Gov. Kathy Hochul announced a conceptual budget agreement Monday that outlined the state's $237 billion spending plan, but as negotiations continue, it was largely void of details of one of the state's greatest expenditures: Medicaid.

Hochul's announcement of the budget's framework comes before leaders have solidified a deal on health care spending and other pieces of a housing package. The Senate and Assembly conferenced the issues Monday night, and will have additional discussions Tuesday afternoon.

"Talks are ongoing — it's a grind," Senate Deputy Majority Leader Mike Gianaris told Spectrum News 1 on Monday night. "I think it's premature to say there's a deal done, but we are very, very close. Our goal is just to get it over the finish line with a good product and hopefully, we'll get that done soon."

Budget officials and lawmakers said significant work must be done on health care spending before the latest budget extender expires Thursday. They hope to vote on budget bills by the end of the week before the start of Passover on Monday.

Several lawmakers Monday declined to discuss Medicaid spending as talks persist, but said they're angry over Gov. Hochul's insistance to cut millions of dollars from various programs. Hochul initially proposed a $1.2 billion Medicaid reduction as the program has grown 11% in the last three years. State Budget Director Blake Washington said at least $800 million was restored related to reimbursement rates for hospitals and nursing homes and support for distressed facilities.

"I think we're in a pretty good place in trying to right the ship a little bit this year as we're waiting for the Commission on Health to give us some better ideas into the future to more holistically reform our state spending in Medicaid," Washington told reporters Monday.

But the governor's announcement of budget parameters shows a flex of her executive muscle in attempts to put a pin in negotiations. Last year, Hochul announced a similar budget framework as talks dragged on more than a month past the April 1 deadline, and the Legislature did not vote to pass budget legislation for several more days.

"Thursday into Friday, maybe, is feasible, but it would take a lot of work getting done in the next day or two," Gianaris said. 

Gianaris said ongoing Medicaid conversations are centered on the Legislature's pushback to cuts or changes that will hurt New Yorkers and impact access to care.

"We are doing our best to make sure no one is hurt, and in fact, people are helped with whatever changes are made," the Senate leader said.

Disability advocates are furious about proposed changes to the Consumer Directed Personal Assistance Program, or CDPAP, to one fiscal intermediary as opposed to more than 700 currently used statewide. The program uses Medicaid dollars to allow family members to provide critical care to disabled New Yorkers, which keeps them at home versus in a private institution.

The change will save the state about $500 million as the cost of the program, reported to be rife with fraud and abuse, has grown 1,200% in recent years, Hochul said. She vowed it would not impact available care for CDPAP recipients.

"Our No. 1 priority is to take care of the people who need it the most, and they certainly fit that description," Hochul said. "They're the ones we're fighting for."

Disabled New Yorkers and disability advocates from around the state brought the fight to Hochul's doorstep Monday, yelling outside executive offices on the Second Floor of the Capitol for over a half-hour to demand an in-person meeting with the governor's staff. 

Anita Cameron, of Rochester, has multiple sclerosis and uses a wheelchair. She's applying to receive CDPAP services and said she does not want a fiscal intermediary from out of state.

"We don't want one fiscal intemediary for the entire state," she said. "When you take that away, you're taking away other services and supports for people with disabilities. The funding for that goes into other programs the independent living center has to support. If we go to just one, I know I'm going to wind up back in an institution."

Hochul's office offered the group from Center for Disability Rights Inc. a virtual meeting Tuesday — after the governor's announcement. They say it shows Hochul's administration does not want to look disabled New Yorkers in the eye to explain the change.

The state will have a competitive bidding process to select the company to serve as CDPAP's fiscal intemediary. 

"These can be like runaway trains if you don't have someone step up and say 'Why is this being done this way and is it really serving the people it's supposed to serve?' " Hochul said to reporters.

Jocelyn Arndt is a business development specialist with Consumer Directed Choices, which serves as a CDPAP fiscal intermediary that provides payroll, administrative services and support for patients enrolled in the Medicaid-funded program.

She said the state Health Department will face steep administrative challenges if New York transitions to a single provider like California has done.

"We pride ourselves in being community-centric," Arndt said. "We understand our communities, we understand their needs and we're able to innovate and develop benefits. ... Even if we're talking about trimming the program, this proposal isn't a trim. This proposal is doing brain surgery with a shotgun." 

Arndt argues the change will threaten widespread job losses. But that's not how the governor sees it.

"This was not intended to be a jobs creation program — this was intended as a health care program," Hochul said.

Assemblyman John McDonald III, a Democrat from Cohoes, is a pharmacist and said New York can successfully reduce unnecessary administrative overhead in the CDPAP program and use a handful of providers like in other U.S. states.

"They play a role, but also take a big cut of resources," McDonald said.

The assemblyman wants the state to issue an RFP to identify a handful of regional administrators to serve as fiscal intemediaries and have the change take effect within a year or two.

"At the end of the day, the person who they communicate with and who cares for them [will stay the same], but who manages some of their back office-type work may change, but that happens a lot," McDonald said of CDPAP patients. "What shouldn't change is the care for the patients — that's what we're primarily focused on retaining."

Meanwhile, the state is waiting for the federal government to greenlight a waiver to temporarily tax Managed Care Organizations to help offset Medicaid costs. California's similar waiver generated an additional $4 billion for the western state for three years.

State Republicans have stood against the proposal since it was included in the Senate and Assembly's one-house budgets. Assemblyman Josh Jensen, a Republican from Rochester, said it's akin to a legalized federal money laundering scheme, and the state should instead tighten Medicaid eligibility thresholds to bring costs down and fully fund needed services.

"We often look at piecemeal proposals just to keep it viable for another day instead of looking at the core aspects of the program," said Jensen, the ranking member of the Assembly Health Committee. "We really have to look at the entire system."