Eva Fowkes is 39 years old. She has cerebral palsy. She lives in a supported home in Boise, Idaho, with one other person with disabilities, and around-the-clock caregivers who make that life possible.
Her parents, Ned and Alice, drive out to see her regularly. They are terrified right now. Not of a health crisis. Of a budget meeting.
Idaho is preparing to cut the exact Medicaid services that keep Eva in that home.
So is Colorado. So is Michigan. So are states across the country, because Congress passed a law last year that cuts $911 billion from federal Medicaid spending over the next decade, and states are now doing the painful arithmetic of figuring out what gets eliminated first. The answer, in almost every case, is home care.
What’s Actually Being Cut
Medicaid is not just health insurance for low-income people. It is the single largest source of funding for long-term care in the United States, paying more than half of the $415 billion this country spends on those services every year.
It covers 60% of all extended nursing home stays. It pays the wages of caregivers, sometimes family members, who help about 4.5 million chronically ill or elderly Americans stay in their homes rather than institutions.
Home care is cheaper than nursing homes. By a lot.
Medicaid spends roughly $47,000 a year on a nursing home stay versus $36,000 for in-home care, an $11,000 difference per person, per year.
The federal government has spent decades pushing people toward home and community-based services because they’re what most people want and they cost less.
The new cuts make that policy harder to sustain. States, facing massive funding gaps, are going to look at what they can legally reduce. Home care services, which are technically optional under federal Medicaid law, are exactly that.
Colorado’s Joint Budget Committee already voted this month to cap caregiver hours at 56 per week and cut services for people with developmental disabilities.
A Democratic budget committee member called it being “gobsmacked.” A Republican committee member said the couch cushions were being shredded looking for spare change. That’s where things stand.
Who These Cuts Actually Hit
Trump and House Speaker Mike Johnson have insisted the cuts target fraud and abuse.
The federal government’s own data says fraud accounts for about $6.5 billion a year in Medicaid spending. The cuts are $911 billion. The math doesn’t work.
The remaining reductions have to come from somewhere real, reduced enrollment, fewer services, lower payments to providers, or some combination of all three.
Every serious analyst looking at this says the same thing: the people who feel it first are the most vulnerable. Disabled adults. Elderly people who can’t advocate for themselves. Children in foster care. Low-income families who have no backup plan.
In Idaho, the cuts put at risk the 24/7 care that lets a 39-year-old with cerebral palsy live independently.
The in-home caregiving that keeps a 26-year-old with brain damage from a birth hemorrhage living with his family. Private duty nursing for a 19-year-old with cerebral palsy who’s already on hospice care.
These aren’t hypothetical cases. They are real people named in state budget hearings, whose families showed up in blue t-shirts reading “Cut Costs, Not Care” to beg lawmakers to find the money somewhere else.
“I feel like I’m always trying to prove their worth, to prove their value, and it’s exhausting,” said one Idaho mother whose two sons depend on Medicaid home care. “We just hold our breath every legislative session.”
The Ripple Effects Nobody Is Talking About
About 40% of home care workers, the people who actually show up and do the physical work of keeping disabled and elderly Americans alive and comfortable, live in low-income households themselves and rely on public assistance.
About a third of them are on Medicaid. Cut Medicaid, and you cut the income of the very workers delivering Medicaid services. Then those workers leave. Then the people they were caring for have nobody.
Urban safety-net hospitals are next. These are the hospitals that serve a higher share of Medicaid and uninsured patients, often the only hospital for miles in rural communities and low-income urban neighborhoods.
The cuts hit their funding hard. “They’re going to lose that cushion for uncompensated care and some of the charity care they do,” said Ahzam Afzal, co-founder of Puzzle Healthcare, which works with safety-net providers. “This could lead to shrinking workforces, longer inpatient stays, and discharges of sicker patients.”
And then there’s the war. Oil above $114 a barrel, sustained, for weeks, adds billions to healthcare supply chain costs. Medical equipment. Pharmaceuticals. Transport. The healthcare system is not insulated from what’s happening in the Strait of Hormuz. It never was.
Where This Goes
The most significant funding cuts don’t formally kick in until October 2027. But states can’t wait until then to prepare, and most aren’t waiting.
Providers say access to home and community-based services is already shrinking as payers pull back contracts, freeze new agreements, and centralize decision-making at national offices.
The people who need care are feeling it now, before the formal deadlines arrive.
There is an argument, a real one, that Medicaid spending was growing at an unsustainable rate and that structural reform was necessary.
That argument deserves to be had. But $911 billion over ten years, implemented at speed, without a plan for what happens to the people currently dependent on the system, is not reform. It’s a funding cliff with a lot of very sick people standing near the edge.
Ned and Alice Fowkes are still visiting Eva in Boise. She’s still in the home she shares with her housemate, still being cared for around the clock. For now.
Whether that stays true a year from now depends on decisions being made in state budget committees by people who have never met her and probably never will.
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