Heartbreak

Justin Martin, 21, is in many respects a typical junior at Kenyon College. He lives in an off-campus apartment, which he shares with six other guys. He’s majoring in English, helps run a student improv group, and last semester he took five courses instead of the usual four ― a “terrible idea,” he now concedes. Sometimes he pulls all-nighters to write papers or study for exams, drawing sustenance from soda and chocolate-covered almonds. And sometimes he stays up late just to have long arguments with his roommates ― like over whether it’s OK to ban campus speeches by white supremacists (Martin says no) or whether the seventh Harry Potter novel was the worst (Martin says yes).

But in one respect, Martin is unique on the Kenyon campus and rare among college students in general. He has cerebral palsy, the disease that severely impairs muscle movement. Martin cannot walk or care for himself without assistance. His life in college ― getting to room with his fellow students, carrying a more-than-full course load ― is a testimony to many things, including supportive administrators and his own stubborn determination. But, Martin says, none of this would be possible if it wasn’t for the help of government programs. And perhaps the most important among them is Medicaid, the federal-state health insurance program that provides coverage to the needy, including people with disabilities.

Most people think of Medicaid as a program for able-bodied, non-elderly adults and their children ― a form of “welfare” that some Americans tolerate and others resent because they think, rightly or wrongly, that it’s subsidizing people too lazy to work. But one-third of the program’s spending is on people with disabilities. Although they account for a much smaller fraction of Medicaid enrollees, there are roughly 9 million people in this category, and almost all have unusually severe health care needs. On average, Medicaid spends more than four times on somebody with disabilities than it does on an able-bodied adult.


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Martin is living at his family’s home on the outskirts of Columbus for the summer. When I visited him there recently, he pointed out some of the places that Medicaid money goes. There is the lift-and-pulley system that operates along a track in the ceiling, similar to the one in his campus apartment. It takes him from his bedroom into the bathroom when he needs to use the toilet or take a shower. To get around, he uses a motorized wheelchair that can change its shape in order to stretch out his legs or make him stand. For longer trips, there’s a van with a lift for the wheelchair. Martin can’t be truly alone, because he requires help with some basic functions ― a list, he frequently notes, that includes “wiping my butt.” That means paying for caregivers who, at school, must be on call around the clock.

Buying and installing the equipment costs many thousands of dollars. Paying those caregivers costs many thousands more, on an ongoing basis. Martin’s father, who lost his factory job several years ago, drives trucks for a living. His mother, who used to work in state government, now has a job at a university. That position provides health insurance, but the plan, like most commercial insurance policies, wouldn’t cover the array of equipment and services Martin needs ― especially the ones that allow him to live independently. Medicaid, in combination with some other government programs, does. And now some of that coverage is at risk because of Republican efforts to repeal the Affordable Care Act.

The American Health Care Act, the bill that the House of Representatives passed in May and that the Senate is now using as the basis for its repeal legislation, would cut approximately $1 trillion from federal health plans over the next decade, according to the Congressional Budget Office. Although few people realize it, a portion of that cut has nothing to do with “Obamacare” per se. It’s the creation of a different funding formula for Medicaid that would affect the entire program. The purpose of this change is to limit the money Washington sends to the states in order to finance their programs. Conservative lawmakers want to scale back the funding even more, either in the repeal bill itself or in subsequent legislation.

The champions of this legislation, including Trump administration officials like Health and Human Services Secretary Tom Price and Republican leaders in Congress like House Speaker Paul Ryan (R-Wis.), deny that these cuts would hurt people like Martin. They say eliminating recent Medicaid expansions and putting the program on a tighter budget would ultimately make it more financially sustainable. And they say that states, given more flexibility over how to manage Medicaid within their borders, would respond by finding ways to innovate. “We believe strongly that the Medicaid population will be cared for in a better way under our program,” Price said during a CNN interview in May.

It’s impossible to disprove these claims. But Medicaid’s history offers reason to be highly skeptical. Funding for the program is already threadbare. And plenty of state officials ― mostly, though not exclusively, Republican ― already want to reduce their share of Medicaid appropriations even more. Cuts at the federal level could embolden these officials, or merely force them to respond in kind because of how the program’s financing works. Either way, coverage for disabilities would be a likely target for cuts, in part because that coverage represents such a large fraction of program spending now.