Amber Christ: Hi everyone and welcome to today’s webinar, Medicaid Cuts in H.R.1-Updates for Aging Advocates. My name is Amber Christ, I use she/her pronouns, and I’m the managing director of Justice in Aging Health Advocacy. I’m joined today by my colleagues Natalie Kean and Gelila Selassie, directors on our health team who have been leading our federal advocacy to defend Medicaid. Before we dive into content, just a few logistics. All participants are going to be on mute, so if you have a question about the material being presented or a technical concern, please use the question function. We will also 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’re going to discuss today will be available on Justice in Aging’s website and our resource library and a recording of this webinar will be posted in our resource library and also made available on our Vimeo page.
The links to the resources will also be shared in the chat box. And if you would like to enable closed captioning during this webinar, you can hit the CC function on your Zoom platform. So just a little bit about Justice in Aging. For those of you who might be new to us, we are a national nonprofit organization and we’re focused on eradicating senior poverty by increasing access to affordable healthcare and increasing economic security for older adults with limited resources. We focus on older adults who have been marginalized and excluded from justice, including older adults of color, older women, LGBTQ plus 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 ensuring that everyone has access to what they need as they age without discrimination. Our advocacy is rooted in ensuring that those experiencing the greatest barriers to economic security, healthcare and housing can exercise their rights and fully access the services and programs they need.
The passage of Budget Reconciliation Act of 2025 or H.R.1 is an attack on that vision and makes the largest cuts to Medicaid funding in history, while also stripping away eligibility and essential coverage from millions of older adults with limited resources. We at Justice in Aging are committed to fighting back against this law. To that end, we are providing extensive education on what is in the law and how it will impact older adults. And we’re equipping advocates with the tools to reduce the law’s harm during implementation, ensuring older adults, their families and caregivers maintain access to essential health and long-term care.
So turning to today’s agenda, Natalie and Gelila are going to provide a detailed overview of the changes to Medicaid and Medicare and H.R.1, with a focus on the provisions that impact older adults. This overview will include a timeline of when those changes will go into effect, and we’ll also be providing advocacy tips on how to start mitigating the harm as this law is implemented at both the federal and state levels. We’ll also do a preview of some new resources we have developed and we’ll leave it open for question and answer at the end. So with that, I’m going to turn it over to Natalie to kick us off.
Natalie Kean: Thanks, Amber. Good afternoon everyone. My name is Natalie Kean. I’m the director of Federal health Advocacy at Justice in Aging, and I use she/her pronouns. Before we get into the details of H.R.1, we want to provide a quick refresher on Medicaid’s role for older adults. More than 7 million people aged 65 and older and 10 million people with disabilities rely on Medicaid. Medicaid also helps more than 12 million people with Medicare access the care they need and millions more older adults and people with disabilities and chronic conditions are insured through Medicaid expansion. And this includes over 5 million older adults, ages 50 to 64 who are enrolled in Medicaid expansion. Medicaid is also not like other typical health insurance. It’s much broader and it really fills in a lot of gaps for older adults who have Medicare. Medicaid covers things like home and community-based services as well as long-term nursing facility stays. It covers things like non-emergency medical transportation that help people get to their doctor’s appointments and it even provides financial assistance for Medicare beneficiaries who are dually enrolled in Medicaid.
So turning to H.R.1 itself, this is a budget reconciliation bill that passed Congress on July 3rd with only Republican votes and it was signed by the president into law on July 4th. The bill was previously named the One Big Beautiful Bill Act, but that name was stripped just before it was passed, and so we will be referring to it as the Budget Reconciliation Act of 2025 or H.R.1 for short. As Amber mentioned, H.R.1 makes the largest cuts to Medicaid in the program’s 60-year history, about $990 billion, so almost a trillion dollars in cuts according to the official score from the Congressional Budget Office. This is nearly four times as large as any previous Medicaid cuts in the program’s history, and when you add cuts to Medicare and the ACA in H.R.1, the total is well over a trillion dollars in cuts to healthcare. The other measure of the law’s impact that we have right now is how many people will become uninsured.
H.R.1 itself is expected to terminate coverage for at least 10 million people, mostly Medicaid enrollees. And then because Congress chose not to extend the Affordable Care Act enhanced premium tax credits in this bill, another four to 5 million people could become uninsured if those tax credits expire at the end of this year. So we’re looking at a total of 15 million people who will become uninsured over a 10-year period, as this bill is implemented, this law is implemented. In terms of the big picture of how these cuts will result in that coverage termination, H.R.1 cuts federal Medicaid funding and shifts cost to states. This will force states to cut their Medicaid services, eligibility or provider reimbursement and likely they will cut a combination of these. The law also increases barriers to accessing Medicaid, things like work requirements that we’ll talk more about in detail. And it also directly terminates eligibility for Medicaid, Medicare and ACA tax credits for many lawfully present immigrants.
So we have a few slides going through an implementation timeline. I am going to go through this quite quickly because we’ll be going over many of these changes in detail later in our presentation. Also, we have a new explainer with a graphical timeline that helps illustrate how the changes impacting older adults are clustered around a few key dates. So we encourage you to check that out for more detail. Several provisions of the law took effect right away, when the bill was signed. These include the moratoriums on the nursing home minimum staffing and Medicaid streamlining rules. Certain lawfully present immigrants are no longer eligible to newly enroll in Medicare and states are prohibited from implementing new provider taxes to fund their share of Medicaid costs. States are also permitted under the law to begin work requirements, whether or not they had a waiver in place or pending.
And then next year, in 2026, at the beginning of the year, and actually even this fall, as people are looking to enroll in the ACA marketplace, those premiums are going to be spiking for everyone, but especially for older adults if Congress does not extend the enhanced premium tax credits. And then later in 2026, in October, many immigrants will have Medicaid terminated and they will no longer be eligible for ACA premium tax credits at the end of 2026.
A lot of the changes we’re going to talk about today that really impact enrollees take effect in 2027. In January is when all states are required to start imposing work requirements on most adults ages 19 to 64. Coverage renewals for the expansion population will become more frequent, at least every six months, and the retroactive coverage period will be shortened. A couple days later in January, older immigrants who are already enrolled in Medicare but no longer eligible under the new law will have their coverage terminated. And in October, states that have expanded Medicaid and use higher provider and insurer taxes now will have to cut those taxes back to meet a new lower safe harbor limit.
In 2028, the Medicaid long-term services and supports home equity limit will be reduced to $1 million in 12 states that currently have a higher limit. Provider taxes and state directed payments, which states, again, use to fund their share of Medicaid costs are going to be further limited. States that choose to take up a new 1915 C waiver option under the law can begin to get approval for those waivers and expansion enrollees are going to start facing copays for many healthcare services. And by the end of 2028, states that received a good faith effort waiver for their work requirement implementation will be required to fully implement those work requirements, so that the good faith waivers expire at the end of 2028.
So that’s an overview. Some changes do take effect later in that period, but the bulk of them will be in effect in the next few years. And we’re going to dive more into more detail on what some of these changes mean for older adults. As I mentioned, H.R.1 cuts federal Medicaid funding in several ways. It restricts state’s ability to fund their share of Medicaid costs by freezing and reducing provider and insurer taxes. These taxes are something that every state, except for Alaska, uses to help fund their share of Medicaid costs and they’re really important because states need to spend their own money first before they can receive reimbursement from the federal government. So the federal match, known as the FMAP, kicks in after a state spends money. If a state has less of their own money to spend, they will also be getting less in federal reimbursement.
The law also ends an extra 5% federal match incentive for states that have not yet expanded Medicaid. It reduces the federal match for emergency Medicaid services provided to adults who are ineligible for Medicaid due to immigration status. And in addition to these, it undermines Medicaid expansion in several ways. It penalizes Medicaid expansion states more heavily. It disincentivizes non-expansion states from expanding and it reduces enrollment in Medicaid expansion. And this is really significant because states that have expanded Medicaid receive a 90% match, at least a 90% match, from the federal government for their Medicaid expansion population. And so if they have fewer enrollees or a harder time keeping that expansion going, that’s less federal funding.
A little bit more detail on restrictions on the funding mechanisms in terms of the provider and insurer taxes, there are provisions that impact these taxes in a couple of ways. First, the law is prohibiting all states from establishing new provider taxes or increasing existing taxes. And second, for Medicaid expansion states, the law lowers the safe harbor limit for these taxes from 6% to 3.5% in 2032. So this effectively acts as a cap on how much revenue states can raise through these taxes. And you can see in an expansion state, it’s effectively cutting that cap in half. So non expansion states can continue to tax up to 6%. And then also the taxes on nursing facilities are subject to the freeze. So states cannot implement new taxes on nursing facilities, but they can still, those that have taxes up to the 6% threshold can keep those taxes.
There’s another section of the law that also restricts state directed payments and managed care with more severe restrictions for expansion states. These payments are tools that states use to increase Medicaid providers in certain specialties, especially to address shortages of providers. So all of these cuts along with cuts to the SNAP nutrition program and new administrative costs for administering work requirements and things really leave states holding a huge bill, and states have to balance their budgets and Medicaid is one of the biggest line items in most states budgets. So that means they’re forced to cut benefits, enrollment or provider payment and likely will cut a combination of those to balance their budgets. In terms of which benefits the states will cut, the benefits that are optional under federal law will be targeted because they can be cut. They are optional. A lot of programs that older adults and people with disabilities rely on every single day are actually optional under federal law. They’re not mandatory for states to provide.
These optional services include home and community-based services, things like dental, vision and hearing that Medicare doesn’t cover. It also includes optional eligibility pathways that benefit older adults, such as the special income rule and spend down or share of cost eligibility. States that choose to cover immigrants with their own state funding might have to roll back that coverage because they can no longer afford it. And then in terms of other cuts to enrollment, states that have expanded their aged and disabled eligibility or eligibility for their Medicare Savings Programs might choose to roll back that eligibility to the federal minimum.
And also states are likely to provide payment rates or at least not increase them. This will certainly worsen what’s already an existing direct care workforce shortage and make it harder for older adults to access long-term care. And home and community-based services are particularly at risk because they account for over half of all optional spending and almost a third of all Medicaid spending. And we know from history that HCBS are cut when Medicaid funding is cut or when state budgets are tight. And we saw this after the Great Recession, but I want to encourage us not to let history repeat itself here. We really need to be making noise and engaging policymakers at every level to do everything they can to stop HCBS from being scaled back. The law does not prescribe these cuts, but it is going to be a very hard fight to keep HCBS from being cut. And later on, Gelila is going to talk about some of our mitigation strategy ideas, but for now I will hand it to Gelila to talk about work requirements and other provisions of H.R.1.
Gelila Selassie: Thank you so much Natalie. Just to [inaudible 00:19:54] Natalie’s earlier point, that we’re still in early days, and particularly on work requirements and some of these other pieces, we are expecting more guidance and information through regulations or informal guidance from the federal government, from Health and Human Services or centers for Medicare and Medicaid services over the next months and years. So with that, just keep that disclaimer at the back of your mind, that we may still have a lot of unanswered questions as to some of these details in the law. But to start, work requirements are one of the biggest pieces in H.R.1 and is responsible for a pretty significant amount of the anticipated coverage loss. It would apply to adults aged 19 to 64 who would now be responsible for completing 80 hours of qualifying activities per month. And by qualifying activities, that can be employment, volunteer work, so paid employment, volunteer work, job training or schooling.
And as a note in the law, this is work requirements are phrased as community engagement activities. So you may see it as either over the next few months. And work requirements don’t apply to certain Medicaid population. So people enrolled in the Aged, Blind, Disabled Medicaid program or getting Medicaid for their pregnancies, those are not subject to these work requirements. And there are additional exemptions, but it’s really important to know that these exemptions are still very limited and there are no automatic exemptions and there is no flexibility for states to provide additional exemptions beyond what the law provides. So it does limit states in some ways and the exemptions they can provide.
People must show that they are working for at least one month prior to enrolling in Medicaid and prior to their eligibility redetermination. So they can’t get Medicaid first and then enroll in a qualifying work activity. They have to first get that job or volunteer work or whatever else and then apply for Medicaid or get Medicaid. And there’s something that was added fairly late is that there is a lockout provision in the law. And so that means that individuals who are not in compliance with these work requirements can also not receive marketplace subsidies. And so this would be somebody who is subject to the work requirements, between the ages of 19 to 64 and not enrolled in one of these other types of Medicaid programs like the Aged, Blind and Disabled program, but they also don’t qualify for an exemption, which, as we’ll get to, is pretty limiting. Well now that individual, even if they would normally qualify for marketplace subsidies, if their income was above 100% of the federal poverty level, they would not be able to do that under this law.
So that’s really concerning and that can lead to a lot of people being uninsured because now they really have no option. The work requirements are targeted to the Medicaid expansion population, that ACA expansion population, but it’s not specifically stated in the law that it only applies to the expansion population. So it can also apply to states like Georgia or Wisconsin that use special Medicaid waivers, 1115 waivers to apply very similar expansion-like services to a similar population. And so as we progress, we’ll continue to monitor if there are any other special Medicaid groups that aren’t subject to the exemptions, but could be subject to work requirements. And looking into some of the harms of work requirements, as I said, this is the biggest basis for the Medicaid coverage losses. 5 million people are estimated to become uninsured. That number is really likely to impact older adults, aged 50 into 64, and people with disabilities who can’t get Medicaid or Medicare for their disabilities because there are very strict Medicaid rules for how to get disability and what is defined as a disability.
So we know that the expansion population does cover a lot of people with disabilities, but they are, for bureaucratic reasons or anything else, they’re limited from getting other types of Medicaid for their disability. And so that’s really, really concerning. As we mentioned, the exemptions are pretty narrow. We’ll talk about the disability exemptions in a bit more detail, but disability is not well-defined. Neither is chronic conditions or any of the other stated exemptions in the law. And parents, guardians and caretakers and family caregivers are also exempt. But again, that definition is pretty limited. So parents of minor children under 13 or caretakers who provide for a family member with a disability is as it’s defined in another statute, the RAISE Family Caregiver Act. We’ve seen, as states have done work requirements, that it’s always failed to, one, get people working and two, ends up harming not just the population that’s subject to work requirements, but also other Medicaid populations as well.
That’s particularly true in Georgia, where there were massive administrative burdens that hurt both the expansion population and other Medicaid populations as well, including older adults. So when Georgia instituted their 1115 waiver that included work requirements, the state spent 90% of their $26 million on the program just on administrative costs to implement the waiver. So that money could have gone to services and everything else, but instead was going to the administrative costs. And then relatedly, there were delays in applications for everybody and a lot of limited customer support because so many of the state’s resources was going into implementing work requirements. So we’re using that as a how not to act in terms of how this will be implemented across all states, moving forward. Next slide. And we do have some resources about some of the challenges of proving disability. We have a blog that highlights how difficult this can be and creates a bit of a paradox.
So as I mentioned, the law does list out, medically frail is a terminology they use, medically frail individuals as exempt, as well a list of chronic conditions and disabilities that can also be exempt as well as a list of examples. But one thing that’s really important to know is that this category of people who are exempt, that aren’t enrolled in disability specific programs like SSI, which is where a lot of people with disabilities get Medicaid, or Medicaid for blind and disabled programs. And we’ve seen when people try to show their disability for some of these Medicaid programs, that it’s an impossible catch-22. Very often, you need medical documentation and medical records to show that you are disabled or the nature of your disability, but you cannot access those doctor’s appointments or those healthcare visits without Medicaid. So it’s really challenging for people to get the services they need just to get Medicaid under these disability-based programs. And now that is likely to be extended with the requirements that the law now imposes for these exemptions.
So that’s very concerning and again, we’ll see more information as the federal government provides some guidance and some regulations on this. There are other eligibility restrictions as well. Starting in January of 2028, there will be a freeze on the maximum allowable limit for people’s home equity that counts towards their countable assets. That will be said at 1 million. Currently, it’s tied to inflation, so it’s at 730, but when you consider inflation costs, that rises up to 1 million 97, 1.097 million, and about a dozen states are at or above the 1 million limit. So for those states, the limit will actually be reduced and then that $1 million isn’t adjusted for inflation. And so regardless of how high property values get, that 1 million will remain. And the only exemption is for agricultural lands.
This is really, really harmful for older adults, many of whom are, if you’ve heard the expression, cash-poor, house-rich, may have purchased their house decades ago when property was much, much cheaper and are now going to be unable to get Medicaid long-term care unless they have to decide to sell their homes effectively, which is really the only asset. They have very limited savings. And so again, as property values continue to rise, especially in high cost states, this is going to be really problematic for older adults needing Medicaid long-term care. There’s also a provision that cuts retroactive Medicaid coverage currently that is three months. So someone can get, if they met all the other eligibility requirements, they can get Medicaid to cover three months prior to the month of application for any healthcare services they received. The law now limits that to one month for the Medicaid expansion populations and two months for all other Medicaid populations. And that begins at early January 2027.
And so a lot of older adults who need long-term care often have a hospitalizing event like a fall or a stroke that puts them in the hospital and then they end up meeting, qualifying for Medicaid. But because they weren’t eligible for Medicaid before, they had whichever condition that caused them to be in the hospital and needing long-term care, they had no reason to apply for it. And so having a longer retroactive period really protects people so that they can get the healthcare they need. Providers like long-term care providers can accept patients knowing that, even if their Medicaid application isn’t submitted, if they’re gathering all the documentation they need, they’ll be reimbursed for whatever services they provide for people during that retroactive period. So by limiting that retroactive period, it’s making it much harder for people to receive care and then use whatever time they need to gather the documentation to show their assets, show their income, to show their functional eligibility requirements as needed. And then again, it makes it harder for providers, especially long-term care providers, to get that reimbursement for a shorter period. Next slide.
And then in the last administration, there were a series of rules that were finalized and published that would’ve really helped with Medicaid access and long-term care quality, long-term care access. The law stops implementation and blocks implementation of those rules. The first is the streamlining Medicaid eligibility and enrollment rules, which help remove a lot of barriers that people face when getting Medicaid or when trying to renew their Medicaid. And this was, the eligibility enrollment rule was across all Medicaid populations. There was another part of the rule that was specific to the Medicare-Medicaid dually enrolled individual because they have receiving healthcare from Medicare on one end and Medicaid from the state, the way they receive their care and their services can be very, very difficult.
And so this rule had strategies to make sure that people weren’t lost in the shuffle between these two programs. And so we do expect a lot of dually eligible individuals to lose their Medicare Savings Program, MSP, that’s administered by Medicaid, that would help limit their Medicare costs and help subsidize their Medicare costs. Without implementation of that rule, many people might fall into the cracks and might improperly lose their MSP, which would make their Medicare unaffordable. The law also blocks the implementation of the nursing home minimum staffing rule, which did just that. Ensured that a minimum number of nurse aides and registered nurses were on staff at nursing facilities across the country. The rule was estimated to save 13,000 lives per year. And as we know that health outcomes and quality of long-term care is based heavily, heavily on the number of nurse aides and nurse staffing that facilities have. So that’s really concerning as well for a population that is really vulnerable to very dangerous outcomes without proper staffing.
And then there are also cuts to Medicare. We’ve talked extensively about these cuts to Medicaid, and Medicare will be impacted in a couple of different ways. One is that there are millions of people who are dually enrolled in Medicaid and Medicare. Almost one third of all Medicaid funding is spent on people who are also enrolled in Medicare. So any of these cuts to Medicaid will have a huge impact on those Medicare enrollees, particularly those dually eligible people who might lose their Medicare subsidies paid for by Medicaid. And then also for many, many of the Medicare enrollees who rely on Medicaid for their long-term care, because Medicare is so limited in how it pays for nursing facility care or even home-based care. In addition to those cuts, there are direct cuts to many people who are on Medicare.
Lawfully present immigrants will no longer be eligible for Medicare unless they belong to three very specific immigration categories. And that’s lawful, legal permanent residents or green card holders, Cubans and Haitians who under a family reunification program and people who are residing under the compacts of free association. And that’s just a very limited number of countries in the Pacific. So outside of those categories, all other lawfully present immigrants will lose their Medicare eligibility. Current enrollees will be terminated in January 2027. And this really is really harmful for a lot of reasons that we’ll discuss. But again, these are people who have paid in their Medicare taxes and paid into the system who will now lose coverage. And then by statute there is also a sequestration issue that could take effect next year, unless Congress acts. By law, any legislation that significantly increases the deficit has to result in an automatic cut to budgetary resources elsewhere. And that’s sometimes you might hear it as a PAYGO or might hear it as the Medicare as a sequestration.
And so that would apply in 2026, unless Congress takes action. If they don’t, then it will automatically trigger a $500 billion cut in Medicare. Now we do expect Congress to take action. They have in the past when this has come up with other legislation, but it’s not an ideal situation for Congress to be in anyways, to have to make sure that these cuts don’t come into effect. Next slide. And so as we mentioned, the cuts to Medicare eligibility for immigrants is really harmful and really dangerous. For one, it decouples social security eligibility and Medicare eligibility. Because of the rules of budget reconciliation, social security can’t be touched with the budget reconciliation process that was used to pass this law. And so for that reason, eligibility for social security for lawfully present immigrants hasn’t changed, but it has changed drastically for Medicare, when normally these two programs have pretty similar eligibility requirements.
Cutting Medicare for immigrants also breaks Medicare’s promise. These immigrants have paid into Medicare for decades through Medicare taxes, expecting to become eligible and then they’re losing a benefit that they paid into, which is just patently unfair. The law also excludes many lawfully present immigrants from Medicaid and the marketplace subsidies on top of Medicare. And so that’s going to significantly increase the number of uninsured older adults that we have because they’re blocked from these major programs from receiving healthcare. Then there’s also significant harms to all Americans, even aside from the immigrants that are losing healthcare. Immigrants play a vital role in healthcare and long-term care. One in four direct care workers are immigrants, and now by losing access to healthcare, by losing, potentially, a path to citizenship, they make it that much harder for them to remain in these vital jobs where they provide care for the most vulnerable of our populations. And so there’s a lot of harms that will occur for immigrants, and then just for us across the board. Next slide.
And so hopefully, on a slightly more optimistic-ish note, in terms of what we can do in some mitigation strategies, we’re going to provide more specific tips and best practices, again, as we move further along into implementation. And so these are just some high level things that, as advocates, you can think about and message to help lay the groundwork as we get some more information. To start, we’re going to have a poll question for everybody, and I believe there’s going to be an option that pulls up, but we’d like to know, are you or your clients and older adults in your community familiar with H.R.1 and the changes to Medicaid and Medicare?
We’ll give folks maybe another 20 seconds or so. And just to read out the options are yes, very familiar, somewhat familiar, or no, not familiar. Okay, responses are slowing down a bit, but it does look like for most people, it’s somewhat familiar or not familiar are the key. So that’s really helpful to note and that’s going to guide us in terms of the resources we provide for everybody and for your community. So thank you for that. Next slide. Going to some of our mitigation strategies, one big thing is, like we said, it seems like about half of folks said that older adults in their communities were unfamiliar with H.R.1 and little under half said were not at all familiar. I think only about four or 5% said they were very familiar. So that’s really important, is to make sure that we’re educating clients and older adults and partners on what is and isn’t in the final law.
There are some things that didn’t happen that are good. So there were no structural changes to Medicaid, like block grants or per capita caps, that would’ve ended Medicaid’s entitlement. It would’ve been a, once the money runs out, it runs out. And so that did not happen in the final law, which is really important. And there were also no changes to income eligibility for most people. So across the board, the eligibility requirements are still there. There may be additional restrictions or there may be some restrictions on how it’s funded on the state side, but for the most part, Medicaid is still there, and so it’s really important that folks enroll if they’re eligible. Relatedly, even the cuts that are going to impact people won’t take effect for months or years. Going back to that timeline that Natalie highlighted at the beginning and the resource that we’ll provide on the timeline, people who are enrolled should remain enrolled if they’re eligible and get enrolled, if they become newly eligible.
What we don’t want is for there to create a chilling effect, where people don’t bother trying to get Medicaid because they think it’s not worth it. It is and it’s still there and so people should use the healthcare services they need and are entitled to. Lastly, and really, really crucially, all individuals have due process protections, including all Medicaid enrollees. So what this means is that the state cannot terminate Medicaid without advanced written notice and an opportunity to appeal adverse decisions. And many people have community organizations or legal aides or other groups that can help with that. So it’s really important that people remember that if Medicaid is terminated, they do have a right to appeal the decision to determine if it was done rightfully or not. And then there are some additional strategies for working with your states, to try to minimize the harm. Again, we might see more on this as we get more guidance from CMS or HHS, but the states generally will have a fair amount of discretion in how they implement these cuts.
For example, in setting the home equity exclusion limit, many states that have that limit at 730,000 now could expand that to 1 million. Same with not requiring more frequent eligibility checks, which is part of the eligibility and enrollment rule that was not allowed to be implemented under the law. Well now, states can decide that they’re going to make sure not to increase eligibility restrictions beyond what the law requires, so that would be really helpful. And then there’s some limit in setting the dollar amount for the Medicaid co-pays, so they can limit how much money people have to pay for their co-pays. Those are just some examples that we see right now. It’s really important that states do not rush implementation faster than they need to and that advocates engage on potential issues. One thing that we learned from the Medicaid public health emergency unwinding a couple years ago, there was a period where a lot of people were getting disenrolled from Medicaid following the health of the COVID-19 public health emergency.
And the states that rushed to disenrolled had massive procedural errors, where people were improperly terminated from Medicaid when they should have gotten coverage and they also had a lot of technical issues. So here, one thing to note is that if there is a longer timeline to implement, states should utilize that longer timeline. Advocates can also encourage their state Medicaid directors and policy makers to ask questions and raise concerns with CMS, even before guidance is written. They do have regular ways of engaging with federal officials on some of these issues, and so letting them know what’s happening can also help guide guidance as well, that that CMS puts out and the regulations that they put out. It’s also really worth noting that even in a state where policy makers were supporting H.R.1 and support the law, it’s very different when you’re talking about the impact of it as it’s happening. Once their neighbors and their constituents are actively losing coverage, there’s a huge, huge difference there.
It’s also really important to encourage your state support HCBS. As Natalie mentioned, HCBS is very often on the chopping block when states have funding concerns and funding restrictions. So that can mean that states can take up Money Follows the Person, which is one type of very popular HCBS program that helps keep people out of nursing homes and diverts them away, transitions them out of institutions like nursing homes. There’s also community first choice and other ways that states can access additional HCBS funding. And then making sure that states, even though the streamlining or eligibility and enrollment rule isn’t implemented, many of those things states can choose to implement. One, it lowers administrative costs for the states and then they can also make sure that people retain their coverage and that there’s fewer uninsured individuals. So working with states to see what areas they do have flexibilities, encouraging them to take those flexibilities to benefit older adults is really crucial.
And then with your community partners, it’s really important to connect with local advocates to monitor implementation and how it’s working across different groups and develop targeted strategies. So that includes direct service advocates, provider groups, aging and disability advocates and the like. As we get rulemaking and guidance, there may be opportunity for commenting from CMS so stakeholders can submit comments about what regulation CMS is putting forward with respect to H.R.1 and provide some insight there. Relatedly, please connect with us. Justice in Aging is very eager to know what’s going on and we want to provide information to you as well.
So look out for additional webinars and resources and you’re welcome to email us at info@justiceinaging.org for any questions or concerns that are occurring with how your community is impacted by the H.R.1 implementation. And then lastly, we’ve said this throughout, as we were gearing up for the bill getting passed, but public education and storytelling is really crucial. We’re always happy to provide the legal analysis and policy analysis and the data, but continue to share how people are being impacted by the implementation. If they’re getting scary notices, if they’re worried about these bills or these cuts, those stories really resonate with both policymakers, with the media, on social media, at public speaking engagements, et cetera. And so please consider continuing to use that as a powerful tool of advocacy as we gear into implementation. And with that, I will pass it over to Natalie.
Natalie Kean: Thank you so much, Gelila. As Gelila said, this is just the beginning and we will be producing more resources and doing more trainings and we really need your help. We want to hear from you. We need your help to document the harm and to help course correct, to mitigate the harm. We do have a few resources already on hr. One brand new today is an explainer on what’s in the Budget Reconciliation Act and what it means for low-income older adults’ access to health and long-term care. And on that link, if you click on the PDF version of this resource, you will see a graphical timeline of implementation. We also have a more detailed section by section of H.R.1’s Medicaid and Medicare provisions. We have some background information on how Medicaid supports older adults. We have a broader resource on the impacts of H.R.1, not only on health and long-term care, but also on nutrition and economic security and older immigrants.
And then most of these resources will continue to be housed on our Medicaid defense resources page, which is the last resource here. And we are providing some resources from partners that explain provisions of the bill in detail, and especially provisions that we aren’t focused on as much, related to the Affordable Care Act and Medicaid that isn’t as directly impacting older adults. Before we answer some of your questions, we have one more poll question for you. We’d love to hear what resources would be most helpful to you in your work to minimize the harm of H.R.1. And the options are analysis and explainers on what is in H.R.1, mitigation strategies and toolkits, something else. And if you have an idea for us, please feel free to put that suggestion in the questions box. And then everyone’s favorite, all of the above.
So we’ll give folks a few moments to answer the poll question. And I think Amber is up some Q&A for Gelila and I. All right, we’ve gotten good participation. Share the results here. So we have about half of people want analysis and explainers, half want mitigation strategies and toolkits. We do have a few folks that suggest something else and another good group of folks that wants to see all of the above. So really appreciate that feedback. We’ll be using it as we go forward. And with that, I think we will turn to Q&A.
Amber Christ: Thanks both, and a lot of good information there. And thank you all for your active participation. We also had a lot of questions in the Q&A, so we’re only going to get to a few of those. The first question I have for you both is we got a lot of questions about definitions and details, especially on work requirements. Actually let me back up. We got a lot of questions about what is the expansion population or what is Medicaid expansion. So before we get into work requirements, maybe let’s define what Medicaid expansion or the expansion population is.
Natalie Kean: Yeah, go ahead, Gelila.
Gelila Selassie: [inaudible 00:52:07]. This refers to people who receive Medicaid under the Affordable Care Act. The Affordable Care Act expanded Medicaid eligibility for all adults, for the most part, all adults earning less than 138% of the federal poverty level. And so outside of this expansion population, you can only get Medicaid if you’re very limited income or meet very specific categories, like you’re on SSI or pregnancy or child under 19 or something like that. So this really expands Medicaid where you don’t have to fit a specific category beyond those that income restriction.
Amber Christ: And I’ll just note that I think it’s, at this point, 41 states, including Washington, DC have expanded Medicaid to this population. So when we were talking about the impacts here, we’re talking about some of the provisions impact people who are enrolled through that pathway, through Medicaid expansion. And some of the provisions impact directly states that have expanded Medicaid and treat states that have expanded Medicaid differently than states that have not expanded Medicaid. So you heard us talking about both of those impacts.
So then now turning to work requirements, we got a lot of questions there, particularly there, but in other places about definitions and details about how the work requirements are going to be operationalized. How is caregiver defined? How do people prove that they have a disability? So can you speak a little bit about what’s broadly in the law and then what’s the process of moving forward on how these types of details will be figured out and what advocates can do to help inform what those details actually end up being?
Gelila Selassie: Yeah. So the law does list out exemptions for caregivers, for parents of minor children, for people with disabilities, or those who have medical frailty is how it’s defined. And how it’s listed, I should say, in the law. How it’s defined more specifically and what the process will be like will really be up to Centers for Medicare and Medicaid services and the regulations and guidance that they put out. And then relatedly, they and/or the states will have some additional guidance for how that process will be. So if someone can fill out a very simple questionnaire or very simple attestation saying, “I am disabled or I should be exempt for a medical condition,” then sure CMS may allow that. They may have more restrictions into how states operationalize this and what that process will be like. So that’s what we’re looking for in the next months and the next year or so.
Amber Christ: Thanks Gelila. I have a question around HCBS. There’s a really pointed question. Are there direct cuts in H.R.1 to home and community-based services or is the anticipated impact due likely to state decisions to cut services, benefit and eligibility?
Natalie Kean: Yeah, there are not direct cuts to home and community-based services in H.R.1 it is the impact of all of the other cuts and undermining of Medicaid that puts pressure on states to cut their home and community-based services program. And the reason why we are really concerned about those cuts and need to be making noise to ensure that they don’t happen is because so much of a state’s spending is on Medicaid home and community-based services and they are allowed, under federal law, to limit, eliminate, put waiting lists on access to those services. So it’s up to us as, advocates, to make sure that those cuts are minimized and avoided wherever possible.
Amber Christ: Thanks, Natalie. We also got a number of questions about whether there’s an opportunity to stop H.R.1 altogether or the provisions in H.R.1, especially considering that many of these changes aren’t going into effect immediately, but are down the road. So maybe we can speak a little bit to what that possibly could look like and what we’re dealing with in real-time and what we could be working towards, moving forward.
Natalie Kean: Yeah, I think there are opportunities, certainly to delay many of these cuts. For example, Gelila was talking about the complications of implementing work requirements and all the things states are going to need to do and defining all of this, setting up all these processes. If we can get states to be telling CMS, “We can’t do this by 2027, we need more time,” that’s an opportunity to delay implementation of this law. There is a bill introduced in Congress now to repeal the health provisions of H.R.1 completely, it’s a Democrat-only bill, unlikely that it will pass, but in future years, as states, again, are trying to deal with all of this and the makeup of Congress changes, we could see efforts to repeal all or parts of the bill, of the law.
Amber Christ: Great. Thank you both. I think that we’re right at time, so I think it makes sense for us to conclude. Any concluding statements from the both of you.
Natalie Kean: Just appreciate everyone’s engagement and … know that, as Gelila talked about what’s not in the bill, that Medicaid is still an entitlement in all of these things. And so that is something we need to keep in mind. We certainly celebrate the advocacy to keep some of those even worse cuts out, but also keep it in mind as we’re moving forward that people continue to get access to Medicaid.
Amber Christ: Thank you everyone for participating and please stay tuned for additional resources as we move forward and you will get an email following this webinar with the slides and the additional resources that were shared. Really appreciate all of the work you’re doing and your partnership.Paste Transcript Here
