and other infrastructure programs. He encouraged committee members to attend the NYSAC legislative conference and to coordinate lobbying visits to the State Capitol.

Ending: Gregoire told the committee the state budget process will continue through the spring and warned that if federal revenues decline the legislature will likely revisit appropriations later in the year. He urged the county to stay engaged and to share local data on needs and project readiness.