Surveys confirm that most older Americans would like to age in place. They may need help to do so. As they grow older, a healthier spouse might care for a disabled spouse. Adult children might choose to live with their parents so they can provide full-time care. Most home care for older adults is provided by unpaid family caregivers.
Many older adults nevertheless benefit from home care services that are funded by Medicaid, a constellation of programs managed by states to help low-income individuals obtain health care. While traditional Medicaid does not cover home care, most states pay for at least some home care services to low-income seniors, either as a state benefit or through a Medicaid waiver. The benefits depend on the state in which the enrollee lives and may depend upon the state plan in which the beneficiary is enrolled.
Home care services typically include personal care services provided by a qualified personal care attendant. Personal care services include assistance with the activities of daily living, such as getting dressed, bathing, and eating.
Some states have also obtained Medicaid waivers to provide homemaker services, including assistance with laundry, cleaning, grocery shopping, and meal preparation. Those services are vital to seniors living at home who cannot perform them on their own.
Non-Medical Services Cut
The Trump administration has used a variety of mechanisms to achieve its announced goal of reducing the federal budget deficit, including raising income through tariffs, declining to honor contracts that require cash disbursements, cutting staff at disfavored federal agencies, and eliminating some agencies entirely. The controversy surrounding DOGE stems in part from its poorly implemented scheme to reduce “waste, fraud and abuse” in federal spending.
Through it all, President Trump has assured recipients of Social Security, Medicare, and Medicaid that their benefits will be protected. Many seniors are justifiably concerned that their benefits will be lost or reduced under the guise of cutting waste, fraud, and abuse.
The agency charged with administering Medicaid, the Centers for Medicare & Medicaid Services (CMS), has announced that it will no longer approve funding for some services that have been covered by state Medicaid waivers, including some in-home non-medical services. A letter to state Medicaid directors specifically cited programs that pay for housekeeping. Other services that CMS will no longer approve of include providing high-speed internet to rural healthcare providers.
Impact of Cuts on Senior Care
CMS takes the position that non-medical services are driving up the cost of Medicaid and “distracting” from the program’s “core mission.” Yet seniors with serious health conditions who want to live at home may be incapable of doing so without the help of individuals who prepare their meals as well as assure them that they are living in a clean, safe, and healthy environment. Driving those seniors into institutional care may be more costly to the Medicaid program than paying for homemaker services.
While CMS maintains that it will continue to grant some waivers for innovative state programs, it will only do so if the program is “focused on improving health outcomes.” That narrow view of “health” focuses on medical outcomes rather than quality of life. A senior’s physical health might be the same, whether she receives care in a nursing home or from in-home providers, but her mental health will often be improved if she receives care in her own home.
Even when they need the assistance of caregivers, older adults preserve a sense of independence when they remain at home rather than moving into a nursing home. They are also better able to maintain community connections if they stay in their neighborhoods. Negative attitudes about nursing home care — driven in part by the pandemic — contribute to dissatisfaction with institutional care. While nursing homes are the best choice for many disabled seniors, eliminating payment for homemaker services will make them the only choice for seniors who cannot remain at home without that help.
Seniors who currently receive homemaker services through Medicaid will likely continue to receive those services until the waiver program comes up for renewal. Most waivers come up for renewal after five years and are then extended for three to ten years, if they are extended at all. Unless state governments pick up the cost of homemaker services, those services over the new few years may be unfunded and thus unavailable to seniors who need them.