The Senate GOP health care bill could lead to cuts in programs that help frail Minnesota seniors and jeopardize many cost-saving services that support caregivers and help seniors stay in their homes.
The Senate bill, which could come up for a vote this week, takes a number of steps to dismantle the Affordable Care Act. It also would massively curb federal spending on Medicaid, a 52-year-old social services program that provides matching federal dollars to help states care for the poor, elderly and disabled.
Seniors are the fastest-growing group to rely on Medicaid, the nation's largest source of public health coverage. In Minnesota, seniors account for about 9 percent of the 1.2 million men, women and children covered under the program, which is called Medical Assistance.
"There's a lack of awareness that Medicaid is really the safety net in Minnesota for so many of our seniors," said Minnesota Department of Human Services Commissioner Emily Piper, whose agency manages the $11 billion program.
The proposed health care bill would end the expansion of Medicaid, allowed under the ACA and implemented by Minnesota. It would also fundamentally change the way states receive federal aid to help care for some of their most vulnerable citizens.
The proposal aims to save billions in federal spending by ending open-ended payments to states and establishing a maximum payment on each enrollee. Minnesota would fare worse than most other states because caps are based on medical costs, which are among the lowest in the nation due in part to programs that limit expensive hospital stays and nursing home care.
The state is in the process of calculating potential losses under the Senate plan. Under the House bill, which appears to be similar through 2025, the state faces a potential loss of about $2.3 billion in federal funding in the first 18 months and up to $11.4 billion by 2025.
Capping federal Medicaid dollars will take needed bloat out of the system and give power back to the states, Republicans backers of the bill argue. But others worry that shifting the burden to states will have an outsized impact on seniors, whose cost of care is growing.
"It's not just the seniors who rely on Medicaid, their whole family does," said Piper. "Their adult children, who are working and saving to send their kids to college, or who are raising young children who can't take on the additional responsibility of providing day-to-day, 24-hour care of aging grandparents."
Seventy percent of people over 75 will spend time in a nursing home or need access to long-term care services in their lifetime. Medicare, the government's health insurance for seniors, doesn't cover assisted living, extended stays in nursing homes or the costs to hire someone to help with cooking, bathing or managing medications for months or years at a time.
Thus, Medicaid serves as a safeguard for growing numbers of middle-class elders, particularly those with challenging illnesses such as dementia and heart disease, who rely on the program after they've drained their personal savings. Half of Minnesota's nursing home residents are currently covered by Medical Assistance.
"The general public thinks of this as an issue for some, and not others," said Jennifer DeCubellis, Hennepin County's deputy commissioner of Health and Human Services.
"What we try to do as a state is provide additional supports to keep people in their homes longer. We know how critical that is to quality of life, for keeping families together. But it's also an expense for the state. Nursing home care is very expensive."
Over the decades, Minnesota has launched a bipartisan effort to get waivers from the federal government to make flexible use of Medicaid dollars to serve seniors in their homes or communities.
Those funds now pay for a broad umbrella of services: help with such daily activities as bathing, grooming and toileting; house calls by nurses or case managers to help manage medications; adult day services; meals; transportation to doctor's appointments; and household chores.
Last year, nearly 30,000 Minnesotans were served by the Elderly Waiver program. The state spent an average of $1,300 to $1,600 per person a month, compared to the average monthly cost of a nursing home of $6,700.
"The proposed cuts will have an unfortunate impact on the progress we've made," said Erin Parrish of AARP Minnesota, citing a recent AARP study that ranked the state No. 2 in care for seniors and their caregivers. "The number of Minnesotans turning 65 this decade will be greater than the past four decades combined. The cap doesn't keep pace with changing demographics."
Minnesota has pushed harder than most other states to try to keep seniors out of institutions. More than three-quarters of the state's Medicaid spending for long-term supports and services goes toward programs that seniors get at home or in the community.
But these are optional services. Faced with less money, advocates fear the state would be forced to cut back or eliminate these programs.
"There aren't many choices at the state level," said Paula Hart, president and CEO of the Minnesota and Wisconsin chapter of Volunteers of America, which serves more than 8,000 seniors in community settings, affordable housing and group homes.
"They'd really be forced to make a 'Sophie's Choice.' Do you not provide services to people? Do you cut the services they get? Do you cut rates to providers? None of those are good solutions."
Informal caregivers likely will feel collateral damage, advocates warn.
Family, friends and neighbors provide 92 percent of long-term care needed by older adults in Minnesota, according to the state Department of Human Services. This unpaid care is worth an estimated $7.8 billion a year, more than the state spends on nursing homes and long-term services and supports through Medicaid.
"It feels like we're pulling the rug out from underneath families and seniors," said Kari Thurlow, an executive at LeadingAge Minnesota, which represents senior housing providers. "If we don't have Medicaid in place, not only will it make it hard for seniors without assets and income to find services, it likely will mean more out-of-pocket expenses for their adult children. There's a trickle-down effect."
Organizations that provide senior housing and services say too much already is being balanced on the backs of those who can afford private pay. Federal cuts will make it even more difficult to pay competitive rates for those eldercare workers who provide front-line care for the aged and infirm with complex needs.
"Right now, you have people in our industry who are hardly making ends meet," said Mary Jo Thorne, a regional director of housing for Augustana Care. "But you get to the point where the provider will say, 'I can't lose money. I can't do this anymore.' Where will these people go? That's what worries me most."
Hennepin County's DeCubellis said the county is prepared to make "the business case" for continuing to fund programs that keep people out of institutions, even if the menu of Medicaid-eligible services shrinks. Her bigger concern is the politics.
"Making the longer-term investment in what's right for people and what's gong to sustain communities and keep communities and individuals stabilized doesn't always fit in a short political cycle," she said.