Your Independent Journal from the Heartland
Miseria, the Roman goddess of misery, woe, anxiety, and suffering, reigns. President Trump has brought her wrath down, but with a twist. Misery for some, wealth for others. This administration’s motto: profits uber alles. The Big Beautiful Cuts have spurred trickle-down misery: 17 million of us will lose health insurance; no federal infrastructure will forewarn us of disasters, like floods; measles is ascendant, with a predicted rise in whooping cough; the decimation of environmental safeguard agencies will surely spur a spike in environmental diseases.The noxious tabulation goes on.
All is not glum, though. The Big Beautiful Cuts will enrich the richest.
Consider children with severe disabilities. Currently at least 10 million people with disabilities live at home, with a cadre of specialists and aides. They live with families who do the herculean task of keeping their dependents at home. The care is often round-the-clock; the equipment is specialized; the medical diagnoses, and treatments, complex. The per-child tab comes to thousands of dollars annually.
Parents - whether or not they stop working to help with care, or keep working - cannot pay the thousands of dollars annually to keep their children home. Their private insurance will not cover it.
So a benevolent Uncle Sam, via Medicaid, has stepped in to cover the costs, letting these children stay at home. One Ronald Reagan-era initiative — Katie Beckett waivers — expressly authorizes Medicaid payments for parents who are not “poor” enough for Medicaid, yet need home care to keep their children out of institutions. Since 1982, a Katie Beckett waiver has allowed Medicaid to waive considerations of income, letting severely disabled children receive services at home.
President Trump has targeted these expenditures as cesspools of fraud and abuse. His Administration will drain the cesspool.
The data do not support that allegation.
A 2023 report from the Centers for Medicare and Medicaid Services said that the “improper payment rate” under Medicaid is $50.3 billion. Yet the majority of errors weren’t fraudulent; most (82%) stemmed from improper documentation. The caregiving staff who serve these children do not earn mega-salaries; some earn little more than minimum wage.
The alternative to home care is institutional care.
Eventually most of the children will outlast their families’ energies; and eventually many will go to group homes or specialized hospitals. But the Medicaid home-care funds are delaying that “eventually,” keeping dependents out of institutions so long as their families can manage.
From one statistical vantage, institutional care can at times be cheaper.
From another vantage, institutional care can enrich the coffers of a slew of private investors.
Private equity stands in the wings, waiting to pounce. Private equity has been gobbling up hospitals, hospices and physician practices with a speed that rivals pac-man. Now it sees disabled children not as people deserving kindness and care, but as profit-centers. So it is turning with impunity to the hospitals and group homes for disabled children.
And this Big Beautiful Bill is abetting the greed of Venture Capital.
If those expected cuts take place, “eventually” will come sooner. Families, unable to afford the thousands of dollars in home care, will gravitate to special institutions, where Medicaid will pay the tab.
Medicaid will not just be paying for services, but enriching the investors wading into the lucrative “disability care” industry. In the not-so-long ago past, the “disability care” industry relied on nonprofits, often with ties to religious organizations. That era is ending, as venture capitalists discover an industry that receives government funds, that has a steady supply of clients, that has less-than-stringent government oversight, and that serves a vulnerable constituency, unlikely to protest.
Looking at this industry, investors recognize profits. Under the guise of efficiency, the rulebook is clear: replace more skilled with less-skilled staff; increase the patient-helper ratio; cut costs in the most creative ways that the MBAs can find. After the cuts, the watchdog groups, like the Private Equity Stakeholder Project (pestakeholder.org) will rise up, with statistics and scandals.
The ultimate victims: children. The ultimate winners: venture capitalists. And the “facilitator”: this administration. Miseria, allied with Mammon, smile.
Joan Retsinas is a sociologist in Providence, R.I., who writes about health care. Email joan.retsinas@gmail.com.
