Though some of the damage that this bill does has been well publicized, there is a particularly odious impact of Trumpcare getting very little attention: It threatens to force seniors and people with disabilities into nursing homes and institutions.

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For the last several decades, disability rights advocates have fought to expand funding for Medicaid-funded home and community-based services, so that seniors and people with disabilities can live in their own homes, control their own lives, and be fully included in society. Thanks to generations of advocacy, millions of Americans with disabilities receive Medicaid-funded home care today.

When the Affordable Care Act was passed, legislators started to prioritize funding for programs that provide people with disabilities with services in their homes, rather than relegating those who require additional support to institutions and nursing homes. Through the ACA, Congress created several programs designed to reward states with additional Medicaid funds if they expanded in-home care for seniors and people with disabilities.

One of the most successful of these programs is the Community First Choice State Option (CFC), which provides funding for services that help seniors and people with disabilities get out of bed, dress, and perform other activities necessary for daily life. A 2015 review of the four states that have been using the CFC the longest found that the program was serving over 500,000 people—today, that number is likely much larger. But the AHCA sunsets this program in 2020, cutting about $12 billion in funding from in-home care from seniors and people with disabilities over the next decade.

That is only a small part of the $839 billion in Medicaid cuts AHCA imposes overall, which themselves will devastate Medicaid-funded services to seniors and people with disabilities across the country. AHCA also sets “caps” on each states’ Medicaid funding that will grow at a much slower rate than the existing Medicaid funding system, cutting hundreds of billions of funding over the next decade relative to current law. In addition, the caps also freeze in place state funding decisions at the time they’re made—so a state that offered relatively stingy benefits to people with disabilities or children in 2017 would no longer be able to access additional federal funds to expand those services in the future.

Some Republican House members realized the harm AHCA will cause to their constituents with disabilities. Rep. Daniel Webster (FL-10) bemoaned the likely impact AHCA’s Medicaid cuts would have on seniors living in his district, so he introduced an amendment to exempt nursing homes from AHCA’s caps on Medicaid funding during the March push to pass the bill. The amendment did not offer protections for home care, so it actually would have worsened Medicaid’s longstanding bias in favor of institutional care.

The GOP leadership still refused to adopt Webster’s amendment. For them, even weak protections for seniors and people with disabilities go too far.

Despite stating clearly on Tuesday that his “concern that Florida will be penalized under the American Health Care Act because demand for Medicaid-funded nursing home beds has not been fixed,” Webster voted in favor of the American Health Care Act today—in exchange for “assurances” from the Trump White House that his concerns will be addressed in the future.

Republicans in the House continue to put their faith in Donald Trump, instead of insisting on meager protections of their own constituents’ needs. For too many members of Congress, the needs of seniors and people with disabilities are taking a backseat to trusting Donald Trump —and advancing his health care bill—at all costs.

No such luck.

Tuesday night, Secretary of Health and Human Services (HHS) Tom Price and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma issued a letter to the nation’s governors laying out their vision for Medicaid. In the letter, they indicate a willingness to waive longstanding rules that are designed to protect low-income Americans from coercion, poverty, and exploitation.

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Price and Verma assert that “rigid and outdated implementation and interpretation of federal rules” hinder the Medicaid program from accomplishing its goals. They reiterate a popular (and false) conservative talking point that by providing states additional funds to expand Medicaid, the Affordable Care Act discouraged them from addressing the needs of people with disabilities on traditional Medicaid. Finally, they lay out HHS’s willingness to grant almost every ill-advised “flexibility” request in the right wing’s wish list on Medicaid—many of which place people with disabilities, seniors, and low-income Americans at extraordinary risk.

Making Medicaid Harder to Access

The letter indicates the Trump administration would be willing to let states introduce premiums and higher cost-sharing for Medicaid beneficiaries.  These measures were rejected under the Obama administration, since they interfere with the program’s ability to serve low-income people. But based on Price’s letter, they now look likely to sail through.

In particular, Price and Verma suggest states may wish to apply for permission to allow “emergency room copayments to encourage the use of primary and other non-emergency providers for non-emergency medical care.” It’s a laudable goal, but in rural areas where there is a shortage of clinicians who accept Medicaid patients—a common problem due to the program’s low reimbursement rates—emergency rooms are often the only practical option for low-income people. Policies that make emergency room visits more expensive are likely to simply discourage people from seeking necessary care.

Price and Verma also suggest states explore charging Medicaid beneficiaries premiums. Such measures ignore the underlying reality that Medicaid serves the deeply poor, who cannot sustain these costs by definition. Still, the suggestion is familiar to Verma—under her leadership as a health policy adviser to then-Governor Mike Pence, Indiana introduced monthly premiums in 2015. Failure to pay them was grounds for losing coverage, or having less access to vital health care services.

This newfound flexibility would also make it possible for states to enact damaging policies that they have been requesting for years. Arizona, Indiana, Kentucky, Montana, and Arkansas have all previously requested permission from the federal government to impose work requirements on Medicaid, which would deny people access to the program unless they are employed.

Arizona is also pursuing a five-year cap on Medicaid benefits. Under the plan, an individual must either be working full time or be receiving disability benefits from the Supplemental Security Income (SSI) or Social Security Disability program in order to keep Medicaid benefits past the five-year cap.

Both work requirements and time limits are likely to disproportionately impact people with disabilities. Even though the time limit proposals provide exemptions for people who are receiving benefits through SSI,  many disabled adults qualify for Medicaid on the basis of their income—not their disability status with the Social Security Administration. That’s because many disabled people are unable to navigate the Social Security Administration’s complex bureaucracy or, particularly among people with psychiatric disabilities, may not be fully aware of their own disability. As of 2009, 1 in 5 adults eligible for Medicaid on a basis other than disability (2.3 million people) and 1 in 10 children eligible on a basis other than disability or child welfare assistance (about 3 million children) had a mental health diagnosis.

As for work requirements, people with disabilities are more likely than other Medicaid recipients to be unemployed. These measures would place them at risk of losing the health care coverage that would help them enter or return to the workforce. Indeed, where Medicaid has been expanded, research has shown that participation in the workforce for disabled adults has increased.

Weakening Protections Against Institutionalization

In their letter, Price and Verma also indicate an intent to weaken vital Obama administration protections for seniors and people with disabilities.

In 2014, the Obama administration issued a rule designed to protect seniors and people with disabilities who receive home and community based services. The Home and Community Based Settings Rule helps ensure that when states fund community services for people with disabilities, they do so in a manner that promotes integration instead of replicating the isolation and control of institutional environments.

The Settings rule requires every state to ensure that those receiving community supports have the right to do basic things like invite visitors into their own home, choose when they eat or what they do during the day, have legally enforceable rights under a lease, and possess options as to where to live other than group homes and other ‘disability-specific settings.’ States have until 2019 to comply with the Settings rule, and a broad range of flexibility to implement it in a way that best meets the needs of their residents.

The rule is designed to protect individual liberty, so that Americans will not lose control over their most basic choices by virtue of old age or disability. Prior to the Settings rule, states were moving to fund community-based services on the grounds of old institutions or by organizing segregated villages “clustering” adults with intellectual disabilities all in one place, limiting contact with the broader society. The Obama administration rightly recognized that these “gated communities” grouping people with disabilities together to get services were institutions by another name, so it limited states’ ability to fund them with scarce community services dollars.

But Price and Verma intend to move the implementation date from 2019 to an unspecified period in the future. Beyond that, their letter also calls for rolling back federal oversight, placing individuals with disabilities at greater risk of warehousing by state governments that are too often willing to defer to service providers about the level of rights their disabled residents should be afforded.

Elsewhere in the letter, Price and Verma express interest in revisiting 2016 Obama administration regulations governing how and under what circumstances states can contract out the operation of their Medicaid programs to private insurance companies, while fast tracking further state requests for “flexibility” in Medicaid.

Advocates at the state level must seek to organize in order to stop the worst of these ill-advised “flexibility” requests that are emerging from state legislatures and state Medicaid agencies. And governors in both parties must be told in no uncertain terms that taking advantage of the Trump administration’s offer to allow the gutting of Medicaid will not be viewed kindly by their voters.

Though this administration fails to recognize it, the rights of people with disabilities deserve federal protection. Just as states frequently fail to protect the rights of racial and ethnic minorities, women, and the LGBTQ community (all constituencies who are also under attack by the Trump administration), so too are state governments frequently willing to compromise the rights of disabled Americans for the sake of cost, convenience, or prejudice.

We can’t afford to be flexible when it comes to freedom and basic access to health care for every American.

Most Americans see Medicaid as only a health insurance program, but it is also the main source of funding for a wide variety of disability and aging services that keep people out of institutions. From the 93-year-old grandmother who needs an attendant to help her get out of bed, to the 24-year-old with Down Syndrome receiving a job coach, to the 6-year-old with a disability whose parents need support paying for skilled nursing care in their home—the Medicaid program is critical to ensuring the independence and freedom of disabled people of all kinds.

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“Block-granting” the program will transform it from a guaranteed benefit for low-income Americans and people with disabilities to an annual lump sum payment to states that is not tied to the need for services. If an increasing number of people needs these healthcare services, a block grant will not adjust to meet rising demand.

In addition, under the current Medicaid program, the federal government matches each dollar spent by states, enabling policymakers to make new investments toward eliminating waiting lists and broadening available services. However, without the guarantee of matching funds, states will not be able to sustain existing services—much less expand them to meet the tremendous unmet need in the disability community.

In fact, previous block grant proposals resulted in a loss of approximately 1 trillion dollars of federal investment in Medicaid over the next decade.

Additionally, the Trump approach would diminish the federal government’s historic role in using Medicaid funds to deinstitutionalize seniors and people with disabilities. For nearly 20 years—since the Supreme Court ruled in Olmstead v. L.C. that people with disabilities have a right to access supports in the community—federal policymakers have used Medicaid dollars to reward states that moved people out of institutional facilities and instead offer in-home services and supports.

These efforts depend on the federal government using innovative programs like Money Follows the Person. This program helped more than 63,300 people with disabilities leave institutional settings by providing an enhanced federal match rate to states to cover the full cost of supporting a person in the first year after they leave an institution.

In the absence of a federal role in Medicaid to promote community living, people with disabilities will find themselves at greater risk of institutionalization—despite the fact that they overwhelmingly express a preference for living in their own homes and communities.

As we fight back against Donald Trump’s assault on so many different communities, people with disabilities supported by the Medicaid program deserve our full advocacy and activism too.