Amber Christ: Hi everyone and welcome to today’s webinar, Protecting Medicaid from Cuts in Congress: Updates for Aging Advocates. My name is Amber Christ. I use she/her pronouns, and I’m the managing director of Justice in Aging’s health advocacy. I’m joined today by my colleagues, Natalie Kean, director of federal health advocacy, and Gelila Selassie, a senior attorney with our team. A lot has happened since our last webinar in March on protecting Medicaid. Most notably, the House passed its version of the reconciliation bill on May 22nd. And if enacted into the law, this legislation would cut over a trillion dollars in federal healthcare spending through drastic cuts to Medicaid, Medicare, and marketplace coverage. These are unprecedented cuts. When you pull out $1 trillion in federal spending from healthcare, every state, every provider, and every single person in this country will be impacted.
The Congressional Budget Office projects that 10.9 million people would lose health insurance. That 1.3 million older adults and disabled people will lose financial assistance to pay for Medicare’s out-of-pocket costs. And because the bill significantly increases the deficit, it could trigger $500 billion in cuts to Medicare. And there’s much more that will cover in detail throughout this webinar. With the passage of the bill in the House, it is now with the Senate. And just yesterday, the Senate Finance Committee released its version making even deeper cuts to Medicaid and Medicare than the House version. Lawmakers repeatedly claim that these proposed health care cuts are designed to protect older adults and people with disabilities. But as we will discuss throughout this webinar, this is not true. These cuts, in fact, would significantly harm older adults and disabled people contrary to the rhetoric being used to justify them. And despite the enormous impact the reconciliation bill would have on healthcare, it is critical to understand that at its core the legislation is a tax bill.
None of its provisions aim to improve or strengthen healthcare. Instead, they aim to do one thing, to take the money the federal government currently spends on healthcare and use it instead to pay for tax cuts that overwhelmingly benefit the wealthiest Americans. Yet right now, many people across the country do not know that that’s what’s happening. Our goal as advocates is to change that, to make sure people know that this tax bill is a healthcare bill that will significantly harm older adults and millions of other people who rely on Medicaid for their health and well-being. Today, we’re going to provide you with an overview of the healthcare proposals and their impact on older adults so that you have the information you need to defend against these cuts. But before we dive into content, just a few logistics. All participants will be on mute. If you have a question about the material being presented or a technical concern, please use the question function and we will leave time at the end for question and answer.
If you experience any difficulties accessing the webinar, please email trainings@justiceinaging.org. The materials we’ll discuss today are available on Justice in Aging’s website and our resource library, and a recording of the webinar will also be posted in the resource library and made available on our Vimeo page. The links to the resources will also be shared in the chat box. If you would like to enable closed captioning, please hit the CC function on your Zoom platform. And just a little bit about Justice in Aging. For those of you who might be new to us, we’re a national organization focused on eradicating senior poverty by increasing access to affordable healthcare and economic security for older adults with limited resources, with a focus on older adults who have been marginalized and excluded from justice, including older adults of color, older women, LGBTQ+ older adults, older adults with disabilities, older immigrants, and those whose primary language is not English.
To carry out our mission at Justice in Aging, we are committed to addressing the enduring harms of racism and other forms of discrimination across all areas of our advocacy. So turning to our agenda today, Gelila and Natalie are going to provide you with a refresher on the critical role Medicaid plays for older adults. They’re going to provide you an update of the current state of play in Congress. And the meat of today’s presentation, they’re going to provide an overview of the cuts to Medicare and Medicaid that are included in the legislation. And then we’re going to pivot to advocacy strategies, including a review of the key messages to push back on cutting Medicaid and resources you can use in your advocacy to protect access to care for older adults and people with disabilities. We’ll then open it up for questions. I’m now going to turn it over to Natalie to kick us off to provide an overview of the vital role Medicaid plays for older adults.
Natalie Kean: Thank you so much, Amber, and it’s nice to be with you all. This is hopefully a bit of a review, but an important one for all of us to keep in mind that Medicaid is just as important for older adults as Medicare, to ensure that they have access to all the support that they need to live healthy and well and stay independent as they age. More than 7 million seniors and 10 million people with disabilities rely on Medicaid. Millions more, older adults and people with disabilities and chronic conditions, are insured through Medicaid who don’t qualify on the basis of their age or disability. This includes at least 9 million older adults, ages 50 to 64, and at least 6 million people with disabilities. Medicaid is very broad. It’s much more than health insurance and covers much more than traditional medical services. Most critically for older adults and people with disabilities, it’s really the only source of home and community-based services and the only coverage for long-term nursing facility care.
It also covers things like non-emergency medical transportation that help low-income older adults get to the doctor, as well as financial assistance for Medicare beneficiaries who are duly enrolled in Medicaid. So, a little bit more about Medicaid’s role for people with Medicare. There are 12.5 million people dually enrolled in Medicare and Medicaid. This means that they have some coverage from both programs. Most of the people who are duly enrolled are age 65 and older and have Medicare for their primary health coverage, but it also includes younger people who are eligible for Medicare based on disability. But the thing that they all have in common is that they have limited income and most have higher healthcare and long-term care needs. Medicaid is what makes Medicare accessible and affordable for these individuals. Medicaid pays Medicare premiums and, in some cases, out-of-pocket costs for over 10 million people. This is help available through the Medicare savings programs.
Medicaid also covers services that Medicare does not. Medicare coverage of home and nursing facility care is very limited and much more focused on medical services and rehabilitation. For example, there’s a maximum of 100 days in a skilled nursing facility that Medicare covers, so Medicaid is what’s often picking up for older adults when they need long-term care. It also provides other services like dental, vision, hearing, as well as transportation that Medicare doesn’t cover at all. So, where are we today? As Amber noted at the top, Congress is considering some massive cuts to Medicaid as well as cuts to Medicare and the Affordable Care Act, right now. In total, we’re expecting 10 million people to have their Medicaid coverage taken away and 16 million people will be uninsured. And those are minimum estimates. The actual harm if this bill is enacted could be much worse.
Congress is looking at doing this through a process called budget reconciliation. It’s a process that’s available to Congress to fast-track legislation when one party holds the majority in both the House and the Senate and the White House. They can utilize this process to move legislation with only 51 votes in the Senate. It means this legislation is filibuster proof and could be passed without any democratic support. Budget reconciliation has specific requirements. Most importantly, that the bills included must relate to the budget and not add to the deficit over a 10-year period. The Senate parliamentarian is a person who decides what can be in the bill and what can be out, and that process is going on right now in the Senate. And notably, these rules are specific to the Senate. So what passed the House may not be able to get through the Senate’s rules. That process, again, is ongoing right now.
So, where are we in terms of this budget reconciliation bill in 2025? The House and Senate, a couple of months ago, adopted the same budget resolution, which is the first part of the process outlining their priorities for this legislation. And then in the House, we saw some process of the energy & commerce committee marking up legislation that includes these massive cuts to Medicaid. There was a hearing that went on for a really long time with lots of proposed amendments to try to limit the damage to Medicaid. Unfortunately, none of those amendments were adopted and the House ended up passing HR 1, also called the One Big, Beautiful Bill Act, we’re calling it the tax bill or the budget bill, on May 22nd of this year. It includes cuts to Medicaid spending of more than $700 billion. That is the version that passed through the House. Now, the Senate is considering this bill. We do not expect any process in the committees.
In the Senate, it’s the Senate finance committee that has jurisdiction over Medicaid and Medicare as well. They won’t be marking up a bill in any sort of public process. All of this is happening behind closed doors. As I mentioned, the Byrd bath is ongoing right now. This is the process where the Senate parliamentarian works with both senators on both sides of the aisle to decide what can remain in this bill and what can’t. We don’t expect big changes from this process. We got a new text from the Senate finance committee just last evening, less than 24 hours ago, that unfortunately changes the bill quite a bit and in a bad direction. It actually deepens the cuts to Medicaid across and will lead to more people insured. As Gelila and I go through some of the specifics today, we’ll point out some areas where we’ve already noted some deeper cuts to Medicaid. But know that our analysis of the Senate text is ongoing, and also that it’s only a draft.
We need to remember throughout all of this, we still have opportunities every single day to try to stop these cuts from being enacted. The process for budget reconciliation ends at the end of the fiscal year, which is September 30th of this year. In order to use this process for FY 2025, the bill would have to pass both the Senate and the House by the end of September. Now, leadership is saying that they really want to finish this up and pass the bill and have it on the President’s desk by July 4th. That is ambitious, but we have to take them at their word that they are moving as fast as possible. So we need to be acting right now to make sure that every senator, and the House as well because they will have to vote on this again since it will change in the Senate, that every member of Congress understands what’s in this bill.
And just a quick reminder that budget reconciliation is separate from the annual appropriations or government funding bill process. The government funding also expires on September 30th, and the FY ’26 appropriations is ongoing. You might hear other references to the budget in the news, and just know there are a couple of different processes going on right now. The main thing again though for this is this is a long process for budget reconciliation and it could drag on through the summer. August recess, as well as some other things happening like the expiration of the federal debt ceiling, could provide additional pressure points for Congress to act. We need to again be vigilant, be ready to stop it if they are going to try to vote before July 4th, but also know that we could be fighting this through the rest of the summer.
Okay. We’ve been focused a lot on Medicaid, because Medicaid has certainly been under attack and we’ve known that from the beginning. But when we saw the House bill come out, we saw even more cuts to Medicare than we had originally anticipated. And this bill takes aim at Medicare in a few different ways. One of our mantras is that a cut to Medicaid is a cut to Medicare and we’ll talk more about that later, about what this bill means for people who are duly eligible for Medicaid and Medicare. But it also ends Medicare eligibility for a large swath of lawfully-present immigrants who have lived in the US and paid into the system for decades. As Amber mentioned, it puts Medicare’s future at risk by triggering $500 billion in cuts due to the increase in the national deficit that this bill would trigger. Focusing on that second bullet, this bill takes coverage away from many lawfully-present immigrants across programs, but including in Medicare.
Right now, US citizens and lawfully-present immigrants can be eligible for Medicare. Their qualifying work history does have a different impact on non-citizens. So lawfully-present immigrants who have 40 quarters or 10 years of work history can qualify for premium-free Part A. Without the full 40 quarters, people who aren’t fully insured, only lawful permanent residents or green card holders who have 5 years of continuous residency can enroll in Medicare and they must also pay a premium for Part A. Immigrants can also qualify based on their spouse’s work history. Very importantly for this conversation is that federal law already prohibits people who are undocumented from enrolling in Medicare and prohibits Medicare payment for anyone without lawful present status. This bill and the change I’m about to show you has nothing to do with people who are undocumented. It is taking Medicare coverage away from lawfully-present immigrants who have paid into the system.
Under the House bill, and this provision appears to be unchanged in the Senate texts that we saw last night, lawfully-present immigrants would only be eligible for Medicare if they are lawful permanent residents, Cubans who entered under a family reunification program, or people residing under the Compacts of Free Associations. These are citizens of Micronesia, the Marshall Islands, and Palau. Every other category of lawfully-present immigrant, regardless of being otherwise eligible for Medicare, will no longer be eligible. These include people with work visas, temporary protected status, refugees, asylees, survivors of domestic violence, spouses and children of citizens who are here with visas. Many categories of immigrants will no longer be eligible for Medicare, and those who are currently enrolled in Medicare will have their coverage terminated after one year. I just want to note too that of the estimated 16 million people who are going to become uninsured if this bill is enacted, over 90% of them are US citizens and lawfully-present immigrants. There’s a lot of rhetoric about what this bill is doing and who is going to lose coverage. And immigrants who are here lawfully and lawfully present are absolutely going to be losing coverage.
This change is shocking and very concerning for a number of reasons. It’s taking Medicare away from older adults and people with disabilities who again have worked in the US and paid into the system for decades, and it’s decoupling social security eligibility and Medicare eligibility. Fundamentally, it’s breaking Medicare’s promise. In this country, when you work and pay taxes, you expect to have health coverage when you retire or can’t work due to disability. Unfortunately, many of the people who lose Medicare will become uninsured because the Senate is also proposing to exclude the same categories of lawfully-present immigrants from Medicaid, as well as excluding them from tax credits to buy their own coverage on the marketplace so they won’t have any affordable health coverage available. This harms US citizens as well. There’s the universal impact of adding to the uninsured rate, but also many people who will lose coverage.
Many of these immigrants work as paid caregivers to older adults and also play important roles in their own families and households. They enable other people in their family to work, and this is just going to grow the direct care workforce crisis that we already have as 1 in 4 direct care workers are immigrants and may not have a path to citizenship open to them. All right, moving on to Medicaid. I’m first going to provide a quick overview. We’ve been using this slide to show the different types of Medicaid cuts that we’ve been looking out for. And unfortunately, this bill includes nearly every type of cut that we were worried about and even more cuts were included that weren’t originally on our radar. It does cut the federal assistance percentage, it restricts provider taxes, it adds work requirements, it repeals regulations and minimum quality requirements, and provides even more eligibility and enrollment restriction.
Again, these cuts total to nearly $800 billion. There’s a long list of cuts, but the total impact is really big. Even though we haven’t yet seen block grants or per capita caps, I think the total impact of these cuts is still nearly the same. I do want to also note that the reason why this bill doesn’t use block grants or per capita caps is because of our advocacy, our collective advocacy. Everyone on this call speaking up, raising the importance of Medicaid, making sure that members of Congress understand that they cannot gut this program. Our key messages from the top, all of these Medicaid reforms are cuts. It’s impossible to cut hundreds of billions of dollars without taking people’s healthcare away. Over 10 million people will have Medicaid taken away. 16 million people will become uninsured. And again, the explicit goal is to generate federal government savings to pay for tax breaks that primarily benefit the very wealthy.
The costs will be pushed to states, and states will be forced to fill their funding gaps by cutting benefits and/or eligibility. Medicaid is already very lean and cost efficient so when these cuts come through, older adults and people with disabilities will be harmed. We’re going to walk through again some of the provisions in the House bill. As we mentioned, the Senate text changes some of these provisions. We’ll try to point out a few places where it does, but know that we will have more analysis of that soon. The bill really attacks immigrants in multiple ways and will make it impossible for many who are lawfully present to find any coverage. One of the ways it does this is by penalizing states that choose to cover immigrants regardless of their immigration status, threatening them with cutting funding for their expansion population by 10% if they continue to provide this coverage with their own state funds.
15 states would be penalized because they provide health coverage regardless of immigration status, including several states that provide coverage to older adults regardless of immigration status. And it could, as written, impact as many as 38 states that cover immigrants paroled into the US. The bill would also end an extra 5% FMAP incentive or federal funding incentive for states that have not yet expanded coverage. In addition to attacking immigrants, another theme of this bill is really discouraging any new states from expanding Medicaid. The bill also restricts provider taxes. And this, despite being a wonky issue, poses a really serious threat to home and community-based services in particular. Every state but Alaska uses provider taxes to fund their share of costs. And as a reminder, the FMAP works as a reimbursement. So states have to spend their own money first before they can receive the federal match.
Restricting these taxes is another way of shrinking state Medicaid spending with the goal, again, of cutting people off to reduce federal spending. So, cuts by another name. The House-passed bill would prohibit states from establishing any new provider taxes or increasing existing taxes. This applies regardless of how many taxes or whether the state is already taxing up to what is currently a 6% safe harbor amount. That acts kind of like a cap on these taxes. The Senate actually deepens these cuts, so they would drop that safe harbor from 6% to 3.5% for states that have expanded Medicaid. The 10 states that have not expanded Medicaid would still not be able to institute any new provider taxes, but their safe harbor would remain at 6%. The bill also would restrict state-directed payments and managed care. This is just another way too that there’s a discrepancy in how the bill treats expansion and non-expansion states.
So, how does something like a provider tax impact older adults? The main takeaway here is that it’s going to shift costs to states and states will be forced to cut spending, and they’re going to cut Medicaid spending because Medicaid is such a large portion of their budget. Not only is Medicaid federal funding being cut and states having their budgets shrink from that, but also there’s going to be a lot of additional pressure from administering work requirements. There are $300 billion in cuts to SNAP and a lot of that funding is going to be shifted onto the states for the first time ever, as well as the expiration of American Rescue Plan Act funding that specifically supports home and community-based services. So when states are facing these pressures, their options are to cut optional benefits or eligibility categories, cut enrollment or cut provider payment rates. And these all harm older adults and specifically home and community-based services.
The reason is because 86% of what are considered optional Medicaid spending on Medicaid services support older adults and people with disabilities. Home and community-based services accounts for 51% of all optional spending. So more than half of states spending, that’s discretionary is another way of thinking of that, is on home and community-based services. And it accounts for almost a third of all Medicaid spending. We know from history this means every state will cut home and community-based services in some way. Following the great recession, after 2010, every single state cut one or more of their programs. Those spending cuts averaged 10 to 12% for waivers and personal care services and 22% for home health. The reductions in the number of people served ranged from two to 15% across states. And these cuts also led to longer waiting lists for home and community-based services.
I’m sure you all see it in your own states, when the budgets are tight, cuts to HCBS get proposed. But we have an example here of when a large amount of federal funding was taken out, this is what happened and so we can expect similar cuts, if not even worse, if this bill is enacted. With that, I am going to turn it over to Gelila.
Gelila Selassie: Thank you so much, Natalie. As Natalie mentioned, this is a really terrible bill, made worse by the Senate bill from yesterday. One of the biggest provisions and most harmful provisions are the work requirements that would be imposed on all states and the District of Columbia. And it requires them to implement work requirements, which they call community engagement activities, for all adults ages 19 to 64. It would require Medicaid enrollees who are very, very low income to report 80 hours of work, community service, job training or schooling or some kind of education program. Under this bill, the states are not required to provide automatic exemptions and there’s virtually no flexibilities for states to provide exemptions in the House bill. The Senate bill does give a little bit of leeway for states who are acting in good faith for a time limited exemption. So even then, it’s very, very limited and it’s at the discretion of the secretary of Health and Human Services.
It makes it very difficult for people to receive any kind of exemptions based on the needs of their state. So it really forces states in a tough position where they’re having to impose these really burdensome requirements, and we’ll go into more detail of how difficult it is for states, on top of the burden and the challenges it poses for individuals. The work requirements need to be satisfied for at least one month prior to enrollment. Someone has to already be meeting these requirements before getting Medicaid. And then it can be verified through 6-month re-determination periods, and those states can require more frequent ones. That’s another challenge that we’ve seen in states that did implement work requirements is the reporting process, how difficult it can be, how burdensome it can be. So people, even if they are following the rules, the reporting requirements and the frequency of it can also just make it more difficult to report it, and so they lose coverage even though they’re doing what they’re supposed to under the requirements.
This bill effectively targets the Medicaid expansion population. For the 40-41 states and the District of Columbia that expanded Medicaid, this is really targeted toward that population. However, it could still apply beyond the expansion populations to certain groups who are getting Medicaid under particular waivers. Wisconsin has one that provides coverage to childless adults. We’re still trying to figure out what this means. But basically if you’re in a non-expansion state, that doesn’t mean that you are in the clear from work requirements. There are particular Medicaid groups, mandatory groups like someone in a disability pathway or someone who is receiving Medicaid as a pregnant person. There are exemptions for that or they’re not subject to this provision at all. But aside from that, there are other pathways where this could apply. That’s just something to keep in mind and something that we’ll be looking at very closely as we dive deeper into the Senate bill. Next slide.
So, why are work requirements so harmful? 5 million people are estimated to become uninsured under the work requirements. One really important thing to note is that most people who are on Medicaid are working or caregiving. They may have a disability or they’re in school. That’s the truth. Most Medicaid enrollees are working or are doing something else or have something else that prevents them from working. That’s a really, really important distinction. This is especially harmful for older adults aged 50 to 64 and people with disabilities who are disabled but are not eligible for Medicare or Medicaid because of very strict disability rules. We’re going to go through this through a few examples, but getting disability-based programs can be very long. It can require a lot of paperwork, it can require a lot of medical visits, and so trying to get on these programs is, like I said, very difficult.
Medicaid expansion can provide a little bit of relief for people who are disabled. That’s a huge note. Millions of people who are disabled are receiving Medicaid through Medicaid expansion because the other pathways are so difficult, so whatever sort of image that might be presented of the average Medicaid enrollee is false. This is especially too as people age. We’re especially concerned about that 50-up population who are more likely to have chronic conditions or a disability that prevents them from working. The exemptions are extremely narrow and burdensome. One quick note between the House and the Senate bill is the exemption for caretakers or caregivers. The Senate language has family caregiver as an exemption, which under the statute it’s referencing refers to people who is taking care of a family member or other individual who provides a broad range of services for a chronic health condition or disability or functional limitation.
In this House bill, there was a very limited definition of a parent or caretaker who might be exempted from this bill, whereas now it might be a little bit broader. But again, it’s something that we’re diving into. And then just again to reiterate, the massive administrative burden impacts all Medicaid enrollees including older adults. Georgia has a limited Medicaid expansion program through their waiver and that has work requirements. And 90% of the $26 million of that program went to administrative costs, which that money would’ve been better spent on actually providing services. On top of that, applications for Medicaid, assistance with Medicaid, redeterminations, all that took longer for all Medicaid enrollees because so many workers were wrapped up in the administrative process for these work requirements. Once again, there really is no way to carve out any population. Next slide. We’re going to talk a little bit about this paradox of having to prove your disability for purposes of getting a work requirement exemption. The bill uses the language of medically frail as one group that is exempt from work requirements, which that language isn’t great.
But because that’s what’s in bill, that’s what we’ll refer to. And it’s effectively provides a list of people with certain types of chronic illnesses or disabilities who would be exempt. This category of exempt individuals are those who, like I said, are not enrolled in a specific disability pathway like Medicaid if you’re receiving SSI or Medicaid under the blind and disabled categories. Because it’s not well-defined and because we are not sure what that process is, we’re very concerned that people who have disabilities are going to be effectively told that, “Because you’re not proving to us that you’re disabled, we’re not going to grant you an exemption.” I’ll provide a couple of examples, but effectively to show that you’re disabled can create this massive catch-22. Because oftentimes you’ll need healthcare, you need medical documentation, you need access to a physician, you might need some medical forms filled out, you might need medical records. All of that might be needed to show why you are medically frail or have a chronic condition or whatever else. But how can you get that if you don’t have healthcare to begin with? Next slide.
Here are 2 examples that we’ll utilize just to compare the situations of someone who gets Medicaid under expansion versus somebody who has to go through these incredibly arduous work requirement exemptions. Maya had to quit her job because she has severe pain following an accident. She applied for SSI, which is through Social Security for people with disabilities, but was denied and told that she could appeal. But that appeal process can take up to 2 years. Fortunately, her state has Medicaid expansion so she can access crucial treatments during that 2-year period while she’s waiting for her SSI. So not only will Medicaid cover her treatment so that she can get rehabilitation services, she can get medications, she can visit her doctor, but she can also collect medical documentation of her disability for her SSI hearing. There’s 2 benefits there. Not only does she have access to healthcare, but it’s going to help her get other benefits as well to show her disability.
And then compare that with someone like Neil who had to cut back his work because of his diabetes wasn’t well controlled, so he had extreme nerve pain. His state will only give him Medicaid if he shows that he is medically frail, which requires extensive medical records and documentation. Because he’s uninsured, he’s unable to show that he’s medically frail because he can’t afford the out-of-pocket cost to visit the doctor. And then, of course, he can’t afford medication as well. Over time, his health eventually deteriorated to the point where he was hospitalized for gangrene and vision loss. Although he later qualified for Medicaid under the blind and disabled pathway, the coverage arrived too late for him to return to the job that he really loved. These are 2 hypotheticals that were altered a little bit, but based on real individuals who had similar experiences in going through this process. So if you look at a situation like Neil, how can he get coverage if he has to prove all this? And waiting to the point where he can no longer work is a huge, huge challenge.
It just shows why the able-bodied language that we’ll talk about in a little bit is really insufficient for capturing that Medicaid expansion population. It is not a good phrase and it just does not capture who is actually on Medicaid. If we turn to the next slide, we’ll discuss a little bit more about who is with some of our messaging tips. One thing to note is that work requirements are also job loss penalties, on top of all the challenges and difficulties I mentioned on the administrative burden and the challenges for people with disabilities. If you’re on Medicaid expansion and you’re fulfilling the work requirements, if you lose your job, you lose Medicaid as well because you can only get Medicaid if you prove you are working. So it effectively penalizes you for losing your job, which can be very problematic if we’re in a precarious economy or if the type of industry a person is in is dwindling and what kind of employment they have.
It’s really important to push back that the only people who deserve healthcare are people who are working or working a certain amount or working paid jobs. Medicaid is not a luxury and, as Natalie said, it covers a wide range of services that people need to be healthy. So the more requirements we add on this group is again, who are very low income, is really taking away something so incredibly vital to make sure that they’re living healthy lives. And then as I mentioned, there’s been a lot of disparaging of Medicaid enrollees by supporters of the bill and by members of Congress with the implication that people can work and won’t. And that is incredibly misleading. As I mentioned, most Medicaid enrollees are working or disabled caregiving in school. And then it’s really important to note who is going to lose their coverage under this horrible able bodied language that, as you mentioned, does not fully capture the wide range of people with disabilities who are enrolled in Medicaid expansion.
One thing to note is that 4 in 5 of expansion enrollees are women. 1 in 4 are age 50 and over. Most people left work to care for a parent or adult with disabilities. All of them are low income by virtue of being enrolled in the program and half would be eligible for SNAP, which are food stamps. And 1 in 4 live in rural areas, so they already may have some challenges accessing healthcare being in a rural area. Many older adults and people with disabilities and chronic conditions, as I mentioned, are going to be enrolled in Medicaid expansion. Another huge concern is the impact on both paid care workers as well as unpaid caregivers. Because a lot of people cannot work to care for a family member, unpaid caregivers could lose their own healthcare coverage. So, what does that mean for the older adult or the disabled person that they’re caring for?
Relatedly, even paid care workers, nurse aides and CNAs, they make very little and their hours vary a lot, so they could lose their Medicaid because they may not able to keep with the reporting requirements necessary. Work requirements really have an all-encompassing impact on older adults, but particularly so for the Medicaid expansion population. Next slide. And then we’re going to go through some other provisions of the bill that are particularly concerning. One is the repeal of really important regulations that were published in the last couple of years, that were aimed at improving access and quality of care from Medicaid enrollees. The first is the eligibility and enrollment rules, which streamlines the process for people to get on and keep their Medicaid, and it was aimed at preventing people from losing coverage for these various processing barriers. There were also a lot of protections under these rules for seniors and people with disabilities who are duly enrolled in Medicaid and Medicare under the Medicare Savings Program or MSPs. That helps low-income Medicare enrollees pay for their Medicare premiums or their Medicare out-of-pocket costs.
Even though it’s called a Medicare Savings Program, it’s actually done through Medicaid and so it works together. The rules would’ve ensured that people who are enrolled in MSPs, particularly people who are very low-income and enrolled in SSI, will be able to get enrolled in that coverage more quickly and without all the barriers that can happen when dealing with these 2 massive programs. And then the rule also establish some parity for people who are on HCBS to allow them to spend down their costs so they can get Medicaid more quickly, which is something that’s allowed for nursing facility residents but was not provided for people who utilize home and community-based services. Under this bill, if this bill would become law and these regulations are repealed, 2.3 million people would lose Medicaid per the Congressional Budget Office, more than 1.3 million duly eligible Medicare Medicaid enrollees would lose cost-sharing assistance through those MSPs.
As I mentioned, this is a very low-income group with very limited assets, just barely above federal poverty level, who would not be able to access their Medicare because they can’t afford it with the loss of MSPs. And then looking at a couple states that really would suffer losses, Florida with 120,000 people would lose coverage for MSPs and it would be 75,000 in Texas. Again, very low-income seniors and people with disabilities who would be affected. The bill would also rescind the nursing home minimum staffing rule, which requires a minimum number of nurses and nurse aides in the facilities. And that’s because under-staffing is the biggest reason for the preventable deaths and injuries that we often see in nursing homes. This rule is estimated to save 13,000 lives that are now in jeopardy because the bill would effectively by delaying implementation to rescind the rule.
Next slide. And then I’m going to skim through some of these other eligibility restrictions. First is freezing the maximum allowable home equity limit at $1 million. Currently, it’s between 730 and a little over 1 million. This is adjusted for inflation and this is controlled by states. States can set this limit between 730 and just under 1.1 million. But it is adjusted for inflation because property costs rise. This bill would not allow that adjustment for inflation would cap it at 1 million. It does have exemptions for agricultural lands, but it makes it really hard for older adults who might need long-term care. There are many seniors who are House rich, cash poor, may have bought property decades and decades and decades ago for a small fraction of what it is today. So even if they are having fixed incomes that are very low, their house is really their only asset. And if they have this home equity limit, then that would impact their ability to get long-term care through Medicaid.
The bill would also limit retroactive coverage. The House bill was going to reduce the retroactive coverage for Medicaid, from 3 months to 1 month before the month of application. Now, the Senate bill changes that to 2 months for all Medicaid enrollees except the expansion population, so it still reduces it from the current 3-month level. And then the expansion population only gets one month of retroactive coverage, and this is especially important because retroactive coverage is one tool that helps people access nursing facility care. Providers are going to be much more likely to provide assistance and help people out and accept them if they know that they can apply for Medicaid later after they get treated and then get the cost of care covered earlier through this retroactive provision.
And then lastly, the bill also eliminates the requirement for coverage during a reasonable opportunity period where older adults would have their immigration statuses verified. And older adults are more likely to have missing data from Social Security or the Department of Homeland Security, which requires longer time to verify their eligibility. This is also very problematic and, also is another thing like Natalie said, is aimed at punishing immigrants. So just some key messages, if we can go to the next slide. As I mentioned, there are no carve-outs, no way to shield older adults from harm. It’s really important to make clear that seniors and people with disabilities are hurt. Medicaid is important for all populations. We cannot hit Medicaid groups against each other because, as we’ve seen with all these other provisions, a cut to one person is a cut to all.
And then if I can jump over, for purposes of time, a couple of slides, for what you can do. It’s really important you educate policy makers and the public on the importance of Medicaid for older adults. Lots of people know about Medicare, but Medicaid is also a really important program for seniors. So be sure to share resources and you’re welcome to use Justice in Aging resources, and then make sure everyone knows that this tax bill that the Senate is going to be voting on soon cuts Medicaid and Medicare. Polling shows that about half of voters are not aware of the implications of Medicaid and other healthcare cuts in this bill. And when they are informed, they drastically oppose it.
Next slide. What else you can do? Another thing you can do is storytelling, which is incredibly powerful. Members of Congress love stories, and they and their staff don’t always understand how important Medicaid is for older adults. That’s really important to share through news media, through op-eds or opinion pieces, blogs, social media, rallies, virtual or in-person, as well as just individual conversations. And then if we come to the next slide, there’s also just direct advocacy. Make sure that you let your member of Congress know as a constituent that you oppose these cuts, and see if we have a link where you can see what states are saying about the impact of Medicaid and how it’ll impact your state or even your particular district. One other thing I’ll note is when talking about Medicaid, it’s really important to use the name of your local Medicaid program.
Sometimes it’s referred to as BadgerCare or SoonerCare or Healthy Living, and so people on these programs might not realize that that program is what’s getting cut. On the next slide, we have some ways to get involved by joining our listserv and getting our alerts, as well as joining the Protecting Medicaid Space listserv and using their toolkits. And then I’ll just highlight again, these key messages, that all of these efforts, these reforms are cuts to Medicaid to provide savings for these tax cuts. It’s going to shift massive costs to the states who will be forced to make cuts to benefits or eligibility. So as a result, people lose coverage. It cuts Medicare too, and there are no carve-outs or shields for older adults or people with disabilities. The next couple of slides are some really helpful resources from Justice in Aging, as well as some other resources as well. With that, I don’t know how much time we have for questions. I apologize for that.
Amber Christ: I think I’m actually going to turn it over to Natalie to do some last minute reminders.
Gelila Selassie: Perfect.
Natalie Kean: All right, sure. Yeah, thanks everybody for sticking with us. I will point out real quick this top resource on the Justice in Aging slide, the analysis of HR 1’s Medicaid and Medicare provisions impacting older adults. That’s our newest resource, going through the provisions of the bill in more detail. So if you’re really wanting to understand what’s in this bill, encourage you to check that out and we will be updating it as soon as we can with changes that the Senate might be making. All right. Just our final reminders. Medicaid is popular, but we have to tell people about it. As Gelila said, education is so important. Call the Medicaid program by the name and your state, the waiver by the name so that people know you’re talking about Medicaid, and tell them that Medicaid is being cut in the tax bill that Congress is considering.
It’s not intuitive that Congress would be cutting Medicaid in a tax bill, so we need to get the word out there. Seize any opportunities you have to talk about Medicaid. Make it personal. We know that’s vulnerable and it can be hard to tell your story, but everyone has older adults in their lives. And Medicaid is our long-term care system, so I’m sure we all have a connection to the program. Sharing those stories and making it personal really helps. The fight is still far from over. It’s long, but we can still stop this together. So really, thanks to our advocacy. Medicaid is at the top of mind, and we are breaking through. Thank you all for being with us.
