Author’s note: The disability community is rapidly evolving to use identity-first language in place of person-first language. This is because it views disability as being a core component of identity, much like race and gender. Some members of the community, such as people with intellectual and developmental disabilities, prefer person-first language. In this column, the terms are used interchangeably.
At the same time as 26 advocates, most with significant disabilities, were arrested for protesting at the House Energy and Commerce Committee reconciliation bill hearing, House Republicans on the committee looked for ways to cut Medicaid. The protesters yelled “no cuts to Medicaid” while Capitol Police pushed some in their wheelchairs out of the hearing. And although Rep. Dan Crenshaw (R-TX) told a 6-year-old boy with Down syndrome and his mother that his Medicaid “is not going anywhere,” the nonpartisan Congressional Budget Office found that the bill would cause at least 10.3 million people to lose Medicaid coverage. The bill passed out of committee even after advocates and experts tried to educate members of Congress and the public about the harms it would have on already vulnerable communities. It will now go to the Rules Committee and then to a full House vote.
Although Rep. Dan Crenshaw (R-TX) told a 6-year-old boy with Down syndrome and his mother that his Medicaid “is not going anywhere,” the nonpartisan Congressional Budget Office found that the bill would cause at least 10.3 million people to lose Medicaid coverage.
NBC News, "GOP-led House committees meet to tackle Medicaid cuts, taxes and SNAP benefits" (2025); Congressional Budget Office, "Energy & Commerce, Subtitle D, Part I - Medicaid" (last accessed May 2025).
The bill, as currently written, would punish Medicaid recipients who are unable to comply with strict work reporting requirements and redetermination reviews, risking coverage loss for procedural reasons. It also would block recent federal rules designed to make Medicaid and Children’s Health Insurance Program (CHIP) applications simpler and more accessible for eligible individuals, primarily children, older people, and people with disabilities. All of these things would increase the costs to administer Medicaid and CHIP.
At the same time, states would be prohibited from creating new or increasing existing taxes on health care providers to help finance their share of Medicaid program costs, making it more difficult for states to sustain Medicaid. As a result, states would have to look at three different strategies: raising taxes, limiting coverage, or reducing or eliminating vital benefits that are not explicitly required by federal law. Services that could be cut include home- and community-based services (HCBS), physical therapy, and speech therapy. These services are often critical for people with disabilities and older adults, who would be among the first and hardest hit by such cuts.
States would have to look at three different strategies: raising taxes, limiting coverage, or reducing or eliminating vital benefits that are not explicitly required by federal law.
KFF, "Follow the Money: How Medicaid Financing Works and What That Means for Proposals to Change it" (2024).
This has happened before. In 2011, Congress allowed the temporary increase in federal Medicaid matching funds from the 2009 stimulus package to expire, even though many states were still recovering from the Great Recession. States immediately began to cut spending to optional HCBS programs, including by reducing per-beneficiary spending or the number of beneficiaries eligible for the program. KFF found that between 2011 and 2012, some states cut dental or denture services; medical supplies or durable medical equipment; occupational, physical, or speech therapy; and personal care services for Medicaid enrollees, all of which are primarily utilized by older adults and people with disabilities. This history makes clear that any federal cuts to Medicaid will disproportionately affect disabled and older people.
Because of Medicaid enrollment and spending patterns, significant cuts almost inevitably lead to harmful impacts to coverage and services for older adults and people with disabilities. In 2021, 22 million people enrolled in Medicaid through disability or aging eligibility pathways. Although these beneficiaries only accounted for 23 percent of the enrollees, Medicaid spent 51 percent of its budget on them in 2022.
Mandatory vs. optional Medicaid benefits
According to the 1965 amendment to the Social Security Act of 1935, states must provide a specific set of mandatory benefits through Medicaid. These benefits include inpatient and outpatient hospital services, rural health clinic services, federally qualified health center services, family planning services, nurse midwife services, home health services, and more. It also requires that children under age 21 receive early and periodic screening, diagnostic, and treatment (EPSDT) services, which may require access to benefits that are only optional for adults.
Optional Medicaid benefits are services that states may choose to cover in addition to those required by federal law. These benefits can be offered through the standard state Medicaid plan or through waivers, such as HCBS waivers. States can pick and choose which services to cover in addition to the mandatory benefits. Many of these services help beneficiaries avoid institutionalization and remain in their homes and communities. Although titled optional, the services are essential to disabled and older people.
Below are some Medicaid benefits that the federal government categorizes as optional for states and that could therefore be at risk if federal funding for Medicaid is cut.
Home- and community-based services
HCBS are services that disabled people, people with chronic illnesses, and older people often rely on most to stay in their communities. Some of the top Medicaid expenditures included in HCBS are the Community First Choice (CFC) option, targeted case management services, and hospice. Other services that disabled people often utilize under this category include respiratory care for ventilator-dependent individuals, personal care, self-directed personal assistance services, services in an intermediate care facility for individuals with intellectual disabilities (ICF/ID), and Certified Community Behavioral Health Clinic (CCBHC) services. Without this coverage, disabled and older people may end up hospitalized or institutionalized.
Prescription drugs
According to the Centers for Medicare & Medicaid Services expenditures report for fiscal year 2023, Medicaid spent more than $1 billion on prescription drugs. Due to the high costs of prescription drugs, states have looked for ways to limit the program, including overseeing preferred-drug lists and establishing value-based arrangements. People in the United States pay an average of $1,564 for pharmaceutical drugs per year. Without Medicaid covering these medications, many people will have to pay for their drugs out of pocket or forgo potentially necessary medicines altogether, resulting in poorer health outcomes.
Outpatient treatment and services
Outpatient services such as physical therapy; occupational therapy; speech, hearing, and language disorder services; tuberculosis-related services; and other diagnostic, screening, preventive, and rehabilitative services are all optional adult benefits states can cover. Medicaid is required to cover these services for children under age 21. If states decide not to cover these services under Medicaid for adults, people may end up having worse health outcomes from significant injuries or illnesses.
Dental services
While all state Medicaid programs are required to provide dental care for children under age 21, coverage for adults 21 and over is an optional benefit. Three states currently do not cover any type of dental services. Most other states provide at least emergency coverage. Eighteen states and Washington, D.C., cover extensive services that can include periodic exams, fillings, root canals, and fluoride treatment. Oral health is closely linked to overall health, and individuals without coverage are more likely to have dental issues that can affect mental health and employment.
Pediatric inpatient psychiatric services
States can choose to cover inpatient psychiatric services for children under age 21 through hospitals and psychiatric facilities. Since the beginning of the COVID-19 pandemic, the United States has seen a rise in pediatric mental health issues. Emergency room visits and hospitalizations for children have also increased. Reducing or eliminating coverage could leave families with hefty hospital bills.
Certain medical equipment
Some medical equipment utilized in homes and communities is an optional service states can cover. This can include prosthetic devices, eyeglasses, cochlear implants, hearing aids, and dentures. Upper-extremity prostheses can cost $20,000 to $100,000, and cochlear implants can cost $50,000 to $100,000. Without coverage, many individuals would have a significantly more difficult time working and remaining in their communities.
Conclusion
Congressional Republicans, such as Kentucky Rep. Brett Guthrie, chair of the House Energy and Commerce Committee, claim that vulnerable populations, including people with disabilities, who need Medicaid will not be harmed by their proposed reconciliation legislation. However, the policies within the bill would result in significant state budget deficits, which would require state administrators to review what to cut to balance their budgets. Past experience shows that optional benefits would be among the first targeted for cuts—and disabled and older people would be directly in the path of those cuts, facing severe consequences that include job loss, institutionalization, homelessness, worsening health, or even death due to how the lack of access to affordable health care destabilizes lives.
The author would like to thank Anuja Gore for fact-checking; Rachael Eisenberg, Andrea Ducas, Andrés Argüello, Colin Seeberger, and Lily Roberts for their reviews; and the Center for American Progress’ Editorial and Legal teams for their guidance.