The cruelest cuts of all

Many Americans were no doubt pleased to hear that the Donald Trump administration’s first budget proposal spared Social Security and Medicare, but the health and well-being of 74 million vulnerable, lower-income Americans who receive Medicaid are still very much in jeopardy. In fact, the means-tested Medicaid program now is directly in the bull’s-eye of cuts and drastic changes the Trump administration and Republican leaders are considering as part of their vow to replace the Affordable Care Act (ACA), also known as Obamacare.

Created in 1965 as part of President Lyndon Johnson’s “War on Poverty,” Medicaid is our country’s largest health care insurance program, with 74 million enrollees, or about 1 in 4 Americans, surpassing the better-known health insurance Medicare program with its 55 million-plus enrollees. Medicaid provides health care services for low-income individuals, including families with children, seniors, people with disabilities, those in foster care, pregnant women and low-income people with specific diseases, such as tuberculosis or HIV/AIDS. Chances are, you probably know many people on Medicaid, such as a 54-year-old woman who is without private insurance, too young for Medicare, who then developed breast cancer; or a young adult who developed a traumatic brain injury after an automobile accident.

Some 60 percent of Medicaid’s spending is for the elderly and the disabled. For many people with disabilities, Medicaid services are the only way they are able to live and work in the community with friends and families. Medicaid helps children and adults with a significant disability — such as autism, cerebral palsy or intellectual disabilities — to remain at home and avoid placement in costlier and harmful segregated nursing homes or institutions. Medicaid also provides services, such as personal care aides who help people in their own homes with everyday needs like bathing, dressing, eating and managing medications. And because adults with disabilities have such a low employment rate (30 percent), they don’t have any other health insurance options for their ongoing and acute medical needs except Medicaid. Under the ACA, there has been a large expansion of Medicaid, although some Republican governors declined that Medicaid expansion.

In California, the program is called Medi-Cal, and as is the case in every state, the feds pay close to 60 percent of the program’s overall expenses. Under the current structure, the federal government has a commitment to help states cover costs, and in turn, states must provide specific benefits to certain groups of people, including people with disabilities. Although Medi-Cal has issues, including a very low reimbursement rate, which prompts many specialists and other providers to limit or simply stop taking on Medi-Cal patients, it is nevertheless a crucial and lifesaving program.

Currently, Medicaid is an open-ended entitlement for states — if residents meet strict income and asset criteria and other health/disability-related criteria, then they can enroll. During economic recessions, more people enroll; other factors, such as expensive new lifesaving prescriptions drugs, also can increase the costs of administering the program. The “block grants” being touted by the Trump administration as a way of giving states more control over their state Medicaid program will translate into a whole new definition of pain, as each state would receive a fixed amount of money based on a predetermined formula, most likely at a per-capita rate. A recent editorial by The ARC (formerly known as the Association for Retarded Citizens, started by parents who had children with disabilities in the 1950s) analyzed the problem: “Unlike the current funding system, the amount provided under a per capita cap will not automatically increase when the cost of providing covered services to eligible individuals goes up. The intent of the per capita cap is to reduce federal spending by restructuring the program and significantly cutting the cost to the federal government. Using this technique, the federal government limits spending, regardless of the needs of the people receiving Medicaid services.”

State governments will be forced to make decisions from an array of bad choices, such as increasing state taxes, limiting services to existing Medicaid patients, reducing eligibility or cutting already low reimbursement rates even further. Health outcome disparities between states will grow as wealthier states can help backfill some of these cuts but poorer states will not be able to do the same. Without early intervention, many infants and toddlers with disabilities will be denied therapies that can change their lives’ trajectories. Without community services and support, too many adults with disabilities will be stuck at home, dependent on aging parents and even forced into unnecessary institutionalization, a huge step backward in the civil rights of people with disabilities. Many Medicaid patients will suffer from delayed or denied medical treatment, and some people may even die.

Kellyanne Conway, counselor to President Trump, has said publicly that moving to Medicaid block grants will ensure “that those who are closest to the people in need will be administering the program,” but what kind of freedom is choosing between bad, worse and terrible? 

Michelle K. Wolf is a special needs parent activist and nonprofit professional. She is the founding executive director of the Jewish Los Angeles Special Needs Trust. Visit her Jews and Special Needs blog at jewishjournal.com/jews_and_special_needs.