BEYOND THE NUMBERS
Pushing for huge Medicaid cuts, including ending the Affordable Care Act’s Medicaid expansion for low-income adults and imposing a per capita cap, some congressional Republicans continue to claim falsely that the Medicaid expansion is squeezing out funding for other Medicaid beneficiaries. Most recently, Senator Ted Cruz and Rep. Mark Meadows claimed that seniors, people with disabilities, pregnant women, and children “have been forced onto waiting lists while money has poured into the expansion population.”
That’s simply untrue. There are no waiting lists to enroll in Medicaid. States must enroll all eligible beneficiaries, including children, seniors, people with disabilities, and adults, in coverage — without exception.
States can — and many do — have waiting lists for Medicaid’s home- and community-based services (HCBS), which give people needing long-term services an alternative to nursing homes. House Republicans have said the Medicaid expansion is responsible. In reality, there’s no connection between the two. Nine of the 11 states without HCBS waiting lists are expansion states, and the two states with the biggest waiting lists (Senator Cruz’ own state of Texas and Florida) are non-expansion states. In fact, Texas’ waiting list of over 204,000 people in 2015 represents almost one-third of the nation’s total.
At a recent House hearing, an analyst from the Foundation for Government Accountability, which has repeatedly blamed the Medicaid expansion for state HCBS waiting lists, admitted that “there is no correlation” between state decisions to expand Medicaid and HCBS waiting lists.
States have had the flexibility since 1981 to use Medicaid funds for HCBS. They can target these services to particular groups, such as people with intellectual and developmental disabilities, seniors, people with HIV/AIDS, and people with traumatic brain injuries. More than 1 million people now receive HCBS, the Centers for Medicare & Medicaid Services estimates. The strong support for HCBS has been key to dramatic progress in shifting care from institutions to the community in recent years; 53 percent of Medicaid spending on long-term services and supports went to HCBS in 2014, up from 18 percent in 1995. Due to high demand for HCBS, most states have waiting lists for these services.
The real threat to funding for home- and community-based services is the House GOP health bill. Its per capita cap would make it far harder for states to meet the need for HCBS by cutting federal Medicaid funding by growing amounts over time. Because nursing home residents would likely suffer serious harm or even death without coverage, states wouldn’t likely cut nursing home care even if they had the flexibility to do so (currently, states must cover nursing home care under Medicaid).
States would far likelier cut HCBS and other services for people in the community, so waiting lists would grow. Some states might even end their HCBS programs, which are entirely optional. Families would face stark choices on how to keep their loved ones at home.