The House Budget Committee will consider as early as this week a 2018 budget plan that will set a framework for budget, tax, and appropriations bills to follow. Media accounts indicate that it will use the fast-track “budget reconciliation” process to mandate substantial cuts in entitlements — one news report puts the figure at $200 billion — which are likely to come primarily from a range of low-income programs, such as food assistance through SNAP (the Supplemental Nutrition Assistance Program, formerly known as food stamps), basic assistance and employment services through the Temporary
Texas rejected billions in federal aid to expand Medicaid under the Affordable Care Act, calling the program “broken.” But now it’s asking the Trump administration to renew a deal that’s brought the state an additional $6.2 billion a year under Medicaid to help care for the poor.
Half the money is used to help hospitals finance care for the uninsured, and the rest goes to hospitals and other providers to test regional programs to improve care and access, such as opening school-based health clinics to steer people away from expensive emergency room visits.
State officials are hoping to win a 21-month extension of an agreement that began in 2011 and will expire in December.
The Trump administration signed off on a similar pact with Florida in April, increasing extra Medicaid funds to that state from $600 million a year to $1.5 billion annually. In December, the Obama administration extended a pact with Tennessee to 2021. It is worth at least $500 million a year to the state.Use Our ContentThis KHN story can be republished for free (details).
Several states receive such funds but Texas’ allocation is the highest. To put Texas’ request in perspective, $6.2 billion represents more than a third of what the federal government now contributes to the state’s Medicaid program annually. Texas kicks in the balance to pay for its $29 billion Medicaid program, which covers nearly 4.8 million people.
Hospitals are counting on the cash to absorb the costs of uncompensated care, which they say has escalated even as the state’s uninsured rate fell from 20 percent in 2013 to 16 percent in 2015, according to the Kaiser Family Foundation’s estimates. (Kaiser Health News is an editorially independent program of the foundation.)
Without the money, programs and services to the poor will have to be cut, including many new health clinics opened to expand access, hospitals say.
“Absent the dollars from the waiver, we would have to start to close the clinics and cut back on the manpower,” said George Masi, CEO of Harris Health System, a large public health system based in Houston.
The uninsured rate has fallen in Houston, but surrounding Harris County still has more than 1 million people without health insurance.
Between population growth and demand from undocumented immigrants, “there is growing need for more uncompensated care,” Masi said. Undocumented individuals are ineligible for Medicaid but cannot be refused emergency care.
When the Obama administration first approved Texas’ Medicaid waiver — and billions in extra Medicaid dollars to go with it — federal officials viewed the action as a glide path toward a formal Medicaid expansion starting in 2014, which the Affordable Care Act encouraged states to undertake. The law required the federal government to fully pay the extra costs of bringing more people onto Medicaid rolls for the first three years in every state that took the offer. Thirty-one states, plus the District of Columbia, did so.
Obamacare Medicaid funding would have added 1 million Texans to the program.
But after the U.S. Supreme Court made the Medicaid expansion optional for states, Texas lawmakers bristled at having anything to do with Obamacare or expanding government health coverage. That left the state’s hospitals in a tough financial spot since they lost some federal funding under the law without gaining patients covered by a Medicaid expansion. Texas hospitals are eager to keep the federal waiver in place as the turmoil in Congress over repealing and replacing Obamacare only increases their jitters.
Last year, the Obama administration was reluctant to promise to maintain extra funding levels to states that did not expand Medicaid and left their hospitals on the hook for treating uninsured people who would have been covered under the law. The Centers for Medicare & Medicaid Services told Texas to expect its Medicaid waiver funding to be cut by billions starting in 2018.
Anne Dunkelberg, associate director of the Center for Public Policy Priorities in Texas, a left-leaning think tank, said Texans would be better served by expanding Medicaid but, since that isn’t politically possible, the waiver money is vital to help hospitals care for the uninsured. “The hospitals still have tons of uncompensated care and it will be painful for them without this money,” she said.
Texas set up 21 regional health programs to oversee hundreds of pilot programs paid for by the waiver money intended to improve care to the poor. The demonstration projects paid for by the waiver money probably could not continue without the federal funds, according to an evaluation report released last month by Texas Department of Health and Human Services. The report concluded some projects did help improve patient outcomes, but it’s too soon to determine if they can help lower hospitals’ costs of uncompensated care.
At Baylor Scott & White Health, based in Dallas with facilities in north and central Texas, the waiver money has provided more than $200 million in funding over the past five years for uncompensated care and another $132 million for health projects. “This money allows us to care for uninsured folks that otherwise might not get care,” said Bill Galinsky, vice president for government finance at the health system.
Baylor Scott & White has participated in 37 health projects funded by the waiver to develop ways to treat more than 100,000 low-income people. Other efforts included placing 10 social workers in primary care clinics to provide one-stop care for patients with mental health and physical health needs. The system has also worked with community agencies to increase providing healthy meals to families. “We are cautiously optimistic” that the waiver money will continue, Galinsky said.
Harris Health used part of its $350 million a year in Medicaid waiver dollars to open six primary care clinics with integrated mental health services. “Before the waiver, the primary care doctors could treat the backache or strep throat but would struggle to deal with the depression or bipolar,” Masi said.
Adding psychiatrists and psychologists to work alongside primary care doctors has helped reduce demand for inpatient mental health care, he said.
Without continued federal funding, most of the new positions would disappear, according to Masi.
Memorial Hermann, one of the state’s largest hospital systems, which is also in Houston, also allocated a portion of its waiver money — $150 million a year — to do more than care for the uninsured, said Dr. Benjamin Chu, the former CEO, who was interviewed before his resignation was announced June 19.
The hospital system opened crisis prevention units and school-based health clinics. Other funds paid for a team that manages mental health patients after discharge from hospitals, connecting them with follow-up services to reduce repeated visits to an emergency room.
“This money is very important,” Chu said.
ORANGE, Va. — Alice Jacobs, 90, once owned a factory and horses. She raised four children and buried two husbands.
But years in an assisted living facility drained her savings, and now she relies on Medicaid to pay for her care at Dogwood Village, a nonprofit, county-owned nursing home here.
“You think you’ve got enough money to last all your life, and here I am,” Jacobs said.
Medicaid pays for about two-thirds of the 1.4 million elderly people in nursing homes, like Jacobs. It covers 20 percent of all Americans, and 40 percent of poor adults.This KHN story also ran in The New York Times. It can be republished for free (details).
On Thursday, Senate Republicans joined their House colleagues in proposing steep cuts to Medicaid, part of the effort to repeal the Affordable Care Act. Conservatives hope to roll back what they see as an expanding and costly health care entitlement. But little has been said about what would happen to older Americans in nursing homes if these cuts took effect.
Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage.
“The states are going to make it harder to qualify medically for needing nursing home care,” predicted Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy. “They’d have to be more disabled before they qualify for Medicaid assistance.”
States might allow nursing homes to require residents’ families to pay for a portion of their care, she added. Officials could also limit the types of services and days of nursing home care they pay for, as Medicare already does.
The 150 residents of Dogwood Village include former teachers, farmers, doctors, lawyers, homemakers and health aides — a cross section of this rural county a half-hour northeast of Charlottesville. Many entered old age solidly middle-class but turned to Medicaid, once thought of as a government program exclusively for the poor, after exhausting their insurance and assets.
A combination of longer life spans and spiraling health care costs has left an estimated 64 percent of the Americans in nursing homes dependent on Medicaid. In Alaska, Mississippi and West Virginia, Medicaid was the primary payer for three-quarters or more of nursing home residents in 2015, according to the Kaiser Family Foundation. (KHN is an editorially independent project of the foundation.)
“People are simply outliving their relatives and their resources, and fortunately, Medicaid has been there,” said Mark Parkinson, president of the American Health Care Association, a national nursing home industry group.
With more than 70 million people enrolled in Medicaid at an annual cost of more than $500 billion, the program certainly faces long-term financial challenges. Federal Medicaid spending is projected to grow by 6 percent a year on average, rising to $650 billion in 2027 from $389 billion this year, according to the Congressional Budget Office.
Even if Congress does not repeal the Affordable Care Act, Medicaid will remain a target for cuts, experts say.
“The Medicaid pieces of the House bill could be incorporated into other pieces of legislation that are moving this year,” said Edwin Park, a vice president at the Center on Budget and Policy Priorities, a Washington nonprofit that focuses on how government budgets affect low-income people. “Certainly, nursing homes would be part of those cuts, not only in reimbursement rates but in reductions in eligibility for nursing home care.”
While most Medicaid enrollees are children, pregnant women and non-elderly adults, long-term services such as nursing homes account for 42 percent of all Medicaid spending — even though only 6 percent of Medicaid enrollees use them.
“Moms and kids aren’t where the money is,” said Damon Terzaghi, a senior director at the National Association of States United for Aging and Disabilities, a group that represents state agencies that manage programs for these populations or advocate for them. “If you’re going to cut that much money out, it’s going to be coming from older people and people with disabilities.”
The House health care bill targets nursing home coverage directly by requiring every state to count home equity above $560,000 in determining Medicaid eligibility. That would make eligibility rules tougher in 10 states — mostly ones with expensive real estate markets, including California, Massachusetts and New York — as well as in the District of Columbia, according to an analysis by the Center for Budget and Policy Priorities.
Dogwood Village receives about half of its $13 million annual operating costs from Medicaid, with rates from $168 to $170 a day. Some residents who come to the facility after a hospital stay are initially covered by Medicare, but if they stay longer than 100 days, that benefit ends, and those without savings move to Medicaid.
“You have patients who have spent their life savings, and they come here,” said Kristen Smith, the admissions coordinator. Smith said patients now were older and sicker than they used to be, frequently arriving directly from a hospital.
“It used to be hips and knee” surgeries, she said. “And now a lot of those patients are going home. What we’re seeing is more complex, sicker patients.”
With cinder-block walls brightened by pictures of horses that evoke this equestrian county, the nursing home offers crafts, bingo and other activities.
Mary Ann Mohrmann is 85, the average age of Dogwood Village residents. An elementary school teacher for 25 years, she has Charcot-Marie-Tooth disease, a neurological disorder that has weakened her legs, feet and thumbs and compromised her fine motor skills.
Two of her children have it, too, she said. None of them can take care of her at home. “I’ve been here years,” she said. “I don’t know how many.”
Medicaid helps pay for care for people with disabilities, like Nancy Huffstickler, 64, who has been here four years and regards herself as “a medical disaster.”
She listed her ailments: spinal cancer in remission, restless legs syndrome, high blood pressure and multiple ulcers. She has had spinal reconstructive surgery and a hip replacement. She is undergoing physical therapy with the hope that, one day, she will be able to leave her wheelchair and use a walker.
Huffstickler is fearful of Republicans’ health care changes. “It may save the federal government money, but what about us?” she asked.
Major Medicaid cuts would compel the facility to cut staff, supplies and amenities — changes that would affect the quality of care for all residents, not just those on Medicaid.
If that does not save enough money, the facility might have to reduce the number of Medicaid residents, said Vernon Baker, who resigned as administrator in April. “It’s not like our toilet paper or paper towels are like the Ritz-Carlton’s,” he said.
Some residents do not even know they are on government insurance; administrators often complete the paperwork to start Medicaid once other insurance expires. Others are embarrassed that they are dependent on a program that still carries stigma.
They should not be, said Jennifer Harper, the assistant director of nursing. Relying on Medicaid for nursing home care has become the new normal.
“These folks have worked their whole lives, some with pretty strenuous jobs, and paid into the system,” she said. But with changes looming, she said, “it may be a system that fails them.”
KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.
Wilhelmina Delco learned to swim at 80. Harold Berman is in his 67th year practicing law. Mildred Walston spent 76 years on the job at a candy company. And brothers Joe and Warren Barger are finding new spots in their respective homes for the gold medals they’ve just earned in track-and-field events at the National Senior Games.
These octogenarians and nonagenarians may not be widely known outside their local communities, but just as their more famous peers — think Carl Reiner, Betty White, Dr. Ruth (Westheimer) or Tony Bennett — the thread that binds them is not the year on their birth certificate but the way they live.
“Age shouldn’t be a reason to slow down,” said Joe Barger, 91, of Austin, Texas.
It never hurts to have longevity in your genes and few chronic health problems, but mindset plays a role in how people age, experts say. Some older adults have been termed “superagers” for mental acuity despite their years because the typical age-related decline in brain volume is much slower.Use Our ContentThis KHN story can be republished for free (details).
However, for most active elders who aren’t among these elite agers, staying vital when others around you aren’t may be about more than physical or mental agility. Researchers find that society’s focus on youth culture and negative stereotypes about aging prompts older adults’ memory loss and stress. These days, older adults who want to dispel notions of growing feeble now have growing ranks to emulate.
Joe Barger and brother Warren, 95, of Chattanooga, Tenn., just wrapped up two weeks of competition in Birmingham, Ala., where Warren earned five gold medals and set a new national high-jump record in his 95-99 age bracket. In badminton, where Warren played singles, doubles and mixed doubles, he had to compete in the younger 85- to 89-year-old bracket because there weren’t competitors in his age group.
“My secret of life is to wake up every morning with something to do,” Warren said. “Some people I feel are old because they allow themselves to get old. When people ask me how I’m able to do what I can do, I say I never did quit trying.”
A former insurance salesman and church music director, Warren plays golf and pickleball once a week and badminton twice a week. He mows his lawn, volunteers weekly at his church and sings in the senior choir.
In a study published last year, David Weiss, an assistant professor of sociomedical sciences and psychology at the Columbia Aging Center at Columbia University in New York, found that those who don’t fall for the inevitability of aging can “counteract the detrimental and self-fulfilling consequences of negative age stereotypes.”
“My research looks at why no one wants to be old,” Weiss said.
“They want to set themselves apart from this negatively viewed age group. They just want to distance themselves from stereotypes. ‘l’m not like the stereotype. I’m different,’ ” he said. “Adults who believe age is just a number showed better memory performance, but adults who believed aging is set in stone and fixed had a decrease in memory performance and a stronger stress reaction.”
Social psychologist Becca Levy of the Yale School of Public Health in New Haven, Conn., said her studies found an increase in negative age stereotypes over the past two centuries.
“Part of it is due to media and marketing,” she said. “An ageist culture produces many more negative stereotypes.”
Such notions do have an impact. Research by Sarah Barber, an assistant professor of psychology at San Francisco State University, published earlier this year found that people blamed “everyday forgetting” on their age as in a “senior moment” because popular wisdom reinforces stereotypes of age-related memory decline. The negative stereotypes about aging made older adults “over-attribute everyday memory losses we all have to age,” she said.
Seniors, Seize The Moment
To stay vital, Westheimer advises older people to “do as many things that are enjoyable to them as possible — participating in activities at a senior center, going to the theater and movies and not just sitting home and saying ‘I’m too old to be out there.’ ”
The younger Barger, a retired mechanical engineer, lives by that creed. He competed in seven track events at the games and took gold in three, including the 800-meter, 1500-meter and 5-kilometer distances.
“I hate to see people slowing down when you know they can do more than what they’re doing,” he said. “Most friends I have are much younger than me.”
Reiner, the 95-year-old iconic writer, comedian, director and creator of the 1960s-era “The Dick Van Dyke Show,” is way too busy to slow down. He and his longtime friend (since 1950) Mel Brooks, who turns 91 on Wednesday, have dinner at Reiner’s house most evenings unless the comedic genius behind such classics as “Blazing Saddles” and “The Producers” is away on business, Reiner said in a phone interview from his Beverly Hills home.
Reiner, 95, is the narrator of a documentary airing this month on HBO exploring why some people continue to blossom in their later years and others wither.
Reiner’s latest book — his 22nd, “Too Busy to Die,” published June 1 — is one of five books he’s written since turning 90. He’s now working on two more books, expected out at Thanksgiving.
“Very, very often, I think of an idea and then I get up and put it on a pad,” he said, though he spends a good part of his day working at his computer.
Reiner also serves as a narrator in the new documentary “If You’re Not in the Obit, Eat Breakfast,” which airs on HBO throughout June. The film, which includes a bevy of the famous and not-so-famous in their 90s and beyond, aims to explore why some thrive and others don’t in their later years.
“I tweet every night before bed,” Reiner said. He has 175,000 Twitter followers.
Resetting Your Mindset
Westheimer, 89, a sex therapist who dishes out advice in a heavy German accent, also tweets, sometimes several times a day.
“I’m very busy. I’m teaching at Columbia. I’m coming out in 2018 with three new books. A movie is being made about me,” Westheimer said in a phone interview from her New York City apartment.
Westheimer is out six nights a week. She visits with friends and family — especially her grandchildren — and she serves on several boards.
Delco, who will be 88 next month, is trying to get a bit less involved with the half-dozen or so boards she’s been serving in Austin. Traffic congestion and travel time to attend board meetings have made this former state lawmaker (1974-94) less inclined to participate, she said.
Delco has been involved in public service since 1968, when she was elected to the school board.
“I still do a lot of public speaking,” she said. “I do not charge fees or anything like that, but the one thing they have to do if you want me to speak is come pick me up and take me home.”
Five days a week, Delco starts her mornings at the neighborhood Y, where her days of swimming laps ended because of arthritis. Now, she exercises with barbells in the pool to maintain strength and agility.
Walston, who turns 95 in September, has also turned her attention to exercise and staying fit.
“It seems to me like it’s boring to sit around if you don’t do anything,” she said. “Where I’m living, there’s something to do all the time. I’m signed up for everything I can.”
Walston worked at Lammes Candies, an Austin family-owned business that opened in 1885, since she graduated from high school in 1940.
“I wasn’t going to retire at all, but I lost my sight,” she said. “I woke up on June 8th of last year and I couldn’t see, so I couldn’t work anymore.”
Walston is legally blind but has enough sight to keep active.
Berman, 91, an attorney in Dallas, says he never thought about retiring.
“I made a pact with myself not to retire as long as I’m able to do it,” he said.
He’s at his desk at 8:30 a.m., takes a break and tends to stop work around 4:30 p.m.
Berman, a World War II veteran who in May participated in an Honor Flight, is at the gym at 5:30 a.m. three days a week.
“I used to go five times a week,” he said. “I have breakfast with the guys after we exercise.”
Although Berman has been a leader in various national organizations and is active in some local organizations, he said he is traveling less and definitely working less.
“My [law] practice used to be 20 hours a day, with the phone ringing and a lot of trial work,” he said. “I’m having to slow down. It’s not by choice. If I had my way, I’d be running all the time.”
In recent weeks, the Senate has launched a process for revising the House-passed bill to repeal the Affordable Care Act (ACA) that, due to its extreme secrecy, independent observers have described as “a situation without precedent” for major health legislation.