For millions, life without Medicaid is no option
Optional services at risk under GOP health proposal.
Frances TUSCALOOSA, ALA. — Isbell has spinal muscular atrophy, a genetic disorder that has left her unable to walk or even roll over in bed. But Isbell has a personal care assistant through Medicaid, and the help allowed her to go to law school at the University of Alabama, and she will graduate next month.
She hopes to become a disability rights lawyer — “I’d love to see her on the Supreme Court someday,” her aide, Christy Robertson, said, tearing up with emotion as Isbell prepared to study for the bar exam in her apartment late last month — but staying independent will be crucial to her professional future.
“I can’t work if I don’t have these services,” Isbell said.
The care she gets is an optional benefit under federal Medicaid law, which means each state can decide whether to offer it and how much to spend. Optional services that she and millions of other Medicaid beneficiaries receive would be particularly at risk under Republican proposals to scale back Medicaid as part of legislation to repeal and replace the Affordable Care Act.
Those services include dental care for adults, long-term care for disabled and elderly people living at home, certain therapies that children with disabilities receive in school, prosthetic limbs and even prescription drugs.
The battle over replacing the Affordable Care Act has focused intensely on the future of Medicaid, the state-federal health insurance program for the poor and vulnerable created more than 50 years ago as part of President Lyndon B. Johnson’s Great Society. Much of the debate has centered on Republican proposals to roll back the recent expansion of the program to millions of low-income adults without disabilities.
But the House and Senate bills would also make profound changes to the nature of Medicaid, shifting it from an open-ended entitlement to a program with strict fed- eral funding limits.
Those changes would have far bigger consequences over time, affecting many more of the roughly 74 million Americans on Medicaid. The threat to optional services may be especially acute in states, like Alabama, that already spend far less than the national average on Medicaid and are averse to raising more revenue through taxes.
“In a poor state like Alabama, you are starting off with a baseline that’s already low,” said James A. Tucker, director of the Alabama Disabilities Advocacy Program, which provides legal services to people with disabilities here. “There’s a fundamental antipathy to spending the public purse on health care services for poor people, and that would only get worse if the resources become capped and more limited.”
The drain on Medicaid funding would worsen over time under the bill that Senate Republicans are working to pass. The nonpartisan Congressional Budget Office estimated that Medicaid spending would be 26 percent lower under the Senate plan than it would be under current law in 2026 — and 35 percent lower in 2036. The office predicted that states would be forced to “eliminate optional services, restrict eligibility for enrollment or adopt some combination of those approaches.”
Under the Senate plan, states would receive a fixed annual amount for each Medicaid beneficiary. The amount would increase every year by a formula that is expected to grow much more slowly than average medical costs, although the growth rate would be slightly higher for disabled and elderly bene- ficiaries. Disabled children would not be subject to the spending caps.
Avalere Health, a consulting firm, estimated in a report that federal spending on individual state Medicaid programs could decline between 6 percent and 26 percent under the Republican plan by 2026. The biggest drops would be in states that expanded Medicaid, but the cuts would compound more sharply for every state in later years.
Conservatives say Medicaid spending, which consumes a major and growing portion of the federal and states’ budgets, needs to be reined in. The current system of unlimited federal matching funds, they say, has encouraged states to milk as much as they can, sometimes wastefully.
Nationally, almost 3 million people received Medicaid long-term care services at home or in their community in 2013, according to the Kaiser Family Foundation. About 13,000 people were getting these services in Alabama in 2015, according to the state.
Medicaid pays for only 25 hours a week of help for Isbell. It is not enough; she received an additional 25 hours of help through a Department of Education program during her three years in law school.