GOP health plan leaves disabled at risk
Changes would eliminate lifesaving aid, services for millions
TUSCALOOSA, Ala. — Frances 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. 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 last week — but staying independent will be crucial to her professional future.
“The point of these programs is to give people options and freedom,” said Isbell, 24, whose family lives a few hours away in Gadsden.
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 openended entitlement to a program with strict federal 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, with the new funding limits starting in 2021 and having the biggest impact more than a decade from now. 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, with each category of beneficiaries, like children and the disabled, getting a different base amount based on recent costs. The amount would increase every year by a formula that is expected to grow more slowly than average medical costs after 2025. 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; capping funding, their argument goes, would make Medicaid more efficient and ensure it can continue to help the most vulnerable Americans, including people with disabilities.
“The fiscal sustainability of Medicaid is essential to making sure that those who depend on the program can know it will be there for them in the future,” Avik Roy, a conservative health care analyst, wrote last week in Forbes.
Nationally, almost 3 million people received Medicaid longterm 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.
“It’s still significantly less than I would get in other states,” she said this past week, eating a lunch of leftover spaghetti in her apartment in Tuscaloosa with the help of her aide.