Debate about “Trumpcare” — the repeal, and replacement, of the 2010 Affordable Care Act — has ignored the fact that congressional Republicans are, effectively, also working to repeal, and replace, the 1965 Medicaid Act.
This “traditional Medicaid” has covered those who are aged, blind and have disabilities for over a half-century. It serves over three-fifths of patients in nursing homes. Were the real objective to close nursing homes nationwide it could not be better achieved.In 1965 more House Republicans voted for creating the Medicaid program than voted against it. Today the Republican House speaker, Paul RyanPaul RyanTrump, GOP lawmakers struggle with messaging Seniors in nursing homes out of luck under GOP health bill Threats against lawmakers already higher than all of 2016 MORE, has said he first thought about cutting Medicaid while “drinking at a keg” in college. His dream is on the cusp of being realized: The House-passed American Health Care Act (AHCA) would reduce Medicaid funding by $834 billion.
President Trump — who had promised to oppose Medicaid cuts — described the House bill as “mean, mean, mean” following his celebration of its passage. It eviscerates the state-federal Medicaid partnership.
The Senate’s Better Care Reconciliation Act (BCRA) would cut$772 billion from Medicaid, but do so in ways even more disastrous for long-term care than the AHCA.. Senate Republicans are still struggling to get the necessary votes.
Medicaid is the primary funder of long-term care, particularly as longevity and costs associated with it, have increased. My paternal grandparents were among many elderly people I have known who didn’t expect to live as long as they did. They made it to 85 and 91, respectively, without ever needing nursing home care — but their last years were difficult.
As of last measure, almost 42 percent of nursing home patients were over 85. Medicaid also funds home-and-community-based long term-care settings for those not needing 24/7 care. The state of Washington, for example, leads in funding the entire long-term care continuum. Since July 2009 there are 1,500 fewer Medicaid patients in Washington’s nursing homes, and 11,000 more in home-and-community-based settings. All of these vulnerable lives are put at risk by congressional GOP efforts.
Currently, the federal government matches state expenditures on Medicaid with a formula based upon per-capita income. Poorer states get as much as 75 percent of costs paid by the federal government, while the most affluent states get as little as 50 percent.
Both the AHCA and BCRA would eliminate federal Medicaid matching funds and replace them with per-capita caps.
The impact would be inhumane. Medicaid beneficiaries will be placed into conflict with one another as states are forced to triage. State support for Medicaid is not robust, especially in economic downturns, even with the “incentive” of federal matching. Without that federal incentive state cuts will be even easier, and fiscally necessary (as states, unlike the federal government, must balance their budgets), to implement.
Closure of Medicaid-serving nursing homes would displace workers — 85 percent of whom are women — and elderly residents, over two-thirds of whom are women.
Examples from my state of New Hampshire illustrate the prospective impact.
New Hampshire already has the nation’s third-worst gap between state payments and Medicaid care costs for nursing homes. Under one projection, the BCRA would rob care by an average of over $1 million per New Hampshire nursing home – though facilities would close well before that occurred.
For the 40–bed Holy Cross Health Center in Manchester, a nonprofit that serves impoverished Catholic nuns, losses on Medicaid care currently run into the hundreds of thousands of dollars. My association’s faith-based members are, in effect, providing charity already for the government – they have no more capacity to give.
Assisted living facilities only receive $49 a day for care, meals, and housing — a Medicaid payment frozen since 2010 — while those providing Medicaid in-home care struggle without living wages. Chronic state underfunding has had the effect of making home-and-community-based settings a less-attractive, and often unavailable, Medicaid option than they should be. Cuts under the BCRA would simply eliminate these options.
The 26-bed Cedarcrest Center for Children with Disabilities, the state’s only intermediate care facility for individuals with intellectual disabilities, serves an all-Medicaid population as young as infants, and struggles to recruit, and retain, quality staff — as do all other Medicaid providers in a state with the nation’s lowest unemployment. It currently has six children on ventilators, and already must hold fundraisers to make up for Medicaid underfunding.
These challenges exist in a system in which the federal government matches, dollar-for-dollar, the pittance a frugal state government spends. So imagine how much worse things will be if that federal matching goes away, and the New Hampshire budget suffers the loss of hundreds of millions of dollars?
Vulnerable people cannot be made to suffer the effects of social science experiments first conceived at college keggers. Nor should they be forced to compete, as in “Lord of the Flies,” to see who can blow the conch shell the loudest as care funding is decimated.
Senators must reject this immorality.
Brendan Williams is the president/CEO of the New Hampshire Health Care Association, which represents 90 long-term care facilities.
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