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Critical home-health services on thin ice during pandemic

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Without more federal dollars, home-based health services could take a hit, further reducing access to programs that can keep people out of institutional care facilities like nursing homes.

Advocates for home and community services are pushing for increased federal funding through Medicaid, an idea Democrats backed in the House-passed HEROES Act but which faces an uncertain future in the Senate.

Home- and community-based services allow people to receive assistance and care in their homes, rather than group settings like nursing homes, which have suffered from explosions of COVID-19 cases during the pandemic. The services can range from skilled nursing care to help with everyday tasks, like bathing or dressing.

Medicaid is the biggest payer for these services. As they're not required coverage, states provide these benefits through waivers. For this reason, advocates and experts are concerned that such services are a big target for cuts as states try to fill in budget shortfalls due to the pandemic.

The reason that the cuts fall the hardest on home- and community-based services is because under the federal law, they re considered optional, said Nicole Jorwic, senior director of public policy at The Arc, which advocates for people living with intellectual and developmental disabilities.

When states are facing these budget crunches, that s where the cuts happen first which is particularly terrifying right now because without home- and community-based services, the only options that are left are those nursing-home or congregate institutions, and that s where COVID-19 is spreading like wildfire all over the country, Jorwic added.

States over the course of the pandemic have tweaked their Medicaid waivers to ensure current recipients of home health services continue to have access. A Kaiser Family Foundation analysis from June reported that 29 states had used Medicaid waivers to increase provider payment rates and 37 states had adopted retainer payments.

But Kaiser experts wrote that, given the anticipated budget shortfalls in states, it may be difficult to maintain or increase provider rates.

Home and community health service providers in Colorado sustained a 1 percent rate cut starting in July. Florida Gov. Ron DeSantis vetoed a proposal to increase the pay rate for personal-support providers and adult day-training providers in June. New York, meanwhile, is considering certain cuts to its Medicaid reimbursements by tweaking its waiver.

The Arc New York argues these could result in an approximately $200 million reduction in payments, and executive director Mark van Voorst said if the slashes in reimbursement are implemented, it would result in a loss in staff. The organization in New York provides residential and family-support services.

What's going to happen is you re going to see draconian cuts of direct-support professionals, possibly clinical staff, the needs of the people that we ve served for decades will begin to go unmet, and that would be a travesty, van Voorst said.

Many states are not changing Medicaid payment rates for home and community health providers, even as these workers are faced with the costs of personal protective equipment, said William Dombi, president of the National Association for Home Care & Hospice, which advocates for home care organizations and their workers.

Probably on a daily basis you ve got about 5 million people receiving care in the home, and that means a set of gloves, a gown, and masks for every one of those visits," Dombi said."They are giving patients masks as well and informal caregivers in the household. If you're not getting a rate increase, where s the money coming from to cover that kind of cost?

Several disability advocacy groups and professional organizations are hoping the Senate will take up two items from the House bill passed in May: an increase in the federal share of Medicaid dollars by 14 percent and a 10 percent bump in federal Medicaid dollars that goes directly to home- and community-based services.

In a letter to Senate leaders in June, several organizations argued that the Medicaid funding bump for home and community services is vital because they re usually on the chopping block when states are balancing budgets.

Because HCBS are optional Medicaid services, they are some of the most at risk for cuts in budget crises, placing people with disabilities and older adults at serious risk of unnecessary institutionalization, stated the letter, which was signed by The Arc and the National Association for Home Care & Hospice.

Advocates in states where home and community programs have not seen a drastic impact yet are expecting to eventually feel a squeeze if there isn't more federal assistance or sufficient economic recovery. Washington state has floated limiting enrollment in its Medicaid home- and community-based programs as a way to save money. These changes have not yet been implemented.

There is definitely a hope that federal money will be released into the states to help them with some of the economic crisis so fewer cuts have to be made, said Stacy Dym, executive director of The Arc of Washington state.

Despite cutting millions from other health programs like $91 million from the Department of Behavioral Health and Developmental Disabilities Georgia added money so 100 more people could enroll in its Medicaid home and community service programs. But if the economy doesn t bounce back or there isn t additional federal funding to make up for budget losses, these services could face cuts in the future, said Eric Jacobson, executive director of the Georgia Council on Developmental Disabilities, which advocates on public policy for people living with developmental disabilities.

Either the economy has to return to where it was or the feds are going to have to make up that difference, because if not, the state and especially the state of Georgia will find ways to cut those services that they don t consider a priority," Jacobson said. "And for us, a lot of it looks like home- and community-based services are not a priority for the state of Georgia.

The article was published in the National Journal on July 13, 2020

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