Closing the door on home care.

• Author: Ervin, Mike
• Position: Medicaid reform

Last winter, Constance Barna of Syracuse, New York, received a letter that knocked the spirit right out of her. Barna is in a wheelchair because of a progressive neuromuscular disorder. She has little mobility or speech capability.

The letter was from an agency that employed her in-home assistants. The letter said that because of Governor George Pataki's plan to cut $1.2 billion from the state Medicaid budget, her hours of in-home aid would be cut so drastically that "we can only encourage you to make provisions" to go into a nursing home "as soon as possible."

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But the timing of the letter was in one way fortunate. Local disability activists, responding to Pataki's assault, had organized a public forum for later that day. The idea was for legislators and the press to hear in undeniable human terms the consequences of Pataki's plans. The room was packed to standing room only. As Barna's friend and fellow disability activist, Bonnie Shoultz, read the letter, there was total silence.

Pataki's plan was to limit the hours of home care anyone could receive in a month to 100. That's about three hours a day. Barna was receiving more than 100 hours in a week. Pataki figured he could reduce hours by having workers no longer do things like cooking and errand-running. State Medicaid funds would only pay for them to perform dressing, bathing, and other basic hygienic tasks.

Activists held demonstrations and lobbied legislators statewide. In the end they defeated the cuts in home assistance. But now, Shoultz says, Pataki's current budget proposal calls for Medicaid funds that support home assistance to be block-granted to the counties. The counties would have complete authority over the amount of service they provide, and whom to serve. Even worse, Shoultz says, Pataki throws in a powerful incentive for them to cut people like Barna loose by allowing them to keep whatever money remains at the end of the fiscal year and spend it on other things.

"But maybe his plan will blow up in his face," Shoultz says.

Currently, the federal government mandates that states provide certain minimum services for people on Medicaid. In order for Pataki to give counties carte blanche to abandon anyone who is too much trouble, the federal government would have to abolish the Medicaid entitlement.

That entitlement is the subject of hot debate in Washington. The "Medigrant" proposal that passed the House removes all requirements, and gives Medicaid money...