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You’re Probably Going to Need Medicaid

By DAVID GRABOWSKI, JONATHAN GRUBER andVINCENT MOR
Niko J. Kallianiotis for The New York Times
Imagine your mother needs to move into a nursing home. It’s going to cost her almost $100,000 a year. Very few people have private insurance to cover this. Your mother will most likely run out her savings until she qualifies for Medicaid.
This is not a rare event. Roughly one in three people now turning 65 will require nursing home care at some point during his or her life. Over three-quarters of long-stay nursing home residents will eventually be covered by Medicaid. Many American voters think Medicaid is only for low-income adults and their children — for people who aren’t “like them.” But Medicaid is not “somebody else’s” insurance. It is insurance for all of our mothers and fathers and, eventually, for ourselves.
The American Health Care Act that passed the House and is now being debated by the Senate would reduce spending on Medicaid by over $800 billion, the largest single reduction in a social insurance program in our nation’s history. The budget released by President Trump last month would up the ante by slashing another $600 billion over 10 years from the program. Whether the Senate adopts cuts of quite this magnitude or not, any legislation that passes the Republican Congress is likely to include the largest cuts to the Medicaid program since its inception.
Much focus has rightly been placed on the enormous damage this would do to lower-income families and youth. But what has been largely missing from public discussion is the radical implications that such cuts would have for older and disabled Americans.
Indeed, Medicaid pays nearly half of nursing home costs for those who need assistance because of medical conditions like Alzheimer’s or stroke. In some states, overall spending on older and disabled adults amounts to as much as three-quarters of Medicaid spending. As a result, there is no way that the program can shrink by 25 percent (as under the A.H.C.A.) or almost 50 percent (as under the Trump budget), without hurting these people.
A large body of research, some of it by us, has shown that cuts to nursing home reimbursement can have devastating effects on vulnerable patients. Many nursing homes would stop admitting Medicaid recipients and those who don’t have enough assets to ensure that they won’t eventually end up on Medicaid. Older and disabled Medicaid beneficiaries can’t pay out of pocket for services and they do not typically have family members able to care for them. The nursing home is a last resort. Where will they go instead?
Those who are admitted to a nursing home may not fare much better. Lowering Medicaid reimbursement rates lead to reductions in staffing, particularly of nurses. Research by one of us shows that a cut in the reimbursement rate of around 10 percent leads to a functional decline of nursing home residents (that is, a decline in their ability to walk or use the bathroom by themselves) of almost 10 percent. It also raises the odds that they will be in persistent pain by 5 percent, and the odds of getting a bedsore by 2 percent.
Finally, these cuts would just shift costs to the rest of the government. Lower-quality nursing home care leads to more hospitalizations, and for Americans over 65, these are paid for by another government program, Medicare. One-quarter of nursing home residents are hospitalized each year, and the daily cost of caring for them more than quadruples when they move to the hospital. Research shows that a reduction in nursing home reimbursements of around 10 percent leads to a 5 percent rise in the odds that residents will be hospitalized. So care for seniors suffers, and the taxpayer pays.
Mr. Trump and the Republicans would lower spending on the frailest and most vulnerable people in our health care system. They would like most Americans to believe that these cuts will not affect them, only their “undeserving” neighbors. But that hides the truth that draconian cuts to Medicaid affect all of our families. They are a direct attack on our elderly, our disabled and our dignity.
David Grabowski is a professor of health care policy at Harvard Medical School. Jonathan Gruber is a professor of economics at M.I.T. Vincent Mor is a professor of health care policy at Brown.
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