Angie Voyles has high hopes for her daughter’s future, and she says support through Medicaid has been essential as the government healthcare covers expensive hospital visits, specialist exams, and school and home health services that are not covered by her insurance.

When Republicans talk about savings in the various health care proposals, most of the money comes from cuts in future Medicaid spending. Beyond limiting enrollment, government analysts say cuts will force states to make tough decisions about the types of services provided to existing Medicaid recipients and how much doctors, clinics and therapists are reimbursed for care.

Haymarket residents Voyles and her husband began fostering their twins in Arkansas soon after their birth, and the couple adopted the children two years later. Now five, Anna has been diagnosed with cerebral palsy, tracheobronchomalacia, subglottic stenosis, chronic lung disease, metabolic bone disease, allergies, eczema and global delays. She has a tracheostomy to breathe and a gastric tube to be fed, as well as oxygen at home when she needs it for colds.

Anna’s medical needs led the family to relocate to the Washington metro area to be closer to specialists, Voyles said. Her husband has spent 22 years in the military, and the insurance covers the family’s basic medical needs. But Medicaid has been filling large gaps in coverage.

The family has already exceeded a cap from the insurance for visits to a specialist in Cincinnati.

Anna also uses a $15,000 machine that helps keep her out of the hospital, but it was deemed experimental in the military health system. Medicaid has picked up these costs, as well as funding for Anna’s nurse to attend school with her.

“At five years old, she’s walking, talking and running. She’s going to school and learning. Who knows where she could go. She could be president,” Voyles said. “This is going to hold her back. This is going to hold a lot of people back.”

Hollow exception? 

If the U.S. Senate plan becomes law, spending on Medicaid will be 26 percent lower than it would have been under the existing law, according to analysis by the Congressional Budget Office. That will climb to 35 percent lower than the current law by 2036.

With restricted access to federal support, states grappling with rising medical costs will face tough decisions, according to a CBO report.

“Under this legislation, after the next decade, states would continue to need to arrive at more efficient methods for delivering services [to the extent feasible] and to decide whether to commit more of their own resources, cut payments to health care providers and health plans, eliminate optional services, restrict eligibility for enrollment or adopt some combination of those approaches,” according to the CBO. “Over the long term, there would be increasing pressure on more states to use all of those tools to a greater extent.”

Federal spending for children with certain disabilities won’t be subject to the general spending cuts, but the narrow definition doesn’t apply to many children with special needs currently receiving assistance.

Of the more than 5 million children with special needs enrolled in Medicaid, only 1.2 million currently meet the Senate’s definition of “disabled,” according to the Kaiser Health News. This is because the bill’s language is tied to payments through Supplemental Security Income.

Without changes, that excludes many children like Anna from families that aren’t impoverished but receive Medicaid to fill gaps in other insurance coverage.

Losing that aid would put Anna’s family on a knife’s edge of bankruptcy. An illness kept Anna in the hospital for more than 100 days in 2015, putting the total medical bill for that visit well over $1 million.

“We could be one illness away from being bankrupt,” Voyles said. 

Already smaller in Texas 

A key concern for all special-needs parents is the threat of losing home and community-based services covered by many states and threatened if funding is scaled back.

We’re seeing this scenario play out in Texas right now. The state implemented a $350 million cut to Medicaid in December that reduced reimbursements for speech, occupational and physical therapy for children. Because of the cuts, clinics have closed and therapists have quit.

“I couldn’t get any therapists to keep working for me who were registered or licensed,” Kathi Strawn told ABC News last month. Strawn initially cut therapists’ pay by 30 percent. She eventually closed her clinic, which served 130 children with special needs, on June 1.

When she tried to refer clients to nearby clinics, one was too booked for new cases and other therapists had stopped taking children because of low compensation rates.

“We’ve had quite a few patents not able to get service,” Strawn said.

In Virginia, school districts are an important service provider for children with special needs. Districts in the state receive nearly $33 million in reimbursements through Medicaid, Sen. Tim Kaine, D-Virginia, noted in a statement June 21.

“Medicaid enables many kids to go to school, plain and simple,” Kaine said. “It shocks me that some people say that cutting these programs would end a dependence on these programs, when these programs are the thing that allows our students to be independent and thrive in the classroom.”

Reimbursements in the 2015-16 school year totaled nearly $3 million in Fairfax County, $2 million in Alexandria, $1.3 million in Prince William County, more than $800,000 in Stafford County and $622,000 in Loudoun County.

Voyles isn’t ignorant of fraud and abuse in Medicaid, but she wants to see politicians focus on fixing what’s broken, not replacing the entire system. “The wheel may not be perfect, but let’s fix what we have.”

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Medicaid cuts could threaten aid to special needs children – Inside NoVA