Financing and regulating health care delivery is one of the biggest responsibilities of state government, yet Governor Hochul had remarkably little to say on that topic in her State of the State speech on Tuesday.

For the fourth straight year, in fact, the word “Medicaid” did not cross her lips – even though that sprawling health plan covers a third of the population and consumes a quarter of state revenue.

Her written message to the Legislature included several mostly small-bore health-related proposals, such as “create a hospital-based peer bridger program” and “support youth mental health in after school programs.” She didn’t bother mentioning any of them to lawmakers gathered in the Capitol complex’s Hart Theatre on Tuesday.

Hochul’s near-silence was disconcerting – because there are plenty of problems in New York’s health system that demand the governor’s urgent attention:

High insurance costs: New Yorkers and their employers pay some of the steepest premiums in the U.S. – and the gap has grown wider in recent years. As part of her “affordability” agenda, Hochul could push to roll back the excessive state-imposed taxes and coverage mandates that contribute to rising costs.

Nursing home neglect: A series of lawsuits brought by Attorney General Letitia James have accused leading nursing home operators of neglecting and abusing patients while taking excessive profits, mostly at the expense of taxpayers. Hochul could lead the charge for an industry-wide shakeup.

Low-quality hospitals: Although New York is home to some of the best-regarded hospitals in the world, the state’s hospital system as a whole consistently ranks near the bottom of quality report cards. The state also contends with some of the longest emergency-room wait times in the country. Hochul could direct her health commissioner, Dr. James McDonald, to crack down.

Spiraling Medicaid spending: The state’s Medicaid budget – already the costliest per capita of any state – has been spiking at double-digit rates in recent years. Hochul could deploy her constitutional budgetary powers to keep spending in check.

Excessive enrollment: Despite a declining poverty rate, enrollment in Medicaid and the Medicaid-like Essential Plan has surged to unprecedented levels – and millions beyond the low-income population those safety-net programs were intended to cover. Hochul could order an audit and prune the rolls accordingly.

Explosive home care growth: The number of New Yorkers enrolled in the Consumer Directed Personal Assistance Program, a Medicaid-financed form of home care, soared by almost 2,000 percent in just eight years, to about 250,000. Hochul’s controversial response was an administrative overhaul that arguably does more to boost union membership than control costs – and might put needy recipients at risk of losing services. Hochul could go back to the drawing board and bring the scale of the program more in line with national norms.

Addressing these issues would reduce health-care costs for all New Yorkers – and make Hochul’s talk of “affordability” more than a slogan. They would also require the governor to stand up to the health-care industry, which is Albany’s most formidable special interest.

Hochul’s apparent lack of a health-care agenda is all the more surprising because she appointed a Commission on the Future of Health Care in 2023. That panel of well-credentialed national experts was supposed to issue its first round of recommendations by the end of 2024, but nothing has yet emerged.

The governor must lay out her bottom-line plans for spending on Medicaid and other programs in the executive budget she is due to present next week. After her speech on Tuesday, New Yorkers looking for stronger leadership on health-care can only hope that her budget has surprises in store.