How Medicaid Coverage Can Fall Short For Americans With Disabilities

The last four years have produced historic debates over the nature of America’s health care safety net. But Medicaid — a state-federal partnership program that serves some of the sickest, poorest, most overlooked Americans — is still in need of serious reforms when it comes to its approach toward covering Americans with special health care needs.

Federal requirements for the populations and services that states must cover under their Medicaid programs are currently broken up into “mandatory” and “optional” categories — misleading characterizations that have nothing to do with the actual medical or financial realities of the Americans these broad generalizations claim to encapsulate. For instance, nursing facility care coverage for Americans over age 21 is considered a “mandatory” service, but more extensive in-home health care services are “optional;” certain groups of the working disabled are considered a “mandatory” coverage population, but disabled Americans with slightly higher incomes can be covered “optionally.”

In an era of perpetual budget deficits and in the absence of federal matching funds for certain Medicaid benefits, states sometimes end up cutting these supposedly “optional” benefits — even for severely disabled Americans who rely completely on that care for everything from following a drug regimen to assistance in carrying out basic day-to-day activities such as moving around the house or going to the bathroom.

That’s exactly what happened to California’s Pablo Carranza, who suffers from severe muscular dystrophy. As Kaiser Health News reports, Carranza received in-home nursing care he needed through Medi-Cal, the state’s Medicaid program, until his 21st birthday — the age at which he became an adult in the eyes of the law and therefore was no longer a member of a “mandatory” beneficiary group. That’s when Carranza decided to challenge Medi-Cal’s in-home nursing benefit policy, claiming that the coverage cutbacks violate the Americans with Disabilities Act:

“We call it the nursing cliff,” said Elissa Gershon, an attorney with Disability Rights California. “When they turn 21, their needs haven’t changed, but the services available are much more limited.”

In a lawsuit filed in federal court in Sacramento, Calif., Tuesday, Carranza asked a judge to stop the state’s Medicaid agency from reducing his in-home nursing care, arguing that the limited hours would force him into an institutional facility, thereby violating his civil rights under the Americans with Disabilities Act. […]

[T]he reductions in health care spending since the start of California’s fiscal crisis in 2008 — more than $15 billion — are coming into conflict, legal advocates say, with federal protections for disabled people. The Americans with Disabilities Act, signed by President George H.W. Bush in 1990, along with subsequent court rulings, require that states help people with disabilities to remain in their homes or in their communities — and out of institutions like nursing homes or psychiatric hospitals — for as long as possible.

Carranza’s story is by no means unique. Millions of Americans with disabilities face these arbitrary, devastating benefit cuts, and federal Medicaid standards aren’t rigorous enough to ensure that Americans in need of “optional” services stay protected in the current scheme. So when politicians talk about block-granting Medicaid to the states in order to promote “innovation,” what they’re really proposing is giving states more authority to leave Americans like Carranza without adequate coverage or the means to live something approaching a normal life.

Carranza’s lawsuit has the potential to spur real change for those suffering with a disability. But ultimately, his story is emblematic of a government health care program that still hasn’t received the attention it should from lawmakers — even in a time of unprecedented reform.