Fear and Loathing in Disability Services
Plus: Medicaid fraud uncovered in nationwide sting
Whew. Do you feel it? The media storm unleashed this week by the Trump Administration and the passage of the One Big Beautiful Bill Act has been intense. With my previous experience working in newspapers, it is clear to me how the combination of social media algorithms that elevate posts with a shock factor, the rush to get out information rapidly and a low-paid and under-experienced journalism workforce is creating a perfect storm of panic, outrage and misinformation.
I am generally a fan of professional journalists, but I can see how many of my colleagues are dropping the ball in significant ways on Medicaid reporting. I have just one story to share in my news round-up this week because so many pieces are reporting on people’s worries rather than the facts. It’s taken me years of up-close research and experience to even begin to understand Medicaid, so I get it, but it’s also frustrating.
In just one example, national NBC News produced a story called “How new Medicaid rules will affect families with disabled children,” about a Missouri woman’s worries that she will lose Medicaid coverage. However, there are enough details in the four-minute story to know that she almost certainly will continue to be covered. The woman works as her adult son’s direct care worker, which means she should meet the 80-hour-a-month work requirement, and caregivers of disabled individuals (children and adults) are excluded from the requirement.
The impacts of this bill to the disabled population certainly exist, but they are more complex than most people seem to understand — and they have a lot to do with how each of the 50 state legislatures will react to the loss of federal funds. Those decisions haven’t happened yet and will be different in each state, so it’s tough to summarize.
As we saw in last week’s Medical Motherhood, the OBBB slashes funding to Protection & Advocacy organizations, often called Disability Rights [State Name], like Disability Rights Oregon. There are also proposed cuts to Administration for Community Living funds, which provides programs to seniors and disabled folks. But the most significant changes to Medicaid that the OBBB enacts are twofold: the “work requirement” — which is actually a work, volunteer or training requirement — and multi-faceted reductions in federal funds to states.
The work requirement is not supposed to directly impact the disabled or caregiver populations. In the bill text, there are exceptions for someone:
(III) who is the parent, guardian, caretaker relative, or family caregiver (as defined in section 2 of the RAISE Family Caregivers Act) of a dependent child 13 years of age and under or a disabled individual;[or:]
(V) who is medically frail or otherwise has special medical needs (as defined by the Secretary), including an individual--
(aa) who is blind or disabled (as defined in section 1614);
(bb) with a substance use disorder;
(cc) with a disabling mental disorder;
(dd) with a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living; or
(ee) with a serious or complex medical condition;However, indirectly, this means that there will be yet more paperwork and more hoops to jump through in Medicaid applications. My own state of Oregon estimates it will cost $100 million for the tech and staff involved in this administrative labor — which of course doesn’t include the time and expense vulnerable individuals themselves will incur. Even those excluded from the work requirement will have to prove their exclusion, navigating a time-consuming and error-riddled process to maintain their coverage.
A similar story will play out with state budgets. If states are smart, they will increase their use of the untouched Home and Community Based Services programs to backfill the fewer Medicaid dollars for the nondisabled populations. (Home and Community Based Services are how most disabled children get home care hours and other services.) But technically HCBS programs are optional — thus why they are often called “waivers,” because they waive the standard rules.
And in order to get the federal matching dollars, states have to pony up their part. Because the spigot of federal funds will slow, if states don’t cut elsewhere or increase taxes, they may simply not have the general funds to spend and could slash HCBS in their attempts to balance the budget. That would be a dumb thing to do, in my humble opinion, but they could feel they have no choice.
On balance, I question the Republican talking point that this bill will “protect” Medicaid for the most vulnerable when there is no language expanding eligibility*, coverage, or services for the disabled population. For example, they could have required states to provide HCBS, increased the federal match rate for HCBS programs or removed the ban on family caregivers. But they didn’t.
[*EDIT: On July 7, the day after this post came out, Senator Eric Schmitt (R-Missouri) announced that he had successfully included amendment language in the OBBB. This language creates a new sort of 1915(c) waiver for non-institutional level care clients. That would not technically be an expansion of eligibility because states could already create a 1915(i) waiver for the same population but it could be more attractive option for states to set up. Schmitt’s amendment also includes reporting requirements.]
The Medicaid-related media confusion extends beyond just this bill.
The Washington Post declared on July 2 that “Trump to cut protections for home health aides, migrant farmworkers.” In the article, it states:
The administration also has plans to rescind an Obama-era rule that granted minimum wage and overtime pay to millions of in-home care workers. The Trump administration said in its proposed rulemaking that current regulations “might discourage essential companionship services by making these services more expensive.”
However, the full story is more complex, and the proposed regulation does not impact the vast majority of Medicaid-funded in-home care workers. The regulation would apply to people who provide “companionship services.” This sort of work is defined as providing 20 percent or less of “activities of daily living” — such as bathing, dressing, and feeding. So in a five-hour shift, that would be less than one hour, with most of the time spent hanging out. These workers must also be hired directly by the individual or their families and not through a home care agency. To me, this implies it is more for babysitters and live-in support, rather than direct care workers. Is it a slippery slope? You could argue that. Does it devalue care work? I would certainly argue that.
But, I also believe it’s best to be as precise as possible in our information, our judgements and our advocacy.
Medical Motherhood’s news round up
Snippets of news and opinion from outlets around the world. Click the links for the full story.
• From WCNC: “9 charged in Carolinas among largest coordinated takedown of health care fraud schemes in US history”
The Justice Department announced what it's calling the largest health care fraud takedown in U.S. history on Monday, charging more than 300 people in connection with over $14 billion in alleged schemes.
Here in the Carolinas, the alleged scams cheated taxpayers out of more than $20 million, according to state and federal prosecutors. Multiple agencies worked across state lines to uncover not one, but two separate fraud schemes operating in North Carolina and South Carolina.
[…]The larger case, dubbed "Operation Border War," involves Donald Saunders of Charlotte and seven co-conspirators who allegedly stole over $21 million from South Carolina's Medicaid program. State officials say the suspects targeted the most vulnerable patients.
"The majority, nearly all of these were severely disabled children," Attorney General Alan Wilson said. "Children who were quadriplegic or nonverbal or autistic, billing for services that these minor, severely disabled children never received."
Investigators say the suspects created fake companies near the border, then filed fraudulent claims using stolen patient information. In some cases, they're even accused of falsifying medical records for children who couldn't speak. […]
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Thank you for some facts, Shasta.