The health care bill being pushed by House Republicans could wind up squeezing many seniors who need long-term help.
Oregon officials and senior advocates say the sweeping changes to Medicaid could someday affect middle-class seniors who never thought they would need a program aimed at health care for the poor.
"What we're really seeing is a cost shift and the federal government saying, 'It's all on you guys,'" said Jerry Cohen, Oregon director of AARP.
As a result, Cohen said he fears it would hurt Oregon's ability to fund programs that allow frail seniors to live independently while putting increased pressure on the state to reduce rates to nursing homes and other providers.
The American Health Care Act could reach the House floor on Thursday. In the build up to a vote, the legislation is generating a blizzard of headlines about how it would roll back the expansion of Medicaid included under the Affordable Care Act.
But less well-reported is how it also cracks down on Medicaid funding for seniors and disabled people who rely on it for long-term care.
Under the bill, Medicaid would no longer be an entitlement program like Medicare or Social Security, which automatically provides coverage for those who qualify.
Instead, states would receive Medicaid block grants with strict growth caps. The Congressional Budget Office projects that the House bill would cut Medicaid spending by $880 billion over the next decade from what it would would otherwise be.
That would have a big impact on seniors and younger disabled people, because a quarter of all Medicaid spending is for long-term care, typically in nursing homes.
Oregon is a leader in using Medicaid to help physically fragile low-income seniors stay in their homes. But that could become harder to do.
Lilia Teninty, the director of developmental disability services for the Oregon Department of Human Services, said the funding squeeze could put the state in a dilemma.
“Do we pull back," she asked, "and say people who are at home can’t have access to funding until they reach that crisis level — and then we'll come in and help them with a more expensive residential or other type of long-term placement?"
Ashley Carson Cottingham, the department's director of aging and people with disabilities, said that the state would lose $150 million of its funding in 2020. That's the year the block grants are supposed to start under the House proposal. Future increases wouldn't keep pace with the rising demand for long-term care, she said.
“We’re serving extremely vulnerable people," she said. "And they all qualify under federal law for meeting a nursing home level of care. So it’s really tough to parse apart who needs more care than somebody else.”
House Republican leaders sought to address some of these complaints in proposed changes they unveiled Monday night. They would allow increases for older and disabled recipients to grow faster than the rate of medical inflation.
But critics say the proposal still doesn't fully address rising costs and the increase in the elderly population.
"This would result in states having to cut their Medicaid programs by increasingly deeper amounts over time," said the Center on Budget and Policy Priorities, a liberal D.C. think tank closely tracking the legislation.
Polls show Americans often don't realize that Medicare doesn't cover long-term care. Nursing home costs in Oregon average around $90,000 a year, and it’s common for middle-class seniors to exhaust their resources and, newly impoverished, turn to the government for help.
That's a big reason why nearly two-thirds of nursing home residents are on Medicaid.
And demand is way up in large part because there are way more seniors.
“The silver tsunami is here," said Keren Brown Wilson, founder and president of the Jessie F. Richardson Foundation, which helps older adults with health and financial needs. "And there is, for every year of longevity, an increased probability of disability.”
In the 1980s, Brown Wilson helped pioneer programs to use Medicaid to help people who needed help with their daily lives but didn't require around-the-clock nursing care.
Brown Wilson said she is particularly worried about the flood of retiring baby boomers, many of whom are not doing well economically.
"This is the group that is least prepared to become old because of the economic recession, because of the housing market crisis," she said. "They are just not well-positioned economically ... and they have little time to recover."
Brown Wilson added that they "are more likely to be sicker, they are more likely to have expensive chronic disease and chronic conditions that need to be managed."
The number of seniors in Oregon is expected to rise from about 640,000 to more than one million by 2030, the state says. Caring for people with Alzheimer's and other forms of dementia is a growing industry.
Oregon Rep. Greg Walden, R-Oregon, and a major author of the Republican House care bill, did not respond to requests for comment. But he has said Medicaid is growing at an unsustainable rate and that states should have more freedom from federal regulations to innovate.
Eric Fruits is a Portland economist who works with the Cascade Policy Institute, a libertarian think tank. He argues that turning Medicaid into a block grant would force state legislators to be more disciplined in setting spending priorities.
“The block granting will make states make decisions instead of saying, ‘Oh gee, let’s just do this and the feds will pay for it,'” Fruits said.
That doesn't sit well with people who gathered recently at the Hollywood Senior Center in Portland for a Tai Chi class.
“I don’t want to be in the situation where I have to say, ‘My care versus immunizations for school age children,'" said Barbara Smith Thomas, 74. "That doesn’t feel good.”
Melinda Pittman was once a performer for such popular Portland groups as the Fallen Angel Choir. Now 63, she walks with the aid of a cane and goes to the senior center twice a week
Pittman went on Social Security disability two years ago after a life-threatening illness drained her savings. She said she may eventually need long-term care, and the Democrat worries about what is in store for seniors like her if the bill passes.
“We’re basically saying money equals life," Pittman said, "and they want to not complete the social contract with the citizens of the United States.”
New Health Care Bill: Find Out Where Your Member Of Congress Stands
The Republican health care bill under consideration in the House of Representatives would change health coverage for a lot of people. It would no longer require that Americans buy health insurance, for instance, and it would eliminate current subsidies, replacing them with a fixed refundable tax credit. To help Americans understand where Congress stands on the debate over this legislation, NPR and Member stations around the country have compiled a database of Congressional members’ positions on the bill.