A number of the Trump administration initiatives are likely to have a deleterious effect on long-term care in Massachusetts and across the nation, though many of the ultimate results are still unclear. These will arise from cuts in the Medicaid (MassHealth in Massachusetts) budget, Medicare reforms and the unavailability of non-U.S. citizen health care workers.
Medicaid
The One Big Beautiful Bill Act (OBBA) cuts $1 trillion from the Medicaid budget over the next 10 years. Much of this comes in two ways, first by imposing work requirements on beneficiaries and the second in curtailing the Medicaid provider tax. The latter is a practice many states have of taxing health care providers but using the money raised to fund Medicaid costs. Since the federal government matches these state expenditures, some in DC see this as a way to to game the system.
At first look it would seem that the new requirement that adult beneficiaries between the ages of 19 and 64 work at least 80 hours a month won’t affect Medicaid-covered long-term care since almost by definition those receiving long-term care can’t work. And most are 65 or older.
However, the Medicaid cuts will likely affect long-term care in two main ways. First, many people stop working for pay in order to take care of family members. The law exempts those caring for a child aged 13 or younger or someone of any age who is disabled from the work requirement. But it’s not clear how disability will be defined or how this will be verified and it will differ from state to state. Many caregivers will lose coverage because they don’t qualify or can’t meet the verification requirements.
Similarly, many Medicaid recipients who should qualify for coverage because they are working will also lose their coverage because they can’t prove it for one reason or another. This and the loss of the Medicaid provider tax will mean fewer federal dollars flowing into the health care system. Many people will just lose their coverage. Some will end up receiving care in emergency rooms at greater cost.
The states will either have to come up with the funds to make up the difference or cut coverage or reimbursement rates. In terms of cutting covered services, home and community based long-term care services are vulnerable because they are discretionary. Nursing home coverage, in contrast, is mandatory. However, states may cut back on how much they pay providers, including nursing homes and home health aides, for Medicaid-covered care with obvious impacts on the quality of such care.
Medicare
The Medicare changes are somewhat more subtle but can still affect long-term care. These include:
- Medicare Savings Programs. Medicare has a number of programs to assist low-income beneficiaries with their health care costs, essentially covering copayments and deductibles. In 2023, the Centers for Medicare & Medicaid Services (CMS) issued new rules targeting barriers to qualified beneficiaries enrolling in these programs. OBBA postpones the implementation of these new rules for nine years. This is projected to save $66 billion, essentially by making it harder for qualified beneficiaries to access the programs.
- Drug price negotiation. OBBA curtails the ability of CMS to negotiate lower prices for “orphan” drugs.
- Nursing home staffing. The law blocks the implementation of new nursing home staffing requirements issued by CMS last year after many years of advocacy by advocates for nursing home residents.
Immigration
Many caregivers are immigrants, according to one study, including 40% of home health aides and 28% of nursing assistants. This includes citizens, individuals with green cards and those with work authorization because they have applied for political asylum or qualify under the temporary protective status (TPS) due to conditions in their home countries, such as Haiti and Venezuela. It does not include the many care workers in the informal economy often hired by directly by families. One estimate is that there are 142,000 such undocumented immigrants providing child care or home health assistance.
There are news reports of undocumented workers staying home because they’re afraid of being picked up by ICE. The Trump administration has ended TPS for immigrants from Afghanistan, Cameroon, Nepal, Honduras and Nicaragua and attempted to do so for those from Haiti and Venezuela, though for those countries litigation has delayed the suspension for now. Estimates are that are about 260,000 immigrants from Haiti and 500,000 from Venezuela with TPS.
Before the Trump administration implemented its efforts to curtail immigration the National Academy of Social Insurance predicted that the United States would face a shortfall of 355,000 paid care workers by 2040.
As I’ve often pointed out, all of this is happening when we are at the cusp of a huge increase in demand long-term care as the oldest baby boomers approach their late 80s.
To learn more about all these changes, REGISTER NOW for our Law School for Social Workers event this Friday, September 26th from 9AM – 12:00PM