Over the last several days, the NCC Blog has attempted to answer some basic questions about the current health care debate, especially as it relates to people with disabilities.
Read the posts so far:
What's going on? And why?
What's the deal with "Pre-Existing Conditions?"
What's the argument over the "Medicaid Expansion?"
What are "Medicaid caps?"
The final question of this series is ...
How would all this affect home care?
We might ask instead, "Why are the Republican health care bills so important to disabled people in a different way from everyone else?"
The two-word answer is: "Medicaid" and "home care."
We've already talked a bit about Medicaid Expansion, but not about Medicaid itself. Medicaid is a health insurance program operated and funded by the federal government and the governments of each state, covering a wide variety of medical services, mostly for people with very low income people. For the most part, recipients don't pay any premiums for Medicaid. Medicaid, along with Medicare which covers an overlapping population of elderly and disabled people, is the closest thing we have in the United States to a single-payer, government-funded health insurance program.
But Medicaid has a special importance for people with disabilities, because it is basically the only insurance that covers home care and a complex, essential array of other disability-specific services, like: physical therapy, speech therapy, occupational therapy, durable medical equipment, and even, in some cases, home accessibility modifications. Those of us who are disabled and on Medicaid not only can't survive without it, we can't live decent lives without it, even if we could, narrowly, avoid dying without it.
Home Care ...
A significant portion of the disabled community relies on some form of home care in order to remain independent and healthy. Let's be clear about what we mean by "home care." Home care is a very broad term that encompasses a variety of services and service approaches that may be different, but have certain key things in common:
Services are provided to a person with a disability ...
• By another person or persons ...
• For pay, under some kind of employer / employee structure, rather than a family connection or charity ...
• Authorized in some way by a medical professional, based on the served person's documented disability ...
• Provided in the disabled person's own home and / or other locations in their community, NOT in any kind of institution or facility.
When we're talking about home care, we generally aren't including other, equally important, but fundamentally different one-on-one disability services, such as: therapies, home nursing for recovery from acute illness, rehabilitation, or other services that are generally meant to be temporary, while home care is generally intended to be more or less permanent.
The other key thing to know about home care, is that while it is paid for in a variety of ways, the only consistent and complete source of funding for individual home care is Medicaid. Private insurance doesn't cover home care. Medicare doesn't cover home care. If you are very wealthy, you might be able to pay for home care out of pocket, but very few people can afford to do that over a whole lifetime.
How "capping" Medicaid puts home care at risk ...
There's nothing in either the House or Senate bills that specifically cuts funding for home care ... (but they both would eliminate important related projects, described below).
However, by limiting funding to Medicaid as a whole in each state, and setting the amounts available for each state in a way designed to ramp down funding by over $800 billion, both bills put home care at serious risk.
Any state could decide to cut or even stop covering home care, if and when their Medicaid budgets go over budget. Since home care is generally not viewed as "essential," (like emergency surgeries, hospitalization, and annual checkups), it would become a tempting target for saving money in a depleted state Medicaid systems.
Instead of disabled people having their services based on documented individual need and basic eligibility, they would be pitted against the other, often vastly different but equally compelling medical needs of every other Medicaid patient. Should a hard-up state fund home care, or pregnancy care? Occupational therapy, or cancer screenings? Suitable wheelchairs, or mental health? Every year, potentially in any state, the basic independence and well-being of significantly disabled people would be on the line in grubby, desperate competitions for adequate funding.
And make no mistake ... loss or even just reduction disability services would upend peoples' lives, and some people would die. Many of us live independently and successfully, but are just a few hours of daily service from institutionalization, or even death. There's no point sugar coating it.
On top of all this, repealing the Affordable Care Act, (ACA, a.k.a. Obamacare), would end extremely valuable programs ... like the Community Choice Option ... that have helped people move out of restrictive and expensive nursing homes, and into their own homes and communities.
This interview with ADAPT protesters spells out what's at stake:
Further reading ...
The GOP health care plan could force Americans with disabilities back into institutions
Ari Ne'eman, Vox.com - March 23, 2017
My Medicaid, My Life
Alice Wong, New York Times - May 3, 2017
I'm a Republican, and I depend on Medicaid
Jonathan Duvall, Pittsburgh Post-Gazette - June 26, 2017