Parents, children and healthcare providers hold signs and gather in the atrium at the Baton Rouge office of Sen. Bill Cassidy to urge him and other senators to avoid cuts to Medicaid.

Advocate Staff Photo by PATRICK DENNIS

As the U.S. Senate pushes forward with its proposal to replace Obamacare, advocates for the elderly and disabled have warned that the planned Medicaid cuts could disrupt care at nursing homes across the country.

Nursing homes and long-term care are a significant and growing chunk of every state's Medicaid budget. The general population is trending older, people are living longer and even middle class Americans are turning to Medicaid in their final years as they outlive their savings. Since the Senate's healthcare bill, currently dubbed the Better Care Reconciliation Act, is estimated to reduce federal Medicaid spending by 35 percent over the next two decades, nursing homes are among the services expected to feel the squeeze.

But that could be less of a concern in Louisiana, where nursing homes are both statutorily and constitutionally protected against budget cuts. In fact, the state is legally required to increase their rates at least every two years, which means the amount spent on nursing homes — totaling more than $1 billion this year — has ballooned at a rate much faster than other state Medicaid providers.

And without changes to state laws, Louisiana nursing home rates would continue to increase, despite declining Medicaid revenues proposed under the federal health care bill.

That leaves some other Medicaid providers in Louisiana and advocates for nursing home alternatives feeling that they could be even more vulnerable if the overall program shrinks.

Andrew Muhl, AARP Louisiana lobbyist, said the Senate health care bill would have a "dramatic effect on older adults who depend on nursing home alternatives (like home- and community-based services) that provide assistance with daily activities like bathing, getting dressed and eating."

"And because of multiple existing constitutional and statutory rate protections for nursing homes, those critical services would absorb the majority of cuts," he said. "Louisiana, like most states, is not in a position to respond to such a massive shortfall of vital services that help older adults."

States are mandated to cover nursing home care under their Medicaid programs, but they have some flexibility in what they pay to the the nursing homes and deciding who is covered.

Health care analysts say the bill will likely result in most states cutting back their nursing home budgets, either by reducing rates paid to nursing homes — which could compromise quality of services — or by tightening the eligibility requirements to reduce the number of people who can get on the program. In Louisiana, state officials could only change eligibility and would have little ability to change rates for nursing homes without changing the law.

Louisiana has about 30,000 people in nursing homes, and more than 80 percent of them are Medicaid recipients.

Dr. Rebekah Gee, secretary of the Louisiana Department of Health, said in a recent interview that if the U.S. Senate bill passed, the state Legislature would likely have to consider revoking some of the rate protections for nursing homes because money would need to be freed up for other services. "We have it written into the constitution that we're forced to spend this money on nursing homes, when we might otherwise need to spend that money on children or other services," she said.

Gee also said cuts in the Senate bill would force the state to move to managed care for nursing homes and long-term care services in order to keep costs down. "With this bill, you'd want managed care in every area you're overseeing in Medicaid," she said.

The state already switched to managed care for its traditional Medicaid populations under former Gov. Bobby Jindal, which means that private insurance companies are hired by the state to oversee Medicaid services and make determinations about how and where patients should receive care. State officials have toyed with moving to managed care for the remaining elderly and disabled populations, but those efforts stalled largely over objections from the nursing home industry.

Mark Berger, the Louisiana Nursing Home Association executive director, said in a statement that said nursing homes in Louisiana would in fact be hurt by the bill, without going into specifics.

"The Senate's draft proposal to repeal and replace the Affordable Care Act includes deep Medicaid cuts that will threaten our ability to provide care to the residents we serve. We are hopeful that the Senate will revise their proposal and protect the funding for the aged and disabled Medicaid population," he said, while declining to answer whether Louisiana nursing homes would somehow be better positioned.

The threat of losing additional Medicaid dollars only exacerbates an already problematic balance of resources in Louisiana, where nursing homes receive a growing proportion of resources at the expense of more preferred, less expensive home-and community-based services.

Nursing homes are a federal Medicaid requirement, but since the 1980s, home- and community-based services have grown in popularity as an alternative for institutionalizing the state's elderly and physically disabled. Louisiana is an outlier among other states because its nursing homes portion of the Medicaid budget is still growing faster than home- and community based alternatives. In the rest of the country, states are shifting their resources away from facilities like nursing homes and into home services.

Louisiana has about 45,000 people on waiting lists for home and community based services for the elderly, as well as the developmentally and physically disabled. Many experts expect the federal health care bill would make those programs, which are considered optional Medicaid services, even less accessible.

"Faced with these cuts in the bill, states would likely have to deal with cutting optional benefits like home and community based services," said Judy Solomon, vice president of health policy at the Center on Budget and Policy Priorities.

The nonpartisan Congressional Budget Office report on the Senate overhaul bill said "eliminating optional services," would be a path states would have to evaluate to manage the federal Medicaid cuts. Other options included shifting state dollars to fund the programs and restricting eligibility for enrollment.

Federal law requires state Medicaid programs to cover nursing homes, pregnant women and children who are poor. But states can also elect to offer optional Medicaid services. Under Obamacare, Medicaid expansion became an option, with 31 states so far opting to expand Medicaid coverage to any adult with income up to 138 percent of the poverty level. Louisiana joined their ranks last year, after Gov. John Bel Edwards took office. 

Other optional services the state offers include waivers that fund the home and community based services, which are offered not only to the elderly and disabled, but also children with disabilities. Optional Medicaid services also include hospice, adult day health care, inpatient mental hospital and pediatric day health care for children with complex medical needs.

Barry Meyer, executive director of The Arc of Baton Rouge, a nonprofit that supports people with developmental disabilities, said he fears the elderly and disabled community who rely on community-based care, who already have to fight at the state level for stable annual funding, will get edged out by more powerful institutions if the funding becomes even more scarce.

"If Medicaid resources are a bucket of money, well the bucket may seem like it's a big at first, but who is going to scoop out of it first? You have the hospitals, then you have the individual doctors, big Pharma will come to the table, and the nursing homes are going to be there to scoop out of the bucket," Meyer said. "After everyone else, that's what left for the Medicaid optional services."

Further complicating the issue, is that states are still legally required, under the Americans with Disabilities Act, to provide alternatives to institutionalization for the elderly and disabled.

The state already has been flagged in recent years for potential violations of such federal laws.

"The Americans with Disabilities Act provides that services for people with disabilities must be provided in the most integrated setting appropriate," said Susan Meyers, an attorney with The Advocacy Center in New Orleans, a group that sued the state several years ago over a lack of home and community-based services. "The integration mandate exists regardless of what happens to Medicaid. As long as the state provides funding for people to receive treatment in nursing homes and psychiatric hospitals, it is legally obliged to fund those services in the community as well."

Among those holding out hope that Medicaid funding remains intact is Central resident Carla Curtis, the primary caretaker of her 56-year-old older brother Tim. Tim has cerebral palsy, is blind and can't speak. He needs help for all of his daily activities. But he's able to live independently because of a Medicaid waiver that pays for around-the-clock personal care attendants. 

They help him get dressed, they bathe him and cook his food, which has to be pureed for him to eat. Without the waiver, Carla said she would have to give up her own life. She'd have to quit one or both of her two jobs and drain her savings to give Tim the personal and medical attention he requires. 

"People like my brother, they're probably some of the happiest people you'll ever meet because they don't know what we know," she said. "It's just a shame we have to beg and plead for our lives." 

Follow Rebekah Allen on Twitter, @rebekahallen.