Today, the Medi-Cal program, California’s version of Medicaid, covers nearly 14 million Californians. Approximately two million — or about 15% — are seniors with low incomes and people with disabilities (SPDs). The number of SPDs enrolled in Medi-Cal varies from 65 in Alpine County to 637,304 in Los Angeles County. (See Medi-Cal SPD Enrollment by California county under Document Downloads below.)

Medi-Cal: A Vital Safety Net

Although Medi-Cal is often perceived as a program for children in low-income households and nonelderly adults, it also provides coverage to close to a quarter of all California seniors. Most seniors are covered by Medicare, but Medicare premiums and cost-sharing requirements are unaffordable for many seniors with low incomes, and Medicare does not cover long-term care. Medi-Cal covers these out-of-pocket costs (PDF) for the state’s poorest seniors and also covers long-term care for seniors who have exhausted their financial resources. Medi-Cal covers three out of five nursing home residents (PDF) in the state.

Medi-Cal similarly provides a safety net for people with disabilities who may not have access to commercial health insurance if they are unable to work or work only part-time. Medi-Cal enrollees with disabilities include those with conditions such as multiple sclerosis, epilepsy, and blindness; HIV/AIDS; spinal cord and traumatic brain injuries; disabling mental health conditions such as depression and schizophrenia; intellectual and developmental disabilities such as Down syndrome and autism; and other functional limitations. Half of all Californians with disabilities (PDF) are covered by Medi-Cal.

Medi-Cal helps many seniors and people with disabilities live independently in the community rather than go into a nursing home. Nationally, Medicaid is the primary payer for long-term services and supports, which includes assistance with self-care and household tasks.

How the Senate’s BCRA Could Affect Medi-Cal Coverage for Seniors and People with Disabilities

The Better Care Reconciliation Act (BCRA), currently under consideration in the US Senate, has been described as a bill to repeal and replace the Affordable Care Act (ACA). However, when it comes to Medicaid, the bill goes much further. Populations that have been covered by Medicaid well before the ACA are at risk, including seniors and people with disabilities.

Medicaid was created as a partnership between states and the federal government, with each contributing to cover the cost of providing medical care for Americans with low incomes. In a dramatic departure from this shared financing model, the BCRA, like the American Health Care Act (AHCA) passed by the House of Representatives in May, would impose “per capita caps” (a fixed federal contribution per enrollee) and cap the growth of federal spending. If Medicaid costs rise faster than the federal growth factor, states would have to pay a growing share of Medicaid costs. According to the Congressional Budget Office (CBO), the BCRA sets the long-term federal growth factor far below (PDF, see p. 29) the rate at which Medicaid spending is projected to rise. Nationwide, federal support for Medicaid would be reduced (PDF) by $772 billion by 2026, or roughly a quarter of the program’s budget.

The California Department of Health Care Services (DHCS) estimates that the BCRA would shift $3 billion in costs to the state in 2020 (PDF), rising to $30 billion in 2027. Cumulatively over the period from 2020 through 2027, the bill shifts a total of $114.6 billion in costs to the state. This includes a shift of about $400 million in costs starting in 2020 to California to provide In-Home Supportive Services (IHSS), growing annually after that. IHSS help the elderly and those with disabilities remain in their homes rather than be placed in a more costly institutional care setting.

It is impossible to predict what changes California would make to its Medi-Cal program under the BCRA. But with dramatically less federal support, California and other states would face severe pressure to make deep cuts to the program. This is particularly worrisome for seniors and people with disabilities, which are a high-cost group due to their extensive health needs. In 2011, SPDs accounted for less than 25% (PDF) of the overall Medi-Cal population but 60% of total spending.

Medicaid coverage for many SPDs and for many services important to this population, such as home and community-based long-term care services designed to help them live independently, are not federally mandated. This makes them a prime target for cuts if states are faced with federal funding reductions.