New York’s home-care fraud scandal exposes Medicaid’s rotten incentives



Medicaid is federally funded and state-run, but the program’s beneficiaries often have the least say in who provides their care and what that care costs.

That’s a built-in flaw. States have every incentive to maximize federal matching funds while federal taxpayers bear much of the cost. The result pits state bureaucrats against Washington’s need to control Medicaid spending — and against taxpayers’ interest in stopping providers, insurers, and contractors from cashing in on weak oversight.

New York’s home-care scandal is not merely a contracting failure. It is a warning about Medicaid’s overall design.

That is why cosmetic Medicaid reforms so often produce more spending, more inefficiency, and more fraud.

Just look at New York.

Democrat Governor Kathy Hochul’s administration botched the reform of its roughly $11 billion Consumer Directed Personal Assistance Program, a Medicaid-financed home-care benefit, so badly that federal prosecutors came knocking.

The U.S. Justice Department recently sued the New York State Department of Health and Public Partnerships LLC, the program’s sole fiscal intermediary since 2025. Prosecutors allege that New York’s CDPAP reform, supposedly designed to reduce waste in a billion-dollar program, instead created conditions for an ongoing Medicaid fraud scheme.

Personal care — nonmedical long-term care provided in the homes of elderly and disabled patients — is especially vulnerable to waste and abuse. The reason? It’s difficult to verify that caregivers worked the hours billed or provided the services claimed.

“The service is delivered by unlicensed caregivers in private residences, usually with no on-site supervision,” Bill Hammond of the Empire Center has explained. “The risk is heightened when the aide is a friend or family member of the patient, which is allowed under the popular and rapidly growing [CDPAP].”

New York’s numbers show the scale of the problem.

In 2021, the state employed 138 home-health and personal care aides per 1,000 residents age 65 or older — more than double the national average. New York City employed 236 aides per 1,000 older residents. By 2024, the statewide rate had climbed to 171 aides per 1,000 older residents.

Home care was supposed to reduce New Yorkers’ reliance on nursing homes. Yet the share of elderly New Yorkers living in nursing homes declined more slowly than in almost every other state, while New York’s per capita Medicaid spending on nursing homes remained the highest in the nation and more than double the U.S. average.

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Over the decade leading up to 2025, hundreds of fiscal intermediaries emerged to process payroll for CDPAP lay caregivers and perform other administrative duties. These intermediaries eagerly tapped loosely supervised Medicaid dollars.

Many aggressively advertised the opportunity to become a CDPAP caregiver and get paid by Medicaid to care for a family member — eventually at the same legally mandated minimum pay as professionally trained home-care aides.

That helped fuel what Hammond described as “seemingly bottomless and unchecked demand for a costly Medicaid benefit, which has been rising almost 10 times faster than the growth of the state’s elderly population.”

In 2024, New York passed legislation consolidating CDPAP management under a single statewide contractor. The state awarded that role to PPL.

By then, CDPAP relied on nearly 600 intermediary firms, and enrollment had exploded from roughly 12,000 to more than 250,000 between 2015 and 2023.

By shrinking the bureaucracy, New York lawmakers claimed they would restrain CDPAP’s soaring costs. Once again, they promised greater accountability and hundreds of millions of dollars in savings.

They did not deliver.

According to the Justice Department, the procurement process for “one of the most lucrative contracts for administering a Medicaid program in the nation” was compromised from the beginning. Prosecutors allege that “PPL was preselected as the winner through a sham bid process.”

The transition from hundreds of intermediaries to PPL was also disorderly. An unrealistic timeline, evident to both PPL and the Department of Health, disrupted patient care.

Most important, prosecutors allege that “PPL and New York, without explanation, have disregarded key limits the contract imposed on the revenues and profits PPL was entitled to.” Those limits were “central to the goal of saving hundreds of millions of dollars through the CDPAP transition.”

PPL allegedly “siphoned millions of dollars of Medicaid funding,” with the state Department of Health complicit in the ongoing scheme.

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PPL can be replaced. But another company eager to rent-seek will inevitably take its place unless the incentive structure changes.

As long as federal taxpayers contribute anywhere from $1 to $9 for every $1 New York contributes to fund Medicaid for New Yorkers, state administrations and health officials will remain too complacent about the misuse of taxpayer money.

Any money recovered from this alleged scheme would be dwarfed by Medicaid’s broader improper spending crisis, which may have exceeded $1 trillion over the past decade.

New York’s home-care scandal is not merely a contracting failure. It is a warning about Medicaid’s overall design.

The program rewards states for spending more, obscures responsibility for waste, and leaves taxpayers chasing fraud after the money is gone. Overhauling Medicaid to restore accountability is long overdue.

The administrative state just took a major hit



The Supreme Court’s decision in Trump v. Slaughter is a major victory for constitutional government.

By restoring the president’s authority over the executive branch and overruling what remained of the mistaken Humphrey’s Executor precedent, the justices took an important step toward democratic accountability. The decision also opens a path for President Trump and future administrations to rein in the administrative state.

Americans should celebrate this ruling as a victory for self-government.

At the heart of the ruling is a simple constitutional principle: The president, as the elected head of the executive branch, must have authority to direct executive policy and hold executive officers accountable.

That authority is not merely an administrative convenience. It is the mechanism through which the American people exercise control over executive government.

Article II vests “the executive Power” in a single president and charges him with ensuring that “the Laws be faithfully executed.” Officers exercising executive power derive that authority from the president and must remain accountable to him.

Without meaningful removal authority, the presidency risks becoming little more than a figurehead while unelected officials pursue agendas beyond democratic control.

For decades, Congress has increasingly insulated parts of the federal bureaucracy from presidential supervision. The founders envisioned no such arrangement.

The expansive appeals processes and employment protections shielding many federal employees are well known. Less appreciated is how much of the current system emerged during the 1960s and expanded over the following decades, producing a bureaucracy increasingly insulated from elected leadership.

Whatever the intentions behind those reforms, the result has been to weaken the president’s authority to manage the executive branch and the people’s ability to govern themselves through elections.

The consequences have become increasingly visible.

A Merit Systems Protection Board survey found that only about two in five federal supervisors believed they could successfully remove an employee for serious misconduct. That finding shows how procedural barriers have eroded managerial accountability.

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The same culture was evident during President Trump’s first term, when career officials embedded policies contrary to administration priorities in guidance documents, subregulatory materials, and even formal regulations.

When executive officials deliberately frustrate lawful presidential policy, the president must possess adequate authority to remove them.

Predictably, critics warn that Slaughter will politicize the civil service and revive the spoils system. Those concerns miss the point.

President Trump has repeatedly said federal hiring should be based on merit, qualifications, and competence. His administration’s executive orders, rules, and regulations reject political loyalty tests in career hiring.

Merit-based hiring and presidential accountability are not competing principles. They are complementary.

A professional civil service should be selected because its members are qualified to perform their duties. But once entrusted with executive authority, those officials must faithfully execute the lawful policies of the elected president.

That’s far from “patronage.” It’s how representative government should function.

The administration’s Schedule Policy/Career executive order reflects that distinction. It applies to career employees in confidential, policy-determining, policymaking, or policy-advocating positions. Those employees remain merit-based career officials, not political appointees.

But senior career officials exercising substantial policy influence should not be able to use endless procedural protections to delay, frustrate, or undermine an elected administration’s agenda.

The Civil Service Reform Act was never intended to create permanent insulation for officials exercising broad executive discretion.

The administration has also appropriately tested constitutional errors by removing officials whose statutory protections conflict with Article II. Those cases have allowed courts to reconsider precedents that steadily weakened presidential control over the executive branch.

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In its 2026 Jackler and Jaroch decision, the Merit Systems Protection Board recognized that statutory employment protections cannot override Article II when applied to inferior officers exercising significant executive authority.

The Supreme Court’s Slaughter decision builds on that reasoning and on other precedent. It rejects the fiction that agencies exercising executive power can remain meaningfully “independent” of the executive.

Those who execute federal law must ultimately answer to the president.

Opponents will characterize the decision as a dangerous expansion of presidential power. In reality, it restores the constitutional structure the founders designed.

Americans elect a president to implement policies on immigration, the economy, national security, and countless other questions. If unelected officials can frustrate those policies through institutional resistance or procedural barriers, elections become less meaningful.

Accountability disappears because voters cannot determine who is responsible for the success or failure of executive policy.

The Slaughter decision restores that chain of accountability. It strengthens the president’s ability to direct officers exercising executive power while preserving a federal workforce hired on merit and expected to execute the law faithfully. That is neither radical nor unprecedented. It is the constitution's design.

The federal government exists to serve the American people, not to function as an independent center of political power.

By reaffirming presidential authority under Article II, the Supreme Court strengthened democratic accountability and helped ensure that executive power remains where the Constitution places it: with the president elected by the American people.

Americans should celebrate this ruling as a victory for self-government.

Elections cannot provide meaningful accountability when officials exercising executive power are insulated from the president voters chose.

Slaughter helps restore that constitutional chain: Executive officers answer to the president, and the president answers to the people.

Marty Makary left behind an FDA families learned not to trust



With so much bad news in the world, it is worth pausing for one encouraging development: Marty Makary finally resigned as commissioner of the Food and Drug Administration last week.

Makary’s tenure at the FDA was marred by internal scandals, forced resignations, dreadful morale, and record staff turnover. More important, he actively sandbagged President Trump’s push to expand clinical trials for rare diseases through the aptly named “right-to-try” framework.

Trump’s next appointee should restore the spirit of right to try and make safe, effective treatments available to children as quickly as possible.

The idea behind right to try is straightforward. Patients with rare conditions, especially those for whom conventional medicine has failed, should have the freedom to pursue experimental treatments that have not yet received full FDA approval. Families fighting the clock have little left to lose. Government should not stand between them and a potentially lifesaving breakthrough.

Makary did.

Members of the MPS community sent more than 10 letters asking Makary for a meeting. They got a form letter in return. Sen. Ron Johnson (R-Wis.) later announced an investigation into the FDA’s denials. Makary’s agency responded by claiming approvals were already “at their peak.” The Wall Street Journal took notice of the FDA’s foot-dragging last year, yet the agency kept rejecting relevant rare-disease treatments in early 2026, including RGX-121 and drugs from Biohaven and Saol Therapeutics.

That stonewalling forced families to escalate.

In March, more than 100 mothers and other advocates staged a mock funeral outside FDA offices. Dressed in black and carrying a real coffin, they sought to draw attention to a group of rare metabolic disorders known as mucopolysaccharidoses. These disorders can show up as mild symptoms such as depression or hyperactivity, or as devastating conditions such as heart disease and skeletal abnormalities.

Many MPS disorders still have no approved treatments, even though they can severely diminish children’s quality of life or kill them outright. The FDA’s regulatory process serves a legitimate purpose. But when a bureaucracy grows so rigid, self-protective, and arrogant that it blocks desperately ill children from access to promising therapies, it stops functioning as a safeguard and starts functioning as a death sentence.

Mark Dant of the Ryan Foundation told Newsweek that some of these drugs were denied because of the FDA’s institutional “dislike” of the accelerated-approval pathway. “For decades we waited for science to find our tomorrows,” he said. “Now it has, and bureaucrats within the agency we pay for are keeping those treatments from our children. We know they are there. … We just cannot reach them.”

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Makary’s resignation will not undo the damage. But it does create an opening. We may not yet know what the FDA’s next leadership will look like, but Trump’s appointee should restore the spirit of right to try and make safe, effective treatments available to children as quickly as possible.

Across the world, in the nation of Georgia, parents have staged a protest lasting more than 500 consecutive days, maintaining a round-the-clock presence outside the main government building in Tbilisi. They are willing to risk everything to give their children the best chance at life. Americans should not have to camp outside federal offices for 500 days to get their government to listen.

The new FDA leadership must explain denials of right-to-try clinical trials with enough specificity that sponsors and families understand what evidence could change the decision. Patient and caregiver testimony should shape decisions early, not get folded in at the end as a token gesture. And Congress must demand transparency without turning each drug review into a partisan circus.

Children’s lives are not bargaining chips. The FDA exists to serve the public, not to protect its own bureaucracy from embarrassment. If Makary’s departure opens the door to that truth, families battling ultra-rare diseases may finally have reason to hope.

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Veterans shouldn’t have to worry about lawyers taking their benefits



I served in combat with the U.S. Army. Like many veterans, I know that men and women who come home carrying the physical and mental costs of war rely on disability payments to maintain mortgages and keep their families afloat. These funds help people rebuild lives that were permanently changed during their years of service and sacrifice.

Benefits are meant to help families recover from the physical and mental costs of war, yet they too often become a revenue stream for law firms that specialize in VA appeals.

Navigating the VA's disability system is rarely simple. Many veterans are already coping with serious injuries, mental health challenges, or financial stress as they transition back to civilian life. Confronting a complicated bureaucracy on top of that can feel like fighting another battle — which is why veterans should have access to a range of options for help.

The current system often leaves veterans with limited options, partly because when disability claims are delayed and pushed into drawn-out appeals, attorneys are allowed to collect a percentage of the veteran’s eventual award. The longer the process drags on, the larger the payout.

The Department of Veterans Affairs paid $394.7 million to accredited attorneys over the past year — money taken directly from veterans who fought to earn those benefits. The CHOICE Act (H.R. 3132) would help ensure that those benefits stay with the veterans who earned them, not the lawyers who see them as a payday.

Federal law limits attorney fees in most VA disability cases at 20% of a veteran’s backpay award. Those guardrails exist for a reason: Without them, veterans’ benefits risk becoming just another profit center for the litigation industry.

Organizations representing trial lawyers spend millions lobbying Congress each year on issues affecting litigation and attorney compensation. Veterans’ disability claims are no exception. When legislation like the CHOICE Act seeks to limit attorney fees and protect veterans’ benefits, the trial bar mobilizes to protect its financial interests.

This opposition raises a simple question: When the debate is about veterans’ benefits, whose side are these lobbyists really on?

Does increasing the share of benefits that go to legal fees serve those who wore the uniform?

Benefits are meant to help families recover from the physical and mental costs of war, yet they too often become a revenue stream for law firms that specialize in VA appeals.

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Veterans deserve strong advocates. The system should prioritize protecting them, not increasing the financial incentives tied to their benefits in an already strenuous process.

The complex VA benefits process can attract bad actors looking to profit from veterans navigating a complicated bureaucracy. Reputable companies that assist veterans with disability claims have been among the loudest voices calling for stronger oversight and clear rules to eliminate those abuses.

The CHOICE Act would establish guardrails that veterans deserve, including stronger consumer protections, limits on fees, and accountability for providers that violate the rules.

Congress must put veterans and their families first. The priority should not be filling trial lawyers’ deep pockets, but ensuring the system truly serves veterans’ best interests. When powerful lobbying organizations treat those benefits as a potential revenue opportunity, the system risks losing sight of whom it is meant to serve.

Our country made a promise: If you serve, and if service leaves you injured or disabled, the nation will stand behind you. The benefits belong to the veterans who earned them and not to the lawyers or lobbyists who see them as a revenue stream. Congress should pass the CHOICE Act and ensure those benefits serve the veterans they were meant for.

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MAHA is sick: RFK’s FDA is drifting the wrong way



If Health and Human Services Secretary Robert F. Kennedy Jr. wants to be true to his word and “Make America Healthy Again,” he must reform the Food and Drug Administration. Dr. Vinay Prasad, whose actions thwart medical freedom, endanger the unborn, and compromise patient choice, needs to go now, not at the end of April.

Prasad is a “Bernie Sanders acolyte” who “doesn’t think patients can be trusted to make their own healthcare decisions,” as Allysia Finley put it in the Wall Street Journal. Prasad disparages the 2018 right-to-try law, which give terminal patients access to experimental treatments, calling it “terrible” and “disingenuous,” written by people who “want to weaken the FDA.”

MAHA won’t survive as a slogan alone. Behind the facade of RFK’s rhetoric is an ideological agenda at odds with key conservative values.

Prasad claims that dying patients already have access to drugs through the FDA’s expanded-use programs and blames drug companies as the “major barrier” to unapproved drugs, downplaying the government’s role in blocking patient choice.

His personal crusade against faster drug approvals has chilled medical innovation. When Prasad originally resigned in July, months into his FDA tenure, amid backlash, the market predicted a shift toward a more patient-centric “right-to-try” approach, potentially cutting the bureaucratic red tape stifling cell and gene therapies and patient access.

Prasad’s pro-abortion record is even worse. He proudly identifies as “pro-choice” and progressive, a stance fundamentally at odds with pro-life conservatism. His appointment to the FDA’s Center for Biologics Evaluation and Research overseeing drug development that affects pregnant women and unborn children is a direct threat to the culture of life.

Prasad consistently casts abortion as a medical issue rather than a moral issue. He also fiercely defended mifepristone, the abortion pill, when a Texas judge tried to suspend its FDA approval. Prasad called the court’s intervention a “dangerous precedent,” and applauded the Supreme Court for preserving access to the drug, framing the issue purely as protecting “FDA authority” and “scientific integrity.” To pro-life voters, that posture reads less like neutrality and more like a commitment to keeping the abortion drug regime insulated from challenge.

Small-government promises are colliding with Prasad’s big-government dogma. Conservatives assumed RFK Jr. and his FDA appointees would shrink regulatory excess in support of President Trump’s innovation agenda, but they have done the opposite. Prasad came in with a “stringent regulatory mindset.” Rather than trusting patients to weigh risks for themselves, he has tightened the FDA’s grip with paternalistic, ideological rules. He has sidelined MAHA’s promise and expanded oversight instead.

Prasad’s policies have often expanded the FDA’s reach in ways that could seriously harm timely access to treatments. He is imposing tougher requirements on industry, insisting on larger trials and refusing to rely on surrogate endpoints for approvals, which means more delays and more red tape before new solutions can reach the public.

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The internal dynamics under Prasad reflect a top-down, bureaucratic rigidity and are under formal investigation, with the FDA retaining an outside investigator to examine workplace complaints alleging a toxic environment. Instead of signaling healthy reform, Prasad’s authoritarian rule of CBER is run on control and fear of pushback, where staff worry that dissent will be punished and experienced voices are pushed out or sidelined. Rather than “draining the swamp,” this approach fortified an insider bureaucracy loyal to Prasad’s agenda.

When the FDA held a meeting on a Commissioner’s National Priority Voucher drug, the voting members were top leaders like Prasad, not the scientists who reviewed the application. Career reviewers were excluded from the vote entirely, a major break from the FDA’s long-standing practice of empowering these staffers to make the final scientific call in order to shield approvals from political pressure.

The paradox for conservatives is obvious. Kennedy and Prasad earn plaudits for pulling back certain excesses, including scaling down aggressive vaccine promotion. Yet at the same time, they are building a larger, more controlling FDA bureaucracy in other domains — one that constricts medical freedom, slows innovation, and keeps pro-life concerns at arm’s length.

MAHA won’t survive as a slogan alone. Behind the facade of RFK’s rhetoric is an ideological agenda at odds with key conservative values. Conservatives who cherish medical freedom and rapid innovation find themselves at odds with Prasad’s FDA. A few welcome policy tweaks cannot obscure the reality of an expanding bureaucracy and pro-abortion policies.

With the 2026 midterms fast approaching, continuing this pattern will hurt Republicans and erode the trust of voters, handing Democrats an easy narrative about broken promises. Such an outcome would leave MAHA dead and MAGA mortally wounded. We must do better.

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