Governor Andrew Cuomo has been adamant in recent weeks that the state needs to find a way to close a projected $4 billion Medicaid deficit before the deadline to pass the state budget on April 1st. But at a Wednesday hearing on the health care budget in Albany, state legislators expressed concern that the governor and state health care officials are using that sense of urgency in order to push through major structural changes to Medicaid—a program that insures a third of New Yorkers and helps sustain many of the state’s health care providers—without sufficient transparency or deliberation.

“Is the cake batter really all mixed and we’re just putting the icing on it?” Assemblymember Richard Gottfried, who chairs the Assembly Health Committee, asked the state health commissioner and Medicaid director at the hearing.

The two main mechanisms Cuomo has proposed for reducing state spending are to shift a greater share of the costs of the program onto New York City and other localities, and to create a Medicaid Redesign Team tasked with finding $2.5 billion in savings and efficiencies (Cuomo is loathe to use the word “cuts”) for the state legislature to approve. The Medicaid Redesign Team has yet to be assembled, though, and State Health Commissioner Dr. Howard Zucker couldn’t say much Wednesday about who would be included on it.

State Senator Gustavo Rivera, who chairs the Senate Health Committee, asked whether the redesign team’s recommendations would be ready by March 1st, so that legislators would have at least a month to review them before being pressured to include them in the budget.

“We will get back to you on that,” Zucker said.

This will be the state’s second Medicaid Redesign Team. Cuomo instituted the first one shortly after he became governor in 2011, and, for about five years, the reforms that came out of the initiative did serve to contain ballooning Medicaid costs, even while growing enrollment in the program.

Yet, Gottfried (D-Manhattan) lamented Wednesday that while the first redesign team was largely hailed as a success, it also lacked transparency. The state encouraged public input but the ultimate decisions of which proposals to accept were made behind closed doors, he said.

One of the major changes Cuomo made to the Medicaid program was to put a cap on annual spending growth. However, in recent years several new expenses—such as state subsidies for health care providers to increase the minimum wage—have been funded outside of the cap, while other costs have simply been shifted to the next fiscal year to preserve the illusion of fiscal responsibility.

“Can we all agree that the formula created 10 years ago is not functional anymore?” Rivera (D-Bronx) asked at the hearing. “The cap has been pierced several times.”

Other state legislators echoed the sentiment that the Medicaid cap has outlived its usefulness.

Lawmakers also panned the state’s efforts to push Medicaid costs onto New York City and other local governments. New York City estimates that this would leech $1.1 billion from its coffers next fiscal year—an estimate the state has not confirmed. Cuomo has sought to justify the move by implying that local governments are frivolous with Medicaid dollars because they don’t bear enough of the cost burden—a premise that belies the fact that counties in New York bear more Medicaid costs than counties in most other states and that they have a limited role in managing the Medicaid program, in large part because of reforms Cuomo made during his tenure.

New Yorkers can still enroll in Medicaid through local administrators such as New York City’s Human Resource Administration, though, and the state says some of these administrators can do a better job of screening applicants to keep costs down.

“Some local districts have found ways to better identify assets or resources individuals have when they apply,” Donna Frescatore, the state Medicaid director, said during the hearing. “That is good program integrity.”

During a press briefing on the same day as the state hearing, city health officials said NYC has already helped generate $180 million in shared Medicaid savings for the city and state over the last three years by using data analysis to identify people who have enrolled in Medicaid through the online exchange but are no longer eligible. But they emphasized that broader Medicaid reforms are under the purview of the state.

Health Commissioner Zucker was unable to say definitively Wednesday whether representatives of New York City and other local governments would be on the Medicaid Redesign Team to help influence the reforms it recommends.

Rivera said the timeline the state has established for finding savings in the Medicaid program using the Medicaid Redesign Team is simply not realistic. “We get it that there is a crisis here and that we have to work together to solve it,” he said. “The best way to do that is to actually be on the same page.”