Recent reporting has put a spotlight on Medicaid fraud and what can happen when large public programs operate without close oversight. When accountability fails, trust erodes, costs rise, and the people who rely on these services suffer.
Medicaid is a public trust. Funded by taxpayers and designed to serve those with the greatest need, it demands careful stewardship. That responsibility cannot rest on good intentions alone. Programs of this size require systems that detect problems early, enforce rules fairly, and ensure resources are going where intended.
In New York, the state has completed one of the largest Medicaid transformations in its history, overhauling the home health care system precisely because of the accountability failures and fraud vulnerabilities now commanding national attention.
Self-directed home care is one of the fastest-growing segments of Medicaid because it can deliver care more efficiently without sacrificing oversight. It enables seniors and people with disabilities to remain in their homes while choosing caregivers they know and trust, rather than defaulting to expensive institutional settings. Multiple states have reported savings of up to 15% compared with traditional nursing home care.
But self-direction needs oversight at scale. In some states, programs were built with multiple individual entities handling payroll, benefits, and compliance using inconsistent standards, leaving no single authority able to see the full picture of who is working where, for how long, and whether services billed to Medicaid were actually delivered. These programs became vulnerable to waste and abuse because the infrastructure made accountability nearly impossible.
Recognizing these risks, Gov. Hochul overhauled the nation’s largest self-directed home care program, the Consumer Directed Personal Assistance Program (CDPAP), by moving from a fragmented system with more than 600 intermediaries to a single, centralized administrator, Public Partnerships LLC (PPL). The goal was to reduce fraud and bring transparency and accountability to a program that had historically grown rapidly without consistent oversight, all while ensuring continued access to high quality care.
Just a few months after the transition, the results show what effective oversight looks like in practice. With a single set of standards and shared data across the program, New York has put stronger controls in place to prevent fraud, waste, and abuse, while also bringing costs back in line. Administrative costs have dropped from as high as $1,050 per member per month to just $68.50 per member per month.
Centralized data systems also make it much easier to identify and correct practices that once went unseen: caregivers logging overlapping or unsafe work hours (sometimes more than 20 hours a day), timesheets submitted without patient review, or services billed in multiple locations at the same time. Tools like electronic visit verification and unique caregiver identifiers help confirm when and where care is delivered, reducing the risk of duplicate payments and ensuring Medicaid dollars are tied to real services.
These practices were impossible to identify under the old CDPAP model. Today, we are on track to deliver more than $1 billion in savings to taxpayers while keeping the program sustainable for the long run.
Too often, Medicaid oversight is framed as a tradeoff between fiscal responsibility and access to care. New York’s experience shows that these objectives can work hand-in-hand. Poor oversight puts care at risk by draining resources, enabling unsafe practices, and undermining long-term sustainability.
When caregivers log excessive or overlapping hours, it raises safety and quality concerns. When patients are not required to review timesheets submitted in their name, it undermines the very premise of self-directed care. Here, oversight protects caregivers and patients alike.
Medicaid will only remain sustainable if accountability is paramount. The recent headlines are a call to action: strengthen Medicaid programs or they will be abandoned by taxpayers. New York is leading the way to show that when oversight is strengthened thoughtfully and fairly, it can protect both public dollars and the people who rely on Medicaid every day.
Kapoor is the CEO of Public Partnerships LLC (PPL).
