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President Trump released a budget. Fortunately in a system of checks and balances, presidential budgets do not amount to much more than a partisan wish list and likely never get enacted. The one thing a budget proposal does is give a sense of what the executive branch is thinking and when it comes to trimming Medicaid, whoever is planning the President’s budget clearly does not have a good grasp on the reality of the situation.

Long-term care Medicaid is essentially broken down into two types of programs. The first program is skilled care in a nursing home, which is considered the core need for long-term care. If you cut this program it looks like you are trying to kick grandma out onto the street and that is just bad optics for any politician.

The second program is based around nursing home alternatives and collectively called Home and Community Based Services (HCBS). These programs vary state to state and include help with home care and some assisted living. When looking at ways to trim budgets, HCBS can be seen by some as the way to reduce the government’s outlay without the perception that you’re booting anyone from a nursing home. Fewer people getting home care puts a strain on individuals and families, but the optics are far less damaging.

In the latest budget proposal, cuts to HCBS care would likely reduce dramatically the availability of HCBS care across the country. This is what happens when you create budgets without a practical understanding of how the system works. Cuts to HCBS programs will likely blow the budget up because it will drive more people from their homes into nursing homes. Caring for someone in a nursing home is typically dramatically more expensive than home care or assisted living depending on the patient’s level of care.

HCBS programs were typically developed as cost-savings mechanisms. States like Ohio have used them effectively to transition people from nursing homes back home with huge cost savings. But states like New York which let patients get up to 24-hour skilled care at home through its Managed Care program are less efficient in saving the state money. Cuts without program reforms, however, would likely lead to a massive transition of patients from less-costly HCBS programs into nursing homes and do exactly the opposite of what the budget wonks in Washington think will happen when they cut those program.

People relying on HCBS care to avoid nursing home institutionalization can only take solace at this point that a presidential budget never gets enacted in its proposed form and seldom do presidents get what they ask for. One can only pray the logic that goes into the final budget-making process is not so short sighted.